ARMY SERVICE FORCES CONFERENCE of PREVENTIVE MEDICINE OFFICERS PREVENTIVE MEDICINE SERVICE OFFICE OF THE SURGEON GENERAL 14-15-16 FEBRUARY, 1945 JOHNS HOPKINS UNIVERSITY SCHOOL OF HYGIENE PUBLIC HEALTH BALTIMORE MARYLAND PROCEEDINGS CONFERENCE 0 F PREVENTIVE MEDICINE OFFICERS PREVENTIVE MEDICINE SERVICE OFFICE OF THE SURGEON GENERAL 1^-15-l6- FEBRUARY JOHNS HOPKINS UNIVERSITY SCHOOL OF HYGIENE & PUBLIC HEALTH BALTIMORE, MARYLAND Foreword Remarkable achievements in preventive medicine have been made during this war. These achievements have been largely a resu.lt of the application of new scientific discoveries; and the recognition of the field of preventive medicine as one of the most important military medical specialties. The preventive medicine officer's function is the reduction of noneffectiveness from disease; and to carry out this mission he must be well qualified to advise the Burgeon on all aspects of disease prevention and to supervise the execution of the methods which are adopted. This conference of medical officers engaged in preventive medicine throughout the United States was arranged to present recent developments in the field and to stimulate further progress through free discussion of problems. I deeply regret having been unable to attend; owing to my absence from the country at the time. I am sure; however; that the results we sought have been obtained. * In view of the success which attended this Initial conference it is hoped that annual meetings of the same sort can be held. \Ut oU /' j JAMES S. SIMMONS / i Brigadier General;, USA V Chief, Preventive Medicine Service; SGO ROSIER OF OFFICERS ATTENDING PREVENTIVE MEDICINE CONFERENCE School of Hygiene and Public Health Johns Hopkins University, Baltimore, Maryland 14-16 February 1945 Allen, Robert W., Lt Col, MC, Headquarters, Seventh Service Command Banton, Huston J., Colonel, MC, Headquarters, Fourth Service Command Brooks, Henry C., Lt Col, MC, Camp Shelly, Mississippi Burns, Francis J., Lt Col, MC, Camp Joseph T. Robinson, Arkansas Buss, Paul, 1st Lt., MC, Fort Penning, Georgia Buzzerd, H. W., MaJ, MC, New York Port of Embarkation Cannon, E. B._, MaJ, New Orleans Port of Embarkation Carpenter, George R., MaJ, MC, Fort Bragg, N.C. Carroll, Francis B., Lt Col, MC, Headquarters, First Service Command Coleman, James A., Lt Col, MC, Camp Blanding, Florida Cooper, Z. P., Capt, MC, San Francisco Port of Embarkation Council, Francis E., Col, MC, Headquarters Ninth Service Command Dewey, Leonard D., Lt Col, MC, Headquarters, Eighth Service Command Farragut, Loyall D., MaJ, MC, Fort Belvoir, Ya. Fehlman, Frederick H., MaJ, MC, Office of the Chief Surgeon, Army Ground Forces Foote, Franklin M., MaJ, MC, Medical Field Service School, Carlisle Barracks, Pa. Franklin, Daniel, Col, MC, Headquarters, Second Army, Memphis, Tenn. Frick, ¥, G,, Lt Col, MC, Charleston Port of Embarkation Goodnight, Scott H., Capt, MC, Seattle Port of Embarkation Heimoff, Leonard, MaJ, MC, Fort George G. Meade, Maryland Hllldrup, Don G., Col, MC, Headquarters, Sixth Service Command Kenna, William A., MaJ, MC, Hampton Roads Port of Embarkation Kogel, Marcus D., Lt Col, MC, Medical Field Service School, Carlisle Barracks, Pa. Lacey, Warren W., Capt, MC, Fort McClellan, Alabama Lacock, Walter B., Lt Col, MC, Headquarters, Fifth Service Command Leclerc, G., MaJ, RCAMC, Office of the Director of Medical Services, Ottawa. Lee, Russel Y., Col, MC, Office of the Air Surgeon Manly, James P,, MaJ, MC, Camp Hood, Texas Marsh, Edward H., Col, MC, Headquarters, Second Service Command Neufeld, A. H., MaJ, MC, RCAMC Liaison Officer, Washington, D. C. Newman, W. H. F., MaJ, MC, Medical Regulating Unit, SGO Norton, John W. R., Lt Col, MC, Headquarters, Ninth Service Command Primer, Benjamin M., Lt Col, MC, Headquarters, Fourth Army, Fort Sam Houston, Texas Quinby, Shepard, MaJ, MC, Headquarters Personnel Distribution Command, AAF Riedel, Robert, MaJ, MC, Headquarters, Air Transport Command Schrader, Lester C., Lt Col, MC, Headquarters, Third Service Command Smith, William M., MaJ, MC, Camp Howze, Texas Smith, Williams., Lt Col, MC, Headquarters, Eastern Defense Command Tillman, Norbert A., Lt Col, MC, Fort Knox, Kentucky Towne, Wilson W., MaJ, SnC, Headquarters, Second Army, Memphis, Tennessee Tucker, Sidney N., MaJ, MC, Headquarters, Ninth Service Command Walker, Ralph J., Lt. Col, MC, Headquarters, Western Defense Command Ward, Edward F., Capt, SnC, Boston Port of Embarkation Weir, James A., Lt Col, MC, Medical Field Service School, Carlisle Barracks, Pa. Wright, James C., Lt Col, MC, Fort Jackson, South Carolina Wylie, Charles R., MaJ, MC, ASF Regional Hospital, Pasadena, California MORNING- SESSION - Ik FE&RUAHY 19^5. PROCEEDINGS GENERAL BAYNE-JONES: We are greatly indebted to the Third Service Command, for an opportunity to hold this meeting, the first meeting of preventive medicine officers probably in,the history of this present war. We are indebted further to the Command- ing General of the Third Service Command for a most understanding and supporting attitude to all. of the things that we have tried to do in the Army in his region and elsewhere to improve and-preserve the health of the Army. X have the honor of presenting Major General Philip Hayes, Commanding General of the Third Service Command, who ■will give you a word of greeting. GENERAL HAYES:, General Lull, General Bayne-Jones, Dr. Maxcy, Col. Strom©, members of the conference, I-want to •welcome you to Baltimore and to the- Third Service Com- mand. I and the Third Service, Command are very happy to have you here. At this time, I also wish to thank Johns Hopkins University for their part in this converence,- I want to say at this time, General Lull, that if at any time we can be of any. service to the Medical Corps-,;in. any way or wise, it is my pleasure to do .so, ■ U .I I personally am a great believer in conferences'. -Fortunately,; . - for me, my particular,:Command is so located that it is possible, in spite of the limitation of fifty .which is now in effect because of OBT, that several •.officers from time to time can-talk- things over. There is nothing like personal contact. You"can write and you,tan. lecture large crowds, but: you just don’t, get across what you can by a relatively small •■ conference and the time in' which the conferees . have to talk over their problems,- ■ I am sure that, for example, Don Hilldrup and Frank Strome some time during their time here togeth- er, will talk over some of their..problems, and life, of course, is Just a matter of problems. • ■ . .f • ' ; ' For you people-it largely concerns the'physical and the mental side. With me'-it is varied, but there are problems and they have to be solved and, of course, that is the basic reason that you are here. I think that from this war will come out a great number of improve- ments in education and that is what a conference like this is.' The value of getting together and the personal contact have been more emphasized in the last two or. tfyree years in every field than over has been before, so I am certain that from this conference you will get a great deal. ' I understand that your conference is on preventive maintenance, so to speak, preventive maintenance of health and body. All I hear is preventive maintenance of vehicles, or this, or that. It certainly makes sense. If we can get the preventive angle- into the situation wo are not going to have so many serious probfciie afterwards. I know, for example, Just as an illustration that carries along the idea, I use my Inspector General differently than the other ser- vice commands. I send them out to contact the people, the post, the camps, the installations, so that I can prevent trouble arising later and so that officers and enlisted men arc not going under some invosti gat ion from which comes some military trial or something like that-. I have found in that way that not only do I know a great deal more of my service command because of the Inspector General's help but also many an officer and enlisted man has been strainghtened out in his path, he has been given the medicine before he became ill and today has a fine record and a good standing. The same idea, I suppose, holds in this question of preventive medicine. It is a thing I firmly believe in and, no doubt, from your agenda., even from a layman’s viewpoint, it looked to me to be most comprehensive and the scope most broad. I have found; though, in conferences, that we have to be very careful about having too heavy a schedule because in haying too heavy a schedule you miss some of the opportunities of people getting together and talking over their problems, I looked at your agenda. It seemed to mo to bo pointed, pertinent and from it will come, I know, a bettor understanding and a clearer solution of the many problems which come up. I would like to say a word at this time, also, as far as my service command is concerned -- and I know it covers a much broader field than that -- for the superior work that every one of the Medical Corps from General Kirk and General Lull down, is doing. I know of no other service doing a greater work in a better way under situations that sometimes arc sort of nebulous. We are all going through this increased hospital load period, casualties coming in. You can’t tell how many people are going to be sick or how many men are going to be wounded. You have to estimate and then your estimate falls short and you go under pressure. More doctors are needed and you haven’t got any more doctors and more nurses arc needed and they arc hard to .got but somehow, some way the problem is being solved. It is only being solved because of the team work amongst you men in the Medical Corps from the very top right down to the post level and the station hospital level. I want at this time to commend each and every one of you, although I don’t know you. I know that you arc doing the Job. Sonic day there will come to you a realization of the inner-satisfaction which is the only thing that a great number of us who can’t get across will got out of this war and that is we say■the only one wo live with, the man inside of us. When wo satisfy him, wecan say to our- selves as the years go on, "Work well done." It is a great pleasure to be,here. I would like to meet you personally. I won’t have the opportunity but I hope you got a great deal from your conference. Thank you very much.. (Applause.) General Hayes withdrew at the conclusion of his address. GENERAL BAYNE- JONES: The Surgeon General has shared all of pur.problems. In the office of The Surgeon General, General Lull has' ’been equally.close to all of tho things that have grown. up in preventive nodicino and worked forward in'hie office and out to,all the rest of us. It is with a sense of honor and a feeling of very close tie that I have the privilege of presenting to you Major General George F. Lull, Deputy Surgeon General, who will speak to us now. General Lull. GENERAL LULL: General Bayne-Jones, Dr. Maxcy, Col. Strome, gentlemen, my word is a word of greeting to you from The Surgeon General’s office. As you know, General Kirk is abroad, in the South Pacific, so ho could not ho here in person. This war that we are all trying to fight, sometimes under great difficulties, has been influenced a great deal by the work that the men in preventive medicine have done and are doing. No one in the Medical Department can help but look with pride upon the results 2 obtained in the prevention of certain diseases- in this war as com- pared to previous wars or in the latter phases of this, war as com- . pared with the early stages. I think malaria is an excellent example of what was done on the jot. The Medical Department, I think, can take full credit for this.-. ■ . ■ ... ... Wo all know that the prevention of .malaria is not a medical jot in itself. It is a jot,for the commanding officer hut it has to he put in effect by the Medical Department and the Medical Department has to keep -needling everybody all down to line to see that it is . carried out . . That is the way with a great many projects that are put on hy the Modical Department. I don’t know whether you know the reason years ago for the regu- lation that officers over years of age should not take the typhoid vaccine. It was because of the General Staff that we had then,..a, . group of elder statesmen who did not know anything_about medicine hut they ran the Army, and they didn’t want to try this new-fangled vaccine of Russell’s hut finally hy wording the order so that no one over had to take it-they approved it. That was- put in not because of any immunity hut because the. General Staff was mostly in those days over and they wouldn’t have to take it. Those days, -fortunately, have passed, Others have arisen. We con’t havo: trouble, with* the old men now.; As a matter of fact , it is the young men who give us more trouble than the,old men,- The older men have been educated through the years and some of the older lino officers ..in the Army are the strongest supporters of this pro- gram. General Hayes has a grasp of the medical situation here in the service command and not only in the service command hut all over the country, - . ■: % ..., ■ ■ . ..... - .... , As I say, fortunatelyj ,many of our senior .officers have become educated so that they realize the important part that the .Modical Department plays in carrying out a.war. -The man who has boon up against something that the Medical Department has done, that is, if' ho has been wounded or if he has been taken to one of our hospitals or if ho has- seen some of the work that we do in the field, his attitude io altogether different, I remember taking a class down at Bcnning one time and they had a critique after the maneuvers. Wo were all in this big tent. One youngster got up and said (they had told them to discuss any- thing they had seen or ask any questions); "You know, I would like to say something. Up at Carlisle yc are taught that when wo are assigned as a battallion surgeon or regimental surgeon we will keep in intimate contact with the com- manding officer and wo will know Just where ho is going and what he is going to do, so we can lay our plans accordingly." Ho was told that that was right. Ho said; "My commanding officer wouldn’t tell me anything. He left mo in the dark." Another hoy got up and said, "My commanding officer kept nio informed of everything he was going to do, so I could go right along •with him.". ■ :'J b. ■ :.,. •, I said, "I will take.q,, guess on this. I may he -wrong hut,I' het the man who wouldn’ tell, you anything was a real young,-major and the other fellow was an older man who had boon in battle, himself." 3 That was- true, The mn who had "been through battle himself realized the- importance of having medical assistance at his right hand so that h©: could call on them, That is one of the things- that has happened in this war. The medical care that the soldier gets immediately after ho is wounded has been a big morale factor. I have told a story in the office a great many times. When General Kirk came back from Europe he was impressed with this. Ho said, "You go into a hospital and ask eight or ten men, ’How soon after you were wounded did you got your first treatment, your initial treatment' and they would say, 'Just as soon as 1 was hit’ , • or maybe’five minutes’, or ’as soon as the aid man could crawl up to mo.1" I told Morris Fishboin this and I said, "Morris, it is really wonderful how soon they get treated after they are hit.. Wo wilt • just ask one of these men," Wo had a fellow in a plaster cast before US. ' ■ . ■ . ;;; f , I said, "Son-, how soon after you were hit did you get-treated?" The follow thought a minute and said, "Two days and a half."-. Wo picked the wrong man. Morris laughed. Then the.boy explained that he was out in a foxhole and that no one know ho was there, and ho said, "it wasn’t anyone's fault. They just didn't know; 1,was there, I was caught out there and I .couldn't attract anyone’s attention,'" because if the aid man had known he was there ho would have gone out after him. That.is something that has boon developed in this war, these: excellently trained aid men who treat the man right on the ground. You might bo interested to know that wo have finally gotten some recognition for the medical men attached to infantry units. They will bp:awarded a combat badge of their own. They will not got.the extra pay, however. There is a bill in Congress to give them the extra-pay. .What you might not know is that in certain divisions on ; pay day the .men in the infantry, the doughboys, put their extra • • pay, back. on the table and then the kitty is dividedup ,them- selves . and .among the aid mon> That comes from the infantry soldier, himself, who does that, bccuaso they appreciate those splendid corpsmon who stay right with them and see that they get the proper treatment whore they.fall. We arc .delighted to think that we have gotten ca combat badge .for them and. we think this bill giving them extra.pay will undoubtedly pass. ■ yd ■ I don't want to waste any of your time and that is just what I am doing becuaso you came here for a conference. As General Hayes said, those conferences arc of the greatest value. You know, you issue a directive from The Surgeon General's office, even the good ones that General Bayne-Jones writes, and ho can write directives. He is very meticulous and he knows how, but ho slips up once in a while, because if you get nine people in the service command to road the directive, there is always some follow who puts another interpretation on it, I don’t say that in criticism. The man puts an interpretation on it because he honestly thinks so, and when he explains it to you sometimes you can see why he put the interpre- tation on it the way ho did. So it is almost impossible to write a directive that everyone-will see olearcut. We have so damn many directives, anyway, you can't road them. It just poans one more directive, but when you can get together and iron out your..problems and discuss what you are doing about certain things;, it is a big help, ■'fco not only you people .in the field but it • , k RESTRICTED is a Dig help to those of us in the office. Wo have had some con- ferences of service command surgeons and when wo can all get toget- her and talk things over -- it is sometimes not long enough Decause there are so many things that can De Drought up - I have come to the conclusion that the smaller the program and the Digger the time for discussion is the important part of these conferences. I appreciate being hero and I appreciate the--'fact that this group can got together and iron out some of thoir problems and pro- bably everyone will go away from hero having derived some benefit from the conference.. (Applause) GENERAL BAYNE-JONES: What .General Lull says about cutting through directives and getting at the heart of the matter must have struck a sympathetic chord in the breast of Gol. Stromo. Wo have found him to be a very direct person, immediately responsive, to any sort of inquiry about preventive medicine that-comes from our office, alert to preventive inquiries, and always a backer Of anything that we have asked him to do in the way of help in solving the situation. In addition, you should know that at the time of this mooting here, under the Third Service Command, there has been a spirit of hospitality and great assistance coming from Col. Stromo who, in the midst of an enormous amount of administration and detail of the Service Command Surgeon’s office that ho has had to handle, has helped us very much in arrangements for this mooting-, as ho has in tho development of preventive medicine in his service command. Colonel Stromo. , ; V: COLONEL' 3TLCME; General Lull, Goneral Bayne-Jonea, Dr, Masccy, follow officers, gentlemen,' it is a pleasure td to hero today and have a few words of welcome from General Hayes and General Lull. I think it is indeed fortunate that Baltimore and Washington are only kO miles apart ■because the'officers of this Command have a rare opportunity in taking part' in this,'what we con- sider a very, important conference,. : Wo hope you will have more of , them and I want to assure General Bayne-Jones, that if he plans any moro, that Baltimore, which is a very friendly city, is wide open to receive you and wo will make all the preparations.' I can assure you of that, , ■ .. ••• ’ I think there is going to bo another mooting hold hero in tho near future and wo believe that tho more sent to Baltimore, the more our men in this command will learn because it is impossible for them to got out to Chicago and tho other places whore these mootings are held. Of course, we would like to see a few meetings in San Francisco, especially the service command surgeons, where they could have a little trip, or down in Now Mexico, but an unfortunate paft of being near Washington is that you never get over kO miles away. I feel that the discussions hero today concerning malaria and other tropical diseases which are local -- the State health depart- ments are very much worried about them -- will be of value to all of us. As far as the state of Maryland is concerned there is no undue alarm. X understand that - in other communities and in some of our small towns in Maryland there is considerable alarm in the vicinity of tho prison camps. However, as General Lull said, ho was not going to talk long, I am not either, , 5 RESTRICTED It Is a pleasure to have you with us and all the facilities of the office of the Service Command Surgeon are open to you. We would he glad to see you at any time. My office - ■ only three can get in at one time - - is Room AlO, Tower Building. If you find any difficulty with your hotel accommo- dations or anything else in the town I would appreciate it if you would let me know and I will pass the tuck to Major Eddie Yinnicombe, who is the man who is responsible for the arrangement of this meeting today. You haven’t mot Major Yinnicombe but I hope'you will all meet him before you leave because he is the "fixer" for the Third Service Command. If there is anything more that we can do, General Bayne*Jones, don't hesitate to call us. Thank you. : GENERAL BAYNE-JONES: It is peculiarly fitting that we are able to have this meeting in the auditorium of the School of Hygiene and Public Health of Johns Hopkins University. We have around-us the spirit of Dr. Welch and all the men who were responsible for the development of much of the knowledge that we use nowadays and we are under the roof that has protected and has housed many of the leaders, important leaders of the public health movements of the country, " I am sure we will' get something out of that without realizing, in fact/ that we are meeting in such an environment. Dr ." Lowell Read, the Dean of the School of Hygiene and Public Health, was going to speak to us, as you noticed on your program-, but he is away. We have the good fortune of having Dr. Kenneth Maxcy, the Professor of''Epidemiology^,'-to spedk'rfor- the School- in place of - • Dr. Read. ■’ ■ : • ' urn , : -• 1 ■ 'Dr.; Maxcy is really one • of us 'In' more ways than you-' may- know. Maybe you’have-met him--out on a post. He is a member of what-we now •< call■the Army Epidemiological Board; He■has been out•oh many invest!- ■ gations in'posts and damps in. thisv; country. ' - - ■ : ■- • • V' - He went" over to •-New Guinea-and studied scrub typhus and he is a - soldier in-every way except 'the Uni form that- lie happens to be wearing right at the moment. I have the great pleasure and honor of presenting my friend and distinguished associate. Dr. Maxcy. (Applause.) DOCTOR- MAXCY: ■ • General Lull, General Bayne-Jones,- Colonel Strome and members of the Conference.: It is my privilege, on behalf of the President of the University and the faculty of the school of Hygiene to extend cordial greetings. We are certainly delighted to have you meet here and use the facili- ties of this school. This occasion has a peculiar significance to me. It brings back, for one thing, a memory of the previous war when I was a young officer under an old man on the Hill, who was Commanding Officer of -the-Base Hospital at Gamp Beauregard, General Lull, at that time Major.Lull. From my experience as a medical officer in the last war, I became interested in preventive medicine and have been so since. This occasion -- the gathering of these distinguished officers and the program which lies before you is to me an indication of the way in which this new, relatively new field of preventive medicine has progressed in the last 25 years. 6 We have come a long ways since 1918. In view of the fact wo have at times seen in the press some criticism of the policies of the War Manpower Commission and their effect upon medical education, I might first revert specifically to the article which Dr.-Graham recently published in the Saturday Evening Post. I presume many of you have road it. ■ It is gratifying to point out that although this may have an unfortunate effdct on medical education, there are ’contributions that the Army has made and not the least of these is in preventive medicine. I think all of us will agree that medical education can be improved in.the first place and so far as teaching preventive medicine It can be improved, by the example of the creation and organization of a Preventive Medicine Service in the Office of The Surgeon General. The field of preventive medicine has boon definitely delimited by the functioning of this Preventive Medicine Service, not only in the installations in this country but in those in the theaters of war and in the occupied countries preventive medicine has demonstrated its importance. The teaching which has been instituted or has been directed stimulated, you might say, from this service and its effect upon medi- cal officers who are serving in the Army will bo of great value in the public health, post-war period, I think wo might also point to the fact that the research which has boon fostered’by the Office of The Surgeon General has made contributions which will bo of lasting value,' These arc some of the assets. I think it is an interesting contradiction and a heartening one that in this period when human life is being destroyed on a scale that is hitherto unknown, that there is still a nucleus of interest and effort under The Surgeon General of the Array, which is directly toward the saving of human life on a:scale that is hitherto unknown. I wish to conclude with the cordial greetings again and welcome you to Baltimore and the School of Hygiene and hope that your conference will bo profitable in every sense of the word. (Applause.) GENERAL BAYNE-JONES; That' concludes the official introductions tut I can’t help wanting to introduce ono more distinguished officer to you. I will just ask him to rice up. I see Colonel Russdll Lee from the Air Surgeon’s office who has. come in. Wo’ aro delighted to have him. Col, Loo. (Applause.) GENERAL BAYNE-JONES: I am looking around for someone from the Ground Forces. MAJOR FEHLMAN; I am representing the Ground Forces. GENERAL BAYNE-JONES; That is right. Major Fchlman representing the-Ground Forces, Before I say-anything more, I would like to 'make a -foW announcements to you. (Announcements.) 7 RESTRICTED GENERAL BAYNE-JONES: General Hayes 'said what I would have said and. will say again about the character of this conference. Wo would like to emphasize what he spoke of as the infor- malities and frankness and discussion. You have a very heavy program in spite of the kind remarks that wore made about it.' This program was really cut down from a lot of topics that wo have had in mind bringing up hero and had to bo cut down from the extraordinary number of fine topics and questions that came to us from preventive medicine officers in the Service Commands. It is pretty full, as it stands. Down at the bottom of the page it says, approximately half of the time allotted to each speaker throughout the conference will ho reserved for open discussion. I hope wo can adhere to that.. I am.not sure how that may work out as wo go along hut wo do want discussion and there will ho plenty of it before wo got through, among yourselves and with those of us who come from Preventive Medicine Service in Washington. There is a notice at the end of the program, on the afternoon of Friday> the l6th of February, at 1330? there is a provision for state- ments by Service Command Chiefs of Preventive Medicine and representa- tives from the Army Air Forces, Army Ground Forces and the Office of the Chief of Transportation, concerning preventive medicine organi- zation and procedure. That may bring out a lot of questions and a summary of some discussions during that afternoon but wo would like discussion as we go along. There arc bound to bo a lot of questions that can’t be answered at the time they are brought up. We will do ■. the best wo can. Perhaps the people in this room can contribute answers. We will try in our record to keep track of the unanswered questions and writ© to you about them later or incorporate them in what I am quite sure is going to bo an adequate coverage of the minutes of this meetingt The leader of preventive medicine in the Army, who called this conference really and about whom we arc all thinking at this time ip General Simmons. I deeply regret his absence. General Simmons, I am sure, would bo thinking of us at this time with a feeling of regret at not being hero. Ho wont off with General Kirk about the end of January to go around the so-called Pacific Ocean areas. They have gone from Hawaii and gone out through Australia and through the Philippines, the Mariannas and will come back on a trip that will take them about two months. - oh. - : • .:;~fj It is rather symbolical of General Simmons .on the whole and of activity of preventive medicine in this war that ouch an expedition should be made into a theater reaching ,so far overseas. He will see many things; ho will bo able to give advice on the way. Characteristic of his' trip there arc a lot of -radiograms coming in from every place where.his plane lands and when he gets back we will know that we have plenty of new things to do in -connection with the preventive medicine program on the long step to Tokyo through Pacific Ocean regions, Southwest Pacific and all the islands and seas with which wo are concerned in that region. General Simmons would have great pride in seeing you her© today and ho would be able to say those things to you that I, as a poor - substitute, can’t say or convey to you. I think it would give him an extraordinary thrill to see, in the first place, the general recogni- tion of preventive medicine in the Service Commands and in the mili- tary posts of the country and in addition to see you and meet you personally and see the kind of people that arc carrying on this groat work in the Army. 8 Of course, some of you don’t know him and those of you who do know him can all agree in regretting not "being able to see him and get some indication-from him of what I think is a very extraordinary thing that we are privileged to live with in his office and that is his vigor, the great energy ho has, the devotion to the ideal of preventive medicine, the extraordinary courage and a quality that we doctors are- not always apt to have and that is an aggressiveness in""; the pursuit of-an ideal that is absolutely necessary in-the Army. It seems superfluous to mo to add anything in the way of welcome. I think what wo would express among ourselves is a sense of gratitude to all of you for having come from far places to this mooting with * us to give us an opportunity to talk face to face about many of the problems. You are front lino people in this country, Just as the preven- tive medicine man is front line man overseas. The.things that you are doing in camps and posts and headquarters in this country are really activities of front line troops against disease, Just as would bo abroad in the battle field. It is interesting to mo to look at the title of this conference. It is called "Conference of Preventive Medicine Officers". That is what General Simmons called the officers but I suppose wo might have called it Medical Inspectors, I bring that up because AR h0-200 calls you medical inspectors,• I would like to toll you a lit about the nano. We had for months "preventive medicine officer" as the min designation of what General Simons and the rest had in mind as the proper title for the chief ' man who would deal with preventive medicine in the post. It was written into the draft of that AR at some time in its multiple wan- ; derings through various concurring and dissenting offices and almost got passed as ''preventive medicine officer". Then there were objections raised to it at the very last minute. It was decided among other things that the title did not have enough power and finally everybody wont back to: the old title of Medical Inspector. They thought perhaps the term "inspector" would give you more of an operational standing than Just to be limited to preventive medicine officer. There is much to bo said on both sides. I am glad to see that this conference is listed here as "Preven- tive Medicine Officers," keeping for the moment, maybe, the proper ' designation that the Array regulation would have it called, because "Medical Inspector" loses out when we are really thinking.abour pre- ventive medicine*- That title keeps' the thought of preventive medi- cine in front of people by repetition. A.R. 1+0-200.'.outlines the functions of the Medical Inspector in general. This is one of the AR series that we hope in time.to get out in an-ofderly fashion, to bring the whole preventive medicine program of the Array more or less together in one place. Those arti- cles , Army regulations, you know, have been revised by cutting, out l' a whole lot of the practice of medicine arid the detailed procedures that' were so valuable, as I understand, to cavalry officers and 'Others in command"who' had read the old regulations of 1923 and later,, ..arid practiced-a little medicine by themselves. 'V There are; all sorts of things in those old regulations .that wore put’ there, I believe, because the Medical Department couldn’t find any other means of getting out a professional manual. ■ Anyhow, now ; 9 RESTRICTED they are much more streamlined and to the point, There aro now ideas in' then and'they, will to more serviceable, We have in preparation, a sort of preventive medicine manual. Colonel Leo had tho same idea, from the office of the Air Surgeon. Wo have loth teen talking it over. It is going to to a very diffi- cult thing to put together in one circular or regulation, all the kinds of things or training manual material, that you would like ■ to have at hand, tut we realize that you need something like that. ■ r You need a coordination and codification of all tho regulations that run over tho vast field in which you have to operate and in addition it will undoubtedly te useful to you to have in a sort of a manual a certain amount of technical detail that you my have at your finger- tips or easily accessible, When you sit down to write up ouch a thing, if you Just put down the list of regulations, you don’t got anything that is much worth while and if you go into a great deal of detail you come out with a tig took before long. Then you know that a lot of that is going to te changed in a short time. We are striving toward this objective and I think Col. Lee also, is still working at it, to get out something that is sort of a helpful preventive medicine manual for the officers so that they will know at least where to go for the things that they want through these intricate regulations. . -t '■ ; ■; .•••; The topic-that I have on this program to talk with you about is the preventive medicine program, of the Army. How to deal with it is a rather difficult problem for me, especially after looking over the rest of the program, because most of the program, the preventive medicine program in the Army, will come out from the reports that will be made to you by Directors of Divisions and from your own dis- cussions, and your own experiences, I should like to try to sum- marize in advance and say some things as to what I have learned about the preventive medicine program from my Chief, General Simeons, and I shall in the course of talking: with you about it quote from him without reference to him, actually using his own words, and many, many other times unconsciously and without knowing that I am quoting from my Chief . mv I think you could -divide, the..preventive medicine program of the Army into four main subdivisions; One of then would have to do With the mission of the Medical Department -in preventive medicine. A second night be called the attitude of the Medical Department and particularly Occupational Health’ Division, Medical Intelligence Division, Nutrition Division, Civil Public Health Division. Within the Preventive Medicine set-up, as you would naturally think, hygienenand sanitation is basic. This Division of Sanitation and Hygiene carries the routine load of sanitary and hygienic measures for the preservation of the health of the Army. Laboratories Division stands as an example of a thought that, has always been in general Simmons’ mind, namely, that laboratories are an essential agency of preventive medicine. Therefore, there should bp maintained a strong Laboratories Division of Preventive Medicine Service in the Office of The Surgeon General, the Service , Commands and in hospitals. Wherever preventive medicine officers have to work, they have to depend on a good laboratory. It has been a drive of the General to- have, .good laboratories. It is much to his regret and to everyone else’o regret to see Service Command labora- tories changed from their previous War Department status to a status that has made their futures very precarious and doubtful. Strong laboratories should exist everywhere and the laboratory man should bo on the top staff. Epidemiology is ohviously-there. Although wo may not know exactly what we mean by that word, wo .know what we do in the field of that work. . The Professor of the subject (Dr. Maxcy) is here. However, I know another member of his faculty who thinks that the word ought to bo abolished because it has no deep, regular significance. What wo mean in the field of epidemiology is infectious disease control and the analysis of statistics and it has to do largely with infectious diseases.. In this curious organization, however,, wo do not include all tjip infectious diseases under Epidimiology Division. The next that stands out.here is a Tropical Disease Control Divi- sion which uses all the epidemiological methods. The Divisions of 16 Tropical Disease-Control and of Epidotiioib£^''aix3';''3ioua©d close toget- her, Tropical Disease Control is so important to the Army now that it has to he represented by a separate Division. Sanitary Engineering on our chart appears between Tropical Disease and Venereal Disease Control, mostly, I think, to separate it from the word "sanitation" in the title ©£’tbr Division of Hygiene and Sanitation Sanitary Engineering represents a profession of the people who are dealing with supplies and the purification methods and all the engineer- ing phases -- and much of the engineering phases of sanitation. It has a very-distinct field and has been maintained as a separate Division in Preventive Medicine Service over since General Simmons started his organization. Venereal Disease Control is sot off from Epidemiology because it is a tremendously specialized subject and deals so much with public end other relationships. In an Army program, extending as we do outside Army cantonments and fields, venereal disease control extraordinarily and clearly represents the type of preventive medicine work going on in'the Army that is affecting civilian communities at the,, same time that it is -aiding the troops and aiding civilian coimaunities at the same time that it is affecting regulations and' behavior of the troops. Occupational Health is a new activity that has boon developed under General Simmons, It arose naturally from consideration of the exposures of people in ordnance plants and privately operated plants. It has grown enormously. It is responsible for-the War Department ’s highly enlightened attitude and plan for industrial medicine in the country. I believe there is no contribution in the .-.field of industrial medicine- that will equal that which has been rr.de -under .Col, Lanza and Preventive Medicine Service during the war in dealing with the problems of people employed in plants of all kinds engaged in war work a breadth of view has been characteristic of.this whole develop- ment. The relationships extend far beyond a troop-.‘basic clear out into communities and legislative bodies. They involve many other considerations than just the affairs of the Army post or group of mili- tary people that arc locally concerned with 1a problem. One -might say the same of Medical Intelligence., That Division grew to meet -the need for assemblage and dissemination of the know- ledge of sanitary and'medical conditions'in all countries and areas of the world. This Division has served,not only-.the Office of the Surgeon General but also the whole Wav Department, ■■There were no such things available as the surveys that have come out of this Division having to do with health conditions and living conditions and' the characteristics of the 'countries to which troops c ould- -bo sent I Nutrition Division has recently been added. It. is of vast importance for the, proper"care of, the troops. Wo will have much dis- cussion here., probably, -endeavoring to work out relations .between the .Quartermaster and the Food Service of Divisions of the War Department, and’other problems, - » ; Civil Public Health Division was formed very recently, within the past year, so that the Surgeon General could live up to certain that have always been on the Medical Department but never in such force and never properly handled until this war. That is the responsibility of the Surgeon General for the-health and care, to some extent, of people;in occupied, and liberated countries, which come under jurisdiction of #oir Army. You will hear more of what that Divi- sion is doing in relation to the Civil Affairs-Division, of the General Staff when Col, Tumor and his associates speak to ydu. That, in gene- ral, is an outline of the organizations. 17 I would just like to conclude with one or two remarks about qualifications of the personnel. The qualifications seem to me to be of two main types. One of those is professional and educational qualifications. It seemssbest that the preventive medicine officer be a medical officer because his long training should be in lines of medical thought. As a medical loan he has a basis in the tradition and the continuity, of knowledge that is activating him unconsciously. I am laboring this point a bit because everyonecknows that the training alone, medical training alone, does not fit a man to be a good officer or a good preventive medicine officer. In fact, it can ruin him. Some men who are professionally trained are either by disinterest or by the actual kind of training that they have received unfitted to be in preventive medicine. They are unhappy and they don’t know what to do and they are not concerned, really, in get- ting results. . r On the other hand, we have conspicuous examples of men who have had no medical training who are very able in the field of preventive medicine and have the thorough confidence of their commanders up to a point where a medical professional problem would he involved. They are often better men in preventive medicine than some of the better medically trained officers. However, as a basis of training for preventive medicine I believe we agree in friendliness and frankness among ourselves that a basic medical training is' the main thing to look for. That has been so specified now after a terrific battle, so that the medical inspector is to have the qualifications that are briefly outlined in AR 1+0-200. Beyond education and training let us go back to what I said about interest and attitude. In the field in which you are working you have to fight a battle all the time to get the things you want, done, to get the ideas over that you wish to put over and to defend the troops against the attacks of disease. , In preventive medicine officers you look for qualities of interest and courage and energy and devotion to the ideal of the preservation of the health of the troops. If I may quote, in conclusion again from'General Simmons, he said at one time that execution of the preventive medicine program is a responsibility which'must be shared by every individual in the entire military force. The effectiveness with which it is exe- cuted will depend on thp intelligence and zeal with which the in- dividual medical officers carry out the primary mission of the Medi- cal Department, finally, het said; "I. hope.you-Will remember that the successful medical officer is one who. exerts every energy to protect the health of his troops. It is important to cure the Sick, but it is more important to prevent sickness," I think many people would agree with that entirely. Wo know that in the meetings that we.are going to have here during those next two days a lot of matters requiring correction will be mentioned. These will be matters concerning' the health of the troops and matters concerning our own relationships,’ rwant to say again, that wo' are very proud to have you accept the invita- tion to come here. Wo hope we will talk together freely before we got through. (Applause.) GENERAL BAYNE-JONES Before we start off, I see two of my distinguished friends'from Canada hero, Major ueufold who is a liaison officer with.the'Canadian Army Medical Corps and Major Leclerc, fr0m Ottawa.. (Applause.,-)- . 18 The next topics are to he presented by Lt. Col, Arthur Long, Director of Epidemiology Division, , He will speak on immunization pro- cedures, the now immunization register, and Diptheria control. Ho said he thought he could do it all in a half hour so you could talk hack to him. Col. Long. Before the Colonel begins, may I ask you if you have questions to ask, will you please give your name distinctly and the post, so that the lady can get it down in the record. INFECTIOUS DISEASE CONTROL, IMMUNIZATION PROCEDURES - NEW IMMUNIZATION REGISTER - DIPHTHERIA CONTROL. LT. COL. ARTHUR P. LONG, MC, DIRECTOR, EPIDEMIOLOGY DIVISION. COLONEL LONG; General Bayne-Jones, follow officers; It is quite a tig order to attempt to present anything like a complete discussion of the immunization program and'in addition to discuss diphtheria control all in thirty minutes. I don’t Believe I can do it as a matter of fact. I will ask you to hoar with no if the things that I have to day seem to ho somewhat disconnected and hurried, I will go along rapidly because wo are extremely anxious to hoar'from you people. I feel that wo will derive much more benefit from, what comes from your experience than from what I might have to say. I will, therefore, ho very brief in my discussion of the immunization subject. The various immunizations have been separated for administrative purposes into whqt we call routine procedures and the special pro- cedures. The routine procedures, include the‘basic three, smallpox, typhoid and tetanus. Tory little needs to be said about those pro- cedures. I would, however, like to point out a few recent changes in the administration of these and to emphasize certain important features of their application. Ofccourse there has been no change in small- pox’ vaccination methods. However, I would like to emphasize or rather to ask you people to continue to emphasize to the individuals with whom you come into contact the necessity for continued attention to vaccination techniques, the proper interpretation of smallpox vacci- nation reactions and the proper care of the vaccine. As a matter of fact, there has recently been some Indication of unrecognized vacci- nation failures. Following re-vaccination some individuals have res- ponded with primary reactions, those individuals having been vacci- nated a year or less before'. That can mean only one’ thing, failure of’ the original vaccination. The Army experience with smallpox is oxtremctly satisfactory. Within the last year there have been leas than one hundred cases reported from the entire Army. I an talking about overseas troops as well as those in this country. However, among those cases that have oc- curred, there has boon very good evidence to indicate that there have been failures of vaccination. There have been in many instances im- mune reactions entered on their immunization records which moans, misinterpretation of the results of vaccination. Col. Callendar will bo with us later today and will go‘into considerable detail on ty- , phoid and paratyphoid vaccination. 19 There is one fairly recent administrative change that occurred a year ago or thereahouts. That was the'adoption of the half c. c. dose annually as a stimulating dose, taking the place of repetition of the three doses every three years. . One other change has heon the acceptande of. longer periods be- tween individual doses of typhoid vaccine. It is now recognized that it is quite acceptable to give typhoid vaccine at intervals of seven to twenty-eight days between the individual doses. I an talking now about the basic series, of course, This was done to bring it into harmony with the tetanus immunization so that it would not bo neces- sary to bring a nan in so many different times for the basic immu- nization. Now tetanus toxoid and typhoid vaccine may be administered at the sane times. The other one of tho routine procedures is .tetanus immunization. I -would like to emphasize that only one routine stimulating dose,is required. This dose to he given at tho end of tho first year after the basic series, Wo fool it is not necessary to give a dose of tetanus toxoid every year. There has been some misunderstanding about that, I am sure. The former requirement that, for men going, overseas, a dose of tetanus toxoid bo given within six months prior . to their departure has now been done away with. There is no longer a requirement for that six months dose of tetanus toxoid. I think wo are on very good ground on this rather minor change of policy. Wo have tried to follow the response of individuals, im- munized to tetanus. Wo know very well what happens to then at the end of the first year. When they are given their stimulating doses, their titor immediately rises'to and beyond the protective level of circulating antitoxin. Duo to the very excellent cooperation of Col. Carroll of tho First Service Command I an able to report today results ho handed me Just five minutes ago of a study that wo had instituted in tho First Service Command, A group of individuals had received the basic, tetanus series over three years ago and their annual-, stimulating , dose at least two years ago. They have received no totanous toxoid then for.at least two years. Those individuals wore given stimulating doses'of toxoid. In every instance they responded .very wll. ..Tho resulting concentrations of antitoxin in the blood,serum wore well bpyond what they actually required’for protection,. It is of considerable interest to note that the level of anti- toxin two years or more after the routine stimulating dose was, in most instances, adequate for protection. Many, of thorn had at least throe-tenths of a* unit of antitoxin in their blood to begin with. When they wore stimulated they' -they wont. up ton-fold, some of then. One, I think, wont as high as thirty units, which is well beyond anything that might bo hooded for protection.- Of the special immunization procedures, those most commonly used,are, typhus, cholera, yellow fever vaccinations and to a lesser extent, plague vaccination. There have boon very few deviations from the original policies governing these immunizations.. One re- co.ntly adopted was a change in administration of typhus vaccine, changing from three to two doses. In tho presence of typhus fevor, tho administration of stimulating doses on a.seasonal, rather than on a calendar basis is recommended,- In. other words-,- in an. area whore typhus fevor is present, the stimulating, doses might well-be given at,tho beginning of tho typhus season and aboutin the middle of tho typhus season, perhaps at the beginning of November and again in .February. 20 It maybe of some interest - to report the Array experience with these diseases, typhus, cholera;’ plague, yellow fever. It has teen very satisfactory. There have been .a. total of fewer than fifty cases of typhus fever reported from the entire Army. There wre no cases reported in as far as we know. S \ ‘ '• ... There have been no cases reported of cholera, plague or yellow fever. This, perhaps, is another example of what General Bayne-Jones spoke about earlier. We have had no problems with those diseases; therefore, perhaps, there are those who say, why go on through all of tho hocus pocus of vaccination, wo have had no diseases. The other special agent which might have been used rather widely or which may still be used widely is the new influenza vaccine. ’ Brief- ly, this, as you know, is a bivalent virus vaccine containing viruses "A’*' and "B," You know tho background of Its development, I believe, pretty well. I won’t go into It’in any detail except to say that in tho experimental group that was used, there was very good evidence to indicate that disease in tho vaccinated was a quarter or a third of that experienced in the controls. Wo still, of course, do not know what type of virus that we had confronting us in 1918, so that there is no absolute proof• that tho new vaccine would be efficacious in tho presence of a sovore epidemic of that kind. There has been none of this vaccine used to date in troops. It is now becoming available in fairly largo quantities. Wo have already shipped small amounts overseas. It looks now as if the season is pretty well passed and wo'will not have to use it this year. .' There will be adequate supplies, however, for use next year, should, the situation present itself,' ,In that respect, wo would like to emphasize tho fact that it is extremely important that every*one of us bo .on our toes to ferret out possible outbreaks of influenza. ' This flu, vaccine‘is specific for virus A and B. It is felt it is not wise to administer a vaccine of this kind in general with the hope of hitting whatever virus might come along. The policy which has been established, then, has been to administer it in tho face of a known or impending outbreak of influ- enza, A or B. There are various listening posts established through- out the' country where there are available the services of the con- sultants of tho Army Epidemiological Board, If at any tine it appears to any one of you people that there is a possible influenza epidemic, if you' will get in touch with us by telephone or telegraph or any way you wish to do it, tho services of those specialists can be made, available. They can bo of great assistance in establishing diagnosis early. This time factor is extremely important if vaccine is to be, of value in preventing or checking an epidemic. I would like to mention tho availability of an .immunizing agent for measles, emphasizing again that we have no active Immunizing agent for measles but we do have a fairly large supply of immune scrum globulin. This is not placental extract. It is probably more effective' than placental extract and gives fewer reactions. It is not adapted to widespread use, -- It is a passive agent. Immunity from its use lasts two to throe weeks only. It is administered in rather large quantities, 10 cc, given intramuscularly, -- All of those are against its widespread use. Whore you are dealing with debilitated individuals, who have been exposed or for military reasons it is ab- solutely essential that exposed people not come down with measles or in case of. unusual exposure such as on crowded transports, this agent mi gilt well Have a place. In submitting requisitions for immune scrum globulin the use: should bo indicated. Wo have tried not to disperse it widely for non-essential uses. 21 One agent that is used not, widely at all hut concerning which questions arise every spring is Rocky Mountain Spotted Fever Vaccine. There are available very limited supplies of this agent. As you know, we have never recommended the mass vaccination against Rocky Mountain Spotted Fever. Rather, it has been felt wise to rely upon othdr pre- ventive practices such as the avoidance of ticks, careful inspection of people in the area where ticks may bo found, early removal of the ticks, and so forth, remembering that a tick does have to bo attached four to six hours before the disease is transmitted. Further than that there is still controversy about the absolute value of the vaccine in preventing the disease. It my veil prevent the disease but it probably very definitely will ameliorate the symp- toms of the disease once contracted. Obviously it is of no value for treatment. The vaccination has boon, then, in general, limited, because-of the limited supply. It has boon limited to those sub- jected to special hazards, those who are unavoidably out in contact with brush in tick country such as patrols, guards? and so forth. Wo had a certain amount of this material made available to us from the U. S. Public Health Service. For purposes of administration certain portions were subalottcd to the various Service Commands, I am sure you arc all familiar with that. For exanplo, the third, fourth, seventh, eighth and ninth Service Commands passed upon re- quisitions reaching them from posts and stations within the Service Commando, If they felt the use was indicated, the request would then be forwarded to the Rocky Mountain Laboratory and the vaccine sent out to the post in question. Requests from other than those Commands wero forwarded to the Surgeon General's office. The procedure will be continued this year* the same as last. Just what amounts will bo made available I don't know yet. Wo would approcio.to it a great * deal if in the Service Commando there is an apparent reason for changing the amounts or for changing the method of distribution of spotted fever vaccine ovor that of last year, you would lot us know at your earliest convenience, It is going to be necessary to make the arrangement for this year's supply ‘with the Public Health Service very soon. You may bo interested in the Army experience with spotted fever. In vo had 37 eases reported, whereas last year wo had only 15 cases. In 19^3> for example, there wore eight cases from tho Seventh and eight cases from tho Ninth Service Commands, whereas last year there wore none from tho Seventh and none from tho Ninth and two from the Eighth. The others wore scattered in the First, Second, and Fourth, Because there has boon an increasing interest recently in diph- theria, I would like to go into some detail in discussing this disease, not because I have in my pocket the answers to control of diphtheria in adults, but because I wish to stimulate some discussion from you people in tho hope that some of you will have tho answers to give me. Tho early interest in diphtheria, as far as tho Army was con- cerned, began about a year and a half ago, when wo noticed the in- creasing, incidence among civilians in Northwest Europe,- v© wore thinking then about tho invasion of Europe and wo had concern parti- - - cularly when we realized that, in the Netherlands, for example, they wore having about as much diphtheria in a month as they normally would have in a year prior to the invasion. It- is comforting to know that despite this increase in diphtheria’ in Europe tho problem has not been a great one in the Army now occupying France and tho other countries. There is somo diphtheria, but it is scattered. There aroo relatively few cases. It has hot reached anything like epidemic pro- portions so far as I know in any of tho units. • : ■ 22 .There has, however, been considerable diphtheria. I don’t think it is fair to say epidemic, let’s say small outbreaks in the Medi- terranean area, Middle East, South Pacific and the Asiatic' Commands.' Recently wo had some reported from Burma, Now Guinea-and Saipan. This" incidence is extremely interesting because here Wo are getting a disease not normally connected with the tropics but hero diphtheria, as far as the Army is concerned, is becoming a tropical disease. A great many of these cases are cutaneous typos*of diphtheria tut they arc interspersed with the nasopharyngeal type. We think we know a little hit about the susceptibility of our troops to dlpthoria. About a year ago a very careful study was cot up and carried out on repre- sentative troops in this country. They were just about ready to go overseas. They wore not recruits and were a pretty well selected group. From that study we determined that about porecent of the troops are susceptible to diphtheria as measured by the Schick test. There isn’t time to discuss what the Schick test means', even'if I was awfully sure about it. It was interesting to-note that,- as wo expected, troops from the Northeastern and North Central States showed the highest susceptibility rate, whereas those from the Southern, particularly the Southeastern States, showed the lowest susceptibi- lity rates. In other words, those troops from areas where there has-been little or no diphtheria over the last few years , and whore there- have ’■ ’ boon good immunization programs have a high susceptibility rate. That sounds paradoxical but actually it is not,* of course, because with low incidence of diphtheria, with a low carrier rate, no natural immunity developed. In the South there has boon diphtheria, high- carrier rates, exposure and experience with the organism. Therefore, lower susceptibility rates from naturally acquired ’immunity. A word about the Schick toot and its'applicability to diphtheria control among troops. It Is, of course, a useful procedure in dis- tinguishing as well as we can between the susceptible and 'immune. It is not fair to say that all Schick positive individuals- arc sus- ceptible to diphtheria. Some may have a latent immunity-not measured' by the Schick test. Wo can’t go into that detail. But in general for working purposes you can differentiate arid divide your people into those two groups. However, the Schick test is not a simple pro- cedure. It is time-consuming.' The results must, bo'road at 72 hours. They should preferably bo read at'it-8 and. 72 hours in order toj pick up the differences, ’ . ... Interpretation of the Schick test is not a simple procedure. It requires a good bit of experience end understanding.. There 'is a fair chance of loco of potency of Schick tost material. That often is not understood. When you see a Schick test survey’done- and when the results show a very high degree of immunity perhaps you bettor question the potency of the Schick toot material. This study that wo wore Just talking about, the first Schick test material wo got had fallen off in potency about 25 per cent, Schick tost material is standardized quite precisely (l/5 Guinea Pig MLD per c.c.) and it is a very dilute toxin arid really quite fragile. In addition, it requires very careful intracutaneous techni- que, itwo injections being required; that moans you have to do an intracutaneous injection on each am of each individual tested. All of.this for large volumes 'of troops, particularly under field condi- tions, has led us to the fooling that in many, many instances, the Schick toot Is not a practicable procedure to bo used for diphtheria ■ 23 control, I don’t wish to give anybody the idea that wo would like to throw out the Schick teot entirely; that ic not go; but for large groups, where wo are dealing with a lot of people, whore tirio io of the eoGence and where you don’t have a great many well-trained, ex- perienced individuala, the Schick toot my well not bo a practical procedure'. • - • ■: For immunization to diphtheria, the mterial that we have, is diphtheria toxoid. Wo believe that fluid toxoid should be ucod in adults. It Is an'extremely difficult problem, however, to immunize adults to diphtheria and this procedure should not bo undertaken lightly and without very careful consideration, Quito severe reac- tions occur in a high proportion of the adults. The local reactions experienced are edema,- induration often a very bad-looking am with bluish discoloration. You my get a whole arm with a sort, of brawny, bluish edema and induration. General reactions' are characterized by malaise, head- aches and elevation of temperature which sometimes goes very high. These reactions tend to come on early and are, in general, just as severe or a little more sevorc than those experienced with typhoid vaccination. Because of these reactions the best method that I know about, is to take the group concerned and administer to each individual what-, wo•call a reaction tost dose of ono-tenth of a c, c. of toxoid under the skin. Wait then about 1+8 hours. The reactors you will know about. They will bo coning in. Anyway at the end of 1+8 hours they.should bo inspected and examined and those who have exhibited severe reactions should be dropped- entirely from the program and then go ahead and start the regular"scries beginning with a half c. c. and then two other doses,'one’ c,c,’each, administered at approximately weak intervals. The results that you can expect from this method arc not too happy, as far as reaction that you will got. If you follow that method, between 55 and 60 per cent of the group will finish the series. They will have gone along: without enough untoward reactions to have • warranted dropping then out. Between 15 and 20 per cent of the group, however, will have had sufficiently severe reactions to warrant treatment either in quarters or in the hospital for a day or two,. When-you are through, then, you have not immunized your entire ■ group . You have completed the series in 55 to 60 per cent but you will: have raised the-general level of Immunity, ■ It. will have.reached certainly 80 per cent or higher. It is well to remember that the.- small dose, the reaction tost dose will, in.-Itself, stimulate .immu- nity in a certain number of those individuals and those ‘arc the, people that I talked about earlier who have a little■latent immunity that night not even bo measurable by the Schick test. The decision to' immunize is extremely difficult. Certainly with the reactions experienced from immunization one is n$t warranted in immunizing a whole command or other group on the occurrence of an occasional case of dyphtheria. This procedure should bo undertaken only from the presence of definite indications of spread of the disease within the Command or components thereof, I think there might be instances where you might want to split a command and immunize only certain portions. I don’t have any golden rule to follow. I can’t give you any rule of thumb to suggest when you should immunize and when you should not. I have something here that might be used as a guide, I would bo 2k qIoA to havo you kick it around a tit.- Ac I cay, I an not laying it down ac a golden rule. Adniccion ratoc for either or loth forms -- I an speaking of the cutaneousror'nasopharyngeal forme -- of a hun- dred per thousand per annum in organizations say of .10,000 or there- abouts night be an indication. That would mean that you: would havo 20 cases per week in a group of 10,000. If you had. a situation like that and you could see that this , was spreading within the comnand, I would give serious consideration to immunization, However, if you have a very snail group, cay, 1,00Q or loss, you night-want to step up that required incidence to say 200 per 1,000 -- that would bo four cases per week in a group of 1,000, or again, even enlarging your organization to say 20,000 you night want to bo a little norc conser- vative , In many instances the admission ratoc probably won’t help you very much and again you havo to rely upon whatever it is that an epidemiologist relies on to determine whether the disease is spreading in the Command or whether it isn’t. It is pretty nebulous and pro- bably this isn’t very helpful. One word about passive immunization,against diphtheria. It is extremely difficult to visualize a situation in which passive immuni- zation, using diphtheria antitoxin for protection, is indicated. I can not think of any offhand. Remember, the duration, again, is two to three, weeks only. There is always danger of serum sickness. It is indicated very, very.seldom, I an sure. There are certain other methods for diphtheria control. I would like to emphasize one thing. ,Wc all know the importance of physical inspection, early treatment and isolation of all communicar-• blc diseases, including diphtheria. I would like to emphasize that cutaneous diphtheria, must bo treated exactly the came way in that respect as naso-pharyngal diphtheria. There has been one instance, for example, where canes of cutaneous diphtheria, were, admitted to a hospital skin ward with resulting secondary cases among other patients on the ward, . . Major Tucker is with us from the Ninth Service,.Command and I hope that ho will give us the benefit of come of his experiences on : the. West Coast where some of these cutaneous diphtheria cases have been coming in from the Pacific. It is extremely,,Important- to main- tain this physical Inspection for at least five days after tho date of tho last contact. -Certainly close contacts should bo excluded from food handling, if possible, until it can bo shown that they aro not carrying.organisms, The treatment of diphtheria carriers has always "been an extremely difficult problem to deal with. It is just the ;came today as always.. We. have one small hope coming up on the horizon and that is penicillin. Before. I,mention it' further I would like to emphasize again, I am sure, unnecessarily but because I .am never able to talk about diphtheria carriers without emphasizing it. -Antitoxin is of absolutely no value in the treatment of diphtheria carriers and should not be used as such» • , ■ ■ We have a very limited experience with the use. of penicillin in the treatment of diphtheria carriers. I bring it up because of tho fact that our experience is so limited that wo are anxious to beam of,other experiences. ■ We know that the diphtheria organism is sensitive in vitro to penicillin though loss,, perhaps; than some other organism#. . . „ ,:- 25 We have been able to collect a series of 2h carriers treated with penicillin, some systemically and some locally. There .is nothing consistent about the dosage, nothing much consistent' about the method. I mention it to bring up a discussion and to ask that if you have any further experience or hear of any, it will be forwarded so that it can be made available to all concerned. Maybe with that we con find out whether-penicillin is good for this purpose nr not. Of these 2h carriers, results indicated that there were repeated negative cultures in 19. Now, the duration of this negative state is not known, . . Of one group of 16 carriers, nine were kept as. controls. They were given saline gargles and of those four because negative spon- taneously, That is the weak point in the whole thing. Five remained positive for 16 to 2.1 days, than were treated with penicillin locally, using nose drops which contained- 'jOO units of penicillin per c. c. They then became negative, Of the seven treated all became negative after five days of treatment, .. • • ■> On the surface that particular study looks pretty good but don 1 t forget we were over enthusiastic about gentian violet and other things. Perhaps penicillin will be the‘answer. y am putting up, a plea'for further information. One problem has arisen, and that is the return of troops With cutaneous diphtheria and other types of diphtheria from overseas. It has been handled very well I would like to congratulate the people on the West Coast, who handled it. It is very important that the post to which incoming troops are to go be notified of the presence , - of cases among the group returning. This, is particularly important with respect to groups returning overseas because those people fan out very rapidly, as you mow. ' Also, the post should be told of the existence of cutaneous ■ diphtheria among groups returning. This, of course, means the noti- fication of the reception stations to which these groups are going. The one Incident that has occurred worked out very favorable, A group came in to San Francisco,.I believe, and they very quickly and properly notified all the reception stations to which these people were going. The reception stations then could pick up the physical inspection of contacts where it,left off aboard ship. Here is the plane where it may be necessary to deviafe from the general policy that has developed over the last two or three years, namely the discouragement of working quarantine, As you know the value of quarantine has been largely discounted in the prevention and control of disease. We feel it is not very effective. At the reception stations, however, it is a slightly different situation and it might, under*certain circumstances, be desirable to detain these people for . a .days so that the physical inspection'and the picking out of any hew cases could be accomplished. In other words, it is better to hold them there a few extra days than to let them go home in the incubation period of diphtheria. . ..■ One minute and I am through,.. I Just want to mention the fact' that there is now a new immunization register. You all .know that.the old Form 8,1 and the method of handling it have over the past years become rather unsatisfactory. We feel now that both have been improved, both the form and the method of handling. The new form is the immu- nization register and other medical data, and the new number is W.D. A.G-.O, Form 8-117. I have copies of this register and they will be available for you later this afternoon. Instructions for use of this register, the method of handling the entries, and so forth, 26 are given in War Department Circular 32, dated 27 January 19^5• I also have a copy of that for you. The important points of difference "between new and old 'forme and the new method of handling are briefly as follows; Row' each' individual, enlisted man and officer, will be given a copy’ of* the 7 immunization register. All new/pe^^el^-will be given a copy of the.'' new form and beginning right how,"" authorized'by this War Department circular, all others, all enlisted personnel, are to be given a. copy of their 8l, which is now filed with the service record. The duplicate of the form for the enlisted men will be filed with the service record and for officers,. the duplicate will be filed with the Form 66-1 - 66-2 - or 66-3. That is the departure, 'There will be no copies retained with the records of the station of which ,, the immunization is done. No other entries.will be made in the serv- ice record. They will be made on the form and that will be filed with the service record. ' Here is something that will take a load off the medical officer. The personnel officer, (unit administrative officer) is responsible for initiation of this record for officers as well as enlisted per- sonnel, for maintaining complete copies and issuing duplicates in case of loss, After you have a chance to look over this record this afternoon, and the War Department ciraular, if you have any specific questions there will be some one of.us here who will try very hard to answer your questions. If we can’t answer it we will try and find someone who can. GENERAL BAYNE-JONES; The whole diphtheria question is open for discussion. Do you want to say something about diphtheria? MAJOE TUCKER: (Letterman General Hospital, Ninth Service Command, San Francisco, Calif.)General Bayne-Jones, Col,. Long, and fellow officers.. I, would like to take about five minutes to support what. Col. Long has said about diphtheria in general and tell you about some of our experiences at Letterman General Hospital with the increase’ in diphtheria cases that come on in . , . September of and has continued up to the present tiem. I think most doctors become bored when they hear some other, doctor talking about his own cones but I think you will find that the situation is one that presented a problem we knew very little about and from which we have learned many interesting facts', if not the final facts. In September of 19ht, having seen no cones of. diphtheria but one in three and half or four years, four cases of diphtheria appeared in-...... the Command at Letterman General Hospital. One was a nurse, .one was a patient and two were enlisted men,_ .all of whom worked• or were housed in the. Same Ward, the ward set aside for dermatology. At that time I could see that -- having seen all the cases -- the common denomi- nator, at least with regard to place, was the dermatology ward, so naturally the next step of action suggested itself in going over to the dermatology ward and finding out if there were any more cases, or where'this thing started. The first thing we did was to ..take nose and throat cultures on all the remaining patients and personnel assigned to,the dermatology section and were misled by a very peculiar thing. All of the nose and thro.at cultures were negative in 2U'hours. 27 For the next four weeks no new cases arose and so it settled back into what I might call epidemiological comfort, and we said "this was probably.just a sporadic thing. Perhaps one of the cases of the four was the original source." That brought us up to Septem- ber 27, and no new cases came out and about October 15th we got two more cases, of diphtheria, in the same ward. These were both in- patients who had returned from overseas. Within the next few weeks the diphtheria went up to between 12 and .15 and was scattered among patients who,had returned from over- seas and members of the Command, A first reaction was to go back to the wards, find out if there were any carriers and we got nose and throat cultures on everybody in sight and found that about twenty- six now had positive nose and throat cultures ,but that of the 26 positive nose and throat cultures, approximately 35 per cent did not show up positive until b8 hours had gone by. That was something that we couldn’t understand because our past medical school training had seemed to suggest that the media will show whether you have diphthe- ria from 18 to 2k hours or you just haven’t got diphtheria. . Cases kept coming in then and we traced them directly to patients arriving from overseas. We had all sorts of cases, nasal diphtheria, naso-pharyngeal diphtheria, and one case an officer with nasal diphtheria, two small ulcers in the inguinal region, from which we also cultured diphtheria bacilli. We went back over to the ward every day and tried to find out where these cases were coming from, be- cause practically all of them arrived with the diagnosis of dermatitis from overseas and for that reason had gotten over to the dermatology service. One. afternoon walking through the ward I noticed dessicated skin on the floor mixed with dust. Many of the patients having severe exfoliative dermatitis, it kept the poor wardmen busy keeping the ward clean. I got some of this dust off the floor, mixed it, took it down to the laboratory and to our great surprise on a direct smear -- just shaking up some dust and skin in saline -- we found an overwhelming number of diphtheria bacilli. That suggested a possibility that the diphtheria bacillus was being carried on the skin or at least since cases had been on this ward, that they had deposited the diphtheria bacilli on the floor in the wards. At that time we had no knowledge whatsoever about what was going on overseas or whether anyone was finding diphtheria cases anywhere else. We got cultures from the skins of many soldiers returning with exfoliative dermatitis’ hut were unsuccessful in finding this again. Whether it was due to the fact that the original finding had been Just a contamination from a diphtheria patient, a pharyngeal case or not, I don’t know. The cases appeared in the Command with about the same regularity as they did with the ships arriving from overseas so it was brought to General Hillman’s .attention that, this was getting out of control and it would be necessary, in our installation at least, to protect the Command and also to devise some means by which we could isolate the .patients who came off the ships, We had a conference and decided that the worst thing that we could do would be to take mans nose and throat cultures on the men returning from overseas. I had considerable difficulty in getting this idea across because having been in other diphtheria epidemics, I knew of the mess that you get into. You get so many positive nose and throat cultures that the more you culture the bigger it gets and the deeper you go and there is no end to it and you accomplish very little/. 28 So leaving the nose and throat cultures as a method of finding., new cases or carriers, we next decided we would like to know what the susceptibility rate was of the men returning from overseas. We did not know about the per cent that Col. Long mentioned this morning, so in order to find out, I did 1,000 Schick tests on men coming back and that was done with controls. We read them at x48 hours and also at five days. We had read somewhere in one of the Journals that at a prisoner of war camp there was an epidemic of diphtheria and they made; the Schick survey but the statement was made that the results’ could be questioned because too many people had read the results so in order to make sure that that didn’t happen at Letterman, my assistant and myself put on all the Schick tests and read them- all so we had at least one common denominator. We found 28 per cent of the men re- turning from overseas as Schick positive. The series wan complete at about November 1. • - u... .• At the end of October or the first week in November the magazine "War Medicine" came out with an article by Lt, Col. Karelitz in.which a similar series of a thousand Schick tests had been done, although he didn’t state where it was and the results were 28.2 per cent and ours .were 28 per cent. We felt that that was a pretty good check on what we were doing. I hope I am not taking too much time with this. . The next question was, "What to do with the positive, with the patients coining in from overseas who we knew were exposed somewhere on the ship to diphtheria, if 28 per cent were Schick positive. We decided that in order to give the.maximum protection, when a patient arrived with diphtheria he should be immediately isolated. It might not be known for the first 2h hours or the first kQ hours, but as soon as it was found he was immediately isolated.. Then all the patients who had been in contact with him were given a, tenth of a CC of toxoid subcutaneously. We felt in that way we could boost the latent immunity of the percentage of positives who were Schick posi- tive but still had immunity and that those few who we would miss, who had no immunity whatsoever, would be small enough to be easily recog- nized if the case came up or were to be controlled. Since most of the ships that came were Navy ships, we had a little difficulty in stimulating interest in diphtheria amongst the personnel involved on the Navy transports but this was finally ac- complished by a joint meeting between Admiral Hunt of the Twelfth Naval District and General Hillman, Commanding Officer of Letterman General Hospital, and following that all the transports’ surgeons were instructed with regard to watching for canes and also concerning proper, treatment, Our big problem, you see, was getting cases that had developed diphtheria on the ships but either no one paid any attention, to it or they were treated inadequately. The last thing, in closing, was with regard to the immunization of the Command. ‘ It was General Hillman’s wish that everyone in the Command be- immunized who was found to be Schick positive, We found quite a large percentage of our nurses, Red Cross workers and person- nel were Schick positive and about three weeks ago we started immuni- zing them and we ran into the very difficult situation which Col, Long mentioned. I know one group of medical officers, in which there were about 35 who were Schick positive. Within 1+8 hours I had 15 with reactions greater than 6 centimeters, that is, induration and edema. Two of them were off duty for at least two days and all I kept writing on the little chart was "discontinued, discontinued, discontinued." 29 About two or three got no reaction from one-tenth of a cc of r toxoid hut did get a severe reaction following a first, dose, of a half cc. subcutaneously hut we planned to go right through with it to the end and find out how many of them we could immunize,■ how many would complete the course and we felt that the general level would go high enough so that at least our Command would be protected in view of new cases arriving from overseas. Thank you very much. GENERAL BAYES-JOSES; Thank you, Major Tucker. There is a lot of interest in this cutaneous diphtheria from Burma and New Guinea. I think we are probably going to have some returning from Europe with it on with, at least, diphtheria problems back of them. One thing' that Col. Ravdln told me about the men that had cutane- ous diphtheria in Burma was that many of them are Schick negative. This cutaneous diphtheria is accompanied by all of the usual severe reactions, neuritis, cardiac trouble. It has decreased very much over there and it.is not much of a problem in Burma at the time. ■ A very interesting observation was made by Major Tucker, that of finding the diphtheria bacilli on the floor. It‘goes back to the observation of Britonneau of Tours who described diphtheria of the feet in ward attendants. • v COLONEL -' JOHN' MINOR; (Medical Consultant for.the Third Service Command): T Just wanted to mention one example which.occurred in. our command with regard to diphtheria which might he called a horrible example and illustrates'some of the things of which Colonel Long spoke. . ■ ...... In brief, one of our stations reported, on a visit, that there were two cases of diphtheria in the hospital'. They were not seen at that time but it was reported a couple of:days later that there were six or seven cases. I was away, for about a week and when X returned, having asked the officers to report to’the command if they had;.fur- ther cases that had been done. There was a- report that there were 26 cases of diphtheria on that post. * vm; ... „■ I launched an investigation at once and saw the following situa- tion: They had all of these cases of so-called diphtheria;.isolated in a ward with the exception of about three or four cases which,were obvious cases of streptococcal infection, I should Say that none of the cases had been critically ill. They had slight fevers. They had had some throat trouble and that was all. ■ The diagnoses had been made in the beginning by cultures and then they got excited, apparently, and started making diagnoses on smears from the throat and immedi- ately instituting the giving of antitoxin in very considerable doses. I have never seen so much serum sickness in one group in my life. There were really plenty of them. As I say, at least four or five of the cases were perfectly obvious streptococcal infections, so it was a combination of bad bacteriology, bad clinical Judgment and certainly most of all the administration of antitoxin and I simply wanted to bring it out as an example of what can occur. GENERAL' BAYEE-JONES; I don’t suppose any other laboratory is doint it but I have known of one that put penicillin .in culture media to hold down the growthoof organisms such as streptococci- so. that the diphtheria organisms would grow out. COLONEL MINOR: That was done in two cases in this particular instance. 30 GENERAL BAYNE-JONES; It is riot a good restraining indium, Just to get a pure culture of -.diphtheria. bacilli. COLONEL MARSH; (Headquarters, Second .Service Command); I would like ask Colonel Long .about the experience in the control of diphtheria carriers, by: x-ray. One of■my Very close friends is the commanding officer in the New York Dispensary, In civil lifb he is a very experienced and competent x-ray man. He has treated cases of diphtheria 'Carriers with x-ray during the past twenty- odd years and all but one recovered within eight days. GENERAL ; BAYNE-JONES: How does he apply the x-ray, Colonel Marsh? COLONEL MARSH: ■ His technique is beyond my comprehension. He said that many were completed with only one treatment, the rest with two and one exception required four treatments Of course, there is no control series hut 50 cases and cures in all with two treatments sounds pretty good. GENERAL BAYNE- JONES: Was the idea that of getting rid of adenoid and tonsil tissue? . COLONEL MARSH: Yes. (HeadquartersFourth. Service Command).. We have had a-good hit of a mild type of diphtheria among German prisoners of war. That has not worried us any hut I would like to know for my information whether there are any troops in Europe that are likely to come hack, with gravis diphtheria. COLONEL BANTON; GENERAL' BAYNE-JONES: Colonel Long? COLONEL LONG; I have taken several notes. Maybe I can cover a number of these questions at one time. GENERAL- BAYNE-JONES: All right. We will collect the questions then (Headquarters, First Service Command); I want to one remark atout the diphtheria carriers among German prisoners, particularly those that were captured after r the Normandy invasion. It-was thought that they might represent what we could expect to find among carriers in general from Western Europe. At Fort Devens we have cultured on routine cultures media- with the bacteriology being done at Ha&vard Medical School,, "so that that was a constant factor. We found a marked increase in-the diph- theria carriers but the virulence test using laboratory methods indi- cated that three-quarters of the cases were avimlent. COLONEL CARROLL: GENERAL BAYHE-JONES: Colonel Lee, did you see some of these cases? COLONEL' LEE: (Office of The Air Surgeon). No* GENERAL BAYNE-JONES; Colonel Council? 31 (Headquarters, Ninth Service Command Laboratory). We had in the beginning an occasional case and the impres- sion was that these were brought up to us from Australia. There was not very much definitive work on it. In other words, there was just one case or'two a month. There was no group epidemic at the time that I left and they were largely in men who had been down to Australia. I understand since I have left that there have been some more cases reported but I do not have definite data on it. COLONEL COUNCIL: GENERAL BAYNE- JONES; Colonel Long, will you conclude? COLONEL LONG; Major Tucker "brought up one point that I did slide over and that is the importance of making certain in attendants of cases of diphtheria that those people are immune, I believe that in attendants in hospitals a person should not be allowed to care for a diphtheria case unless he is immune, I think that we will keep away from a good bit of trouble in that way. The measure of the severity of reactions, as a guide to whether or not to continue diphtheria immunization, xssextremely difficult. I think you will find in TB Med. 11!4, which is the latest publica- tion covering immunizations -- and I will have a copy of that for you this afternoon, too, you may all have seen it -- you have seen the .' , guide, "local reaction not greater than 6 centimeters and general reaction not greater than 10.1 degrees fever." Again, those are just guides and it is extremely difficult to know when to stop immunizing them and when to carry on-, Tnere is in process now a technical bulletin’ on cutaneous diphtheria, which I hope will be out' soon, . It was written by the Medical Consultants Division,largely. We assisted in a small section on control. I think you will be disappointed when you try to find out how to control cutaneous diphtheria from this bulletin because it is not there. We don’t know how to control cutaneous diphtheria. We have tried to Indicate something about the method of prevention of the spread of diphtheria from patient to patient. You mentioned the treatment of carriers. One of the things that is normally done in diphtheria carriers is removal of tonsils and' adenoids or this position (indicating.:) That represents a relatively small number of cases compared to the 1917-1918 for our strength is somewhere in the vicinity of 8,000,000, Next slide: Here is a comparison of.typhoid and diarrheal disease rates. Note the diarrheal diseases practically to the level of 1905. It does not look as though our field sanitation had improved and these rates are for troops in the United States, because we didnH have anybody abroad in : The typhoid rates show the complete typhoid with the paratyphoid added, so that in 1916 the whole group of enteric diseases is way back at the level before vaccination, if we count the paratyphoid as well as the typhoid. That sharp Jump around 1921 is due to only 22 cases in a very small army. The other figures over here tro • the ■ right are way down. You notice they are almost 100 times lower than they were in the preceding war. The $ump, as I said, is from ,02 to . for the year during the time that we had those cases in North Africa and the paratyphoid in Sicily and Italy, Slide: This is Just to. show you the antigenic or somatic antigens that we are using. There is’ a cross protection between the members of this particular group and between these groups and a number of other Salmonellae. S, hirschfeldii has no common antigenic components of the somatic type with the . rest of the organisms .so that if it did occur we definitely would have no protection against this organism. Next slide; This, is the. only-controlled protection test that I am aware of,* for the typhoid vaccine:. The,1 Vaccine, was used in'1917 and the outbreak occurred' in Hawaii. The water supply for Barracks came from the north fork of the river. It is a sort of a hillside-up here and the south fork is considerably lower. That was a badly contaminated water but in cases of drouth this pumping station pumped from the south fork into the main supply* It was not supposed to be used unless the post was warned, and all water boiled. : - The' officers of the cavalry unit had been boillng. .their water in the -officers* homes on the recommendation of the, surgeon-because"he felt that the chances of contamination were good and a lot of diarrhea made him spend too much time on. the line. The troops: were,-- of course, all protected and most of the officer families, were at the same-time. Down here we had 800 laborers who were Japanese and Koreans and drank mostly tea and not too much water. After a drouth, a heavy rain washed the contents of one of these privies down into the south fork while they were pumping from here. A man hod gone up to convalesce from typhoid and we eventually found him still in the carrier state. Ten days following the appearance of muddy water in the bathrooms at the post, there was an outbreak of approximately fifty cases of ty- phoid among the h,000 immunized persons and approximately 50 among the 800 non-immunized persons, a relative proportion of one to five or an 80 per cent protection, whichever way you want to put it. There were seven who died in the non-immunized group and three died in the immunized group. The vaccine was Rawlings strain with a fairly good B and a rather poor A, I may say that we have had more A abroad than we have'- had B. Our A is the poorest of the group of three organisms. That is, it is not as antigenic as one would wish, although it is the best one that we have been’able to find in some five or six years searching through- out the world. Thank you. (Applause.) 37 GENERAL. BAYHE.-JOKES; I know Colonel Callondar would like ,to discuss this with you. Any questions that anyone wants to ask? Captain Sartwoll, wasn’t there some typhoid in Italy this last winter? CAPTAIN . SARTWELL: .. . Yes, >sir. GENERAL BAYNE-JOKES; Anything peculiar about it? CAPTAIN . SARTWELL; I think it was the water supply. GENERAL BAYNE-JONES; I .think you arc impressed, hy seeing what’Col, Callendar has said and he can extend it further, * I'think that I will he hacked up hy the statistician in saying that there has heen an enormous number of cases of diarrheal disease in North Africa and all through the Southwest Pacific area and relatively much less typhoid than you would expect. COLONEL CALIENDAR; There is only one thing that I might say about that and this 'is pure theory, A man first gets his organism which he passes on from civil life, lot us say.. He is protected against typhoid so he doesn’t pick up typhoid and does not contaminate his own latrines’. That is just a theory. It may he'worth while. What do you think of that, General? • ■ * ‘ . * GENERAL BAYNE-JONES; I will .get some of these statisticians, I think it is reasonable, Colonel Callendar. : COLONEL CALEENDAE; It ifc the only explanation that I have got. COLONEL LONG;' ‘ ¥e have, adopted the use of a. half c.c. suhcutanocus does or.the..booster dose. Everyone is aware of^the fact1that the Navy is using the tenth cc. dose ihtracutaneotisly. There-.are. various reasons for .the Army in adopting the half c.c,. sub- cutaneous.. ■ One of the, reasons yas and'I think one of the most' impor- tant is that in giving vaccines .to. a large number of people; as they ■are filing.hy and giving theia the vaccineA you can he sure 'of getting a half c.c. under the skin ‘much, hotter than.you can of getting a tenth into the skin. ■ ”• -• - -.. ...I should like Colonel Callendar to give us an idea of the relative ■effectiveness of those.two methods'because I am sure that all of yoU are asked, that question, . Why is a half c.c, under the skin as good' as a tenth in the skin? : \ COLOKEL CMLENEBR: The figures published by Leopold,aLongfellow and Luippold showed that the booster dose, intracutaheously> was Just as effective in a tenth c.c. as a half cf-c. subcu- taneously, There .was ,no advantage one way or another, but when you line up a group, you arc. going to give'a lot of l/lOth c.c.’s subcu- taneously and then it is not as effective. COLONEL LONG; I wanted. Colonel Callondar to bring out that point be- cause I am sure all of these gentlemen are asked that. COLONEL CALLENDAR: I think you might reserve that tenth c,c. intracuta- neously for the hypersensitive individual. 38 COLONEL NORTON: I would like to ask Col. Callendar for a comparison of the reaction from one-half c.c, and the one-tenth c.c. My personal experience was that I got a worse local re- action from the one-tenth intradermally than I did from the one-tyalf subcutaneously. COLONEL CALLENDAE; That was my experience hut I think that on the whole, in the hypersensitive individual, the one who gets an arm that is markedly swollen you can sometimes give a tenth c.c. and get hy with it. You may have a had reaction hut I prefer the subcutaneous for myself. Over in Hawaii they vaccinated the whole population as soon as we could get vaccine to them after Pearl Harbor. As near as I could make out over 50 per cent were intracutaneous vaccinations, primaries, and they had a considerable number of cases, perhaps one in three or four thousand, that had a residual left in the skin, a foreign body like reaction. Just what the cause of that was we don’t know but it did occur. There were some of them Inspected and in the only one I have seen, I found a very small bit of material that would go through a very fine needle. GENERAL BAYNE- JOKES; I know a one-star general who has keen rather strongly against the intracutaneous injection, hut took it prior to his last trip. He was showing us his arm about every day. It seemed to me the reaction produced was a large red spot that gave him some discomfort. COLONEL CALLENDAR; That little place in the skin will last longer than the reaction to the subcutaneous injection. GENERAL BAYKE-JONES: Thank you very much, Colonel, As a continuation from -1 the epidemiology, we now have a series of topics to he discussed by Captain Philip Sartwell on Infectious di-• sease control, sulfadiazine prophylaxis -- Reporting and investigation of communicable disease cases and outbreaks -- Administrative procedures in the control of certain diseases. You have an hour, Captain, but if you will do as Colonel Long did and give us an opportunity to talk to you before the end of J.t we will appreciate it. Captain Sartwell. ; 39 v; _x •. * . j.-tv .. . INFECTIOUS DISEASE CONTROL. SULFADIAZINE ' PROPHYLAXES'■ •*.-.• . REPORTING AND INVESTIGATION OF COMMUNICABLE.DISEASE CASES AND OUTBREAKS;- ADMINISTEATIYE .PROCEDURES IN THE CONTROL OF CERTAIN DISEASES, r' CAPTAIN PHILIP E. SARTWELL, 1C, EPIDEMIOLOGY DIVISION* ' CAPTAIN ; SARTWELL: General Bayne-Jones and fellow officers:.•If Col. Long ' was in a predicament this morning, I. am in a woise one - JO now Because from the little list of subjects that General. Bayne--Jones has reeled off, it is obviously impossible to coyer ‘them, except, in a superficial way. I, think that you all received -- at least until the supply ran out --‘■these directives and.technical bulletins. They refer to both the subjects covered this morning and some of those that I am going to take up. My assignment this afternoon is to continue the discussion begun by Col. Long this morning on matters in which the Epidemiology Division, Preventive Medicine Service, has primary interest. An attempt.,will be made to sketch the background of certain directives which this Division has initiated and to emphasize a few points that may not be entirely clear. Some of the routine activities in connection with reporting' and ■investigation of communicable diseases will also be Be- cause of the number of topics suggested for discussion at.this meeting by various Commands, in response to our request, I am sure it would be best to make the formal presentation brief in anticipation of a con- siderable amount of discussion. • * It will also have to’ be rather disconnected as ,;there are several unrelated matters to be covered. First, I should like to make a few observations concerning the prophylactic use of sulfadiazine, ‘There are in the audience' those who-are recognized experts on this subject and I • am not going to do more than touch on- certain administfative: p phases ■ - c„v. ... • -■-u ; ■■--..•.y-.i • ' As- you all ...know, a'large* anpunt of. -Work has been:; done ’ ph this: subject., beginning; in ■ the-’-winter af. 19^2 by-both .the. the Army. The Army Air 'Forces .Research Program, has-been particularly-- energetic and the Army Epidemiological Bdard has made -a definite con- tribution. Two SGO directives have appeared, the first being"a circu- lar letter in the fall of dealing with prophylaxis against meningi- tis only and the second a TB Med published 1 November which rec- commends its use also against streptococcal and other respiratory dis- eases . Fortunately, the incidence of all these diseases this winter has been remarkably low so that few stations have had to use diazine. I believe the number is probably less than twelve. Such work as has been done, however, seems to bear out previous belief in its efficacy and the very limited danger from reactions. There have been rumblings on the horizon, perhaps, that a state of sulfonamide resistance has been created in certain instances. I have not had an opportunity to see any of the data bearing on that point as yet. Cultural studies indicate that the meningococcus is quite com- pletely eliminated from the naso-pharynx by prophylactic doses while the streptococcus may continue to flourish in the throat in spite of streptococcal disease having been brought under control. It will be 4o noted that the present instructions provide for daily administration of one-half to one gram dosages over a period up to three weeks. There is, however, at least one good indication for going hack to the method recommended in the directive of giving a two or three- gram dose on one day only. This method is not mentioned in the present directive for reasons of; simplification hut it is not hy any means pro- hibited. This method would he desirable for a meningitis outbreak without undue prevalence of respiratory diseases in a relatively closed group, the classical example of which is aboard a transport. Here it is possi- ble to reduce a meningococcus carrier prevalence quickly to a low point and since new personnel are not being brought into the group, the carrier prevalence should rise very slowly so that continued adminis- tration of the drug is unnecessary. The desired effect is attained with a smaller total dosage,, thus conserving diazine and reducing the like- lihood of reactions somewhat. A few words about reporting the use of diazine. TB Med 112 eon- tains instructions that when it is used a notation to that effect should befmade on Form 86ab. This is because the SGO wishes to know how.wide- ly it is used and to continue to receive information as. to its effec- tiveness. It would be helpful if preventive medicine officers of the various echelons called on to authorize diazine would remind station surgeons of this provision. An outbreak of any disease considered severe enough for diazine is severe enough, also, to be discussed in the Sani- tary Report of the organization. There has been some criticism of the indications for diazine set forth in TB Med 112, Granting at once that it is impossible to put down any hard and fast rule and that you have got to rely on epidemio- logical knowledge and sound judgment, it seemed wise to set up some kind of a guide to go by to suggest the general range of incidence rates that warrant consideration of this action. So far, it does not appear that there is any tendency to use it for insufficient reasons. Diazine should not bo lightly resorted to but it is after all the first really encouraging agent, for the control of strep and meningococcal .infections. You are all familiar with the general demand in an epidemic sit- uation to "do something," In the past that "something" has often been the imposition of complete or working quarantine of the unit, which usual- ly does no good, and is very seldom indicated. With diazine perhaps thbso in authority will more often bo content to stop short of working quarantine, since positive action is already being taken to satisfy these demands. There appears to be some uncertainty about the reporting of special diseases by telegraphic means. ' With your permission I would like to go into that briefly. Since the time’-when telegraphic reporting of . - meningitis was stopped there have been no special requirements except those listed in AR h0-1080 which specifies that each case of yellow fever, epidemic typhus fever, encephalitis, poliomyelitis, cholera and plague should be reported to the Surgeon General and to the Service Command by telegram. All alarming and potentially serious epidemics of.other diseases should bo reported in the same way. That is left to thb dis- cretion of the station surgeon. Form 86ab is relied upon routinely for information about communicable disease prevalence. The Epidemio- logy Division' maintains liaison with the office of the Air Surgeon and reports to it all significant data reported by telegram from air forces installations, iH The reasons for needing the most prompt information possible' on unusual epidemics are apparent to everyone! Direct personal.investi- gations by the SGO are seldom made, but in certain instances, the Army Epidemiological Board decides to send workers to the post to aid in study of the outbreak and make suggestions for its control. Even when such action is not.taken, it is obviously necessary for the SGO to know about these things. One of the questions submitted for discussion concerned the coordi- nation of reports of communicable diseases prevailing at a station when troops are transferred with special reference to staging areas. I am not quite sure what difficulties the individual making this sugges- tion had in mind and would welcome discussion of the point. In numerous complaints were received that the directive ask- ing for these reports was being misinterpreted and that all sorts of trivial situations were being reported, for instance, reports were being sent to Station B that gonorrhea was present at Station A, A War Depart- ment Circular was written to correct this and no further difficulties have been heard of. This circular was recently rescinded because the present AH h0-1080 covers the subject adequately. It is not known how close a relation Preventive Medicine Officers of stations and higher echelons have with the personnel responsible for making up' Form 86ab. Probably, however," they can accomplish a good deal toward the improvement of communicable disease reporting. When an unusual incidence of respiratory disease or diarrheal disease'is reported on 86ab, experience has taught us to look first for an error in reporting since the epidemic is frequently just;.a statistical arti- fact. Changes in personnel in the registrars office and issuance of new instructions on reporting make for trouble. Among the most common errors is the reporting of cases confined to quarters for less than 2k hours or merely seen on sick-call in.,the dis- pensary. This, of course, makes the rates .nonoomparable with other stations ■ A case .of this,, sort arose this month when a large post, which really did have a lot of communicable disease, reported remarkably high rates, and,a total communicable disease Incidence in excess of the total ad- missions for-all’causes shown,on the front of the form. Here the'mis- take, had been made of counting dispensary cases in part 9 of Form 86ab. Another common error is to report carriers as cases’, and reactions to vaccination as cases of the disease against which vaccination was done. Since Preventive Medicine Officers are the. chief users of the information ofi 86ab, they will be Interested in making the'reports as reliable as possible. In certain service commands the Monthly Medical Bulletins frequently carry reference to 86ab entries which should be .very, helpful, There is opportunity for Preventive Medicine Officers to be of considerable assistance to post surgeons by advising; on the best means .of .tabulating and. charting, communicable disease data. Many times one finds., unnecessary wo;rk ’being done by computing rates for diseases which are occurring in too small numbers to make the rates Significant, The solution here, of course, is to base'the rates on longer time intervals or not to break down the organ!zatlens' into such small com- ponents , This should not be taken to mean that one should not bother to find out what organization, what barracks or what mess each case comes from. Such information is often highly important for the control of the disease, k2 I should like to outline the diseases and situations which at the present t.ime are investigated -from The Surgeon General'*s office.- No doubt many of you have "been mildly annoyed to receive requests for epidemiological reports on outbreaks of diarrheal disease. These requests have teen made, however, with a. definite purpose in mind. Realizing that in most instances adequate reports are already being;rendered and that the requests entailed duplica- tion of work, decision was made to await the Monthly Sanitary Report of the organization having the outbread before anything is done. .If this contains a satisfactory description of the outbreak and , control measures taken, no further report is asked for. Specimens of blood and spinal fluid .together with a clinical his- tory as outlined in SGO Circular Letter Jk, published in > are requested in all cases of lymphoctic choriomeningitis and encephalitis. Specimens should be drawn, packaged and shipped as described in the Circular Letter and sent to the Division of Virus and Rickettsial Diseases, Army Medical School. In appropriate cases where frozen blood serum or spinal fluid from patients who are still febrile is received, it is possible to isolate the virus directly. More often, however, rise and fall in neutralising anti-bodies and complement fixation titers must be used as a diagnostic aid. • Colonel Harry Plots, Director of the Virus and Rickettsial Division, has asked that publicity he given to the fact that specimens are not ordi- narily desired on poliomyelitis cases since the Laboratory is not equipped to do virus isolations on the lo,rge numbers of specimens received. There is no serological procedure -which is practical for general use in the diagnosis of poliomyelitis. There may be occasions when it is particularly important for epidemiological reasons to do virus isola- tions and in such cases we suggest direct communication with the Pre- ventive Medicine Service, SGO. For several years blood specimens have been requested by the Virus and Rickettsial Disease Laboratory from patients with rickettsial dis- eases ,• chiefly endemic typhus fever and Rocky Mountain spotted fever. This program is continuing- and is adding a good deal to our knowledge of serological reactions in these diseases as well as being of service to the medical officers in making their diagnosis. Some service com- mands have, I believe, gone into the business of doing endemic typhus fever complement fixation tests, which is all to the good. It is still desired, however, that all stations submit specimens to the Army Medi- cal School in addition to any examinations which are done locally. We attempt to get sub-cultures from every case of typhoid and paratyphoid fever for confirmation and study at the Bacteriological Laboratory, Army Medical School, under the supervision of Colonel Callender, The importance of this in relation to the'immunization program is obvi- ous . In this connection, since it' is not set forth in any directive, it may be wise to indicate the present policy regarding disposition of typhoid carriers who, as you know, are to be reported to The Surgeon General after they have retained their carrier status for six month q. If there'are no other Indications for discharge from the service, the carrier should have- bile drainage to determine if he is a gall bladder carrier; if so, and if there are no medical contra-indications, cholecys- tectomy should be offered. If this is refused or if the individual is not a biliary carrier, he should be placed on limited service in the United States and prohibited from all food handling. Since very few typhoid carriers have been discovered, all cases to date have been handled on an individual basis. *4 Suggestions:have "boon received that the manner of investigation of outbreaks of bacterial food poisoning can be considerably improved; from our observations, this is certainly true. One of you. has suggested a proposed form to bo used on such investigations and another has suggested that a directive be issued to serve as a guide. Each-.'outbreak must be handled individually and it is not possible to set up in advance any rigid procedure that will apply to all, yet there is. merit in a general plan which would be ready to bo put into effect upon the first indica- tion that an outbreak is under way. This should diminish the frequency of investigations which determine neither the offending food nor the responsible bacterial agent. It seems important to,emphasize that the first step in an investigation is to secure samples of all foods served at the suspected meal before there is an opportunity to discard them; second, to take brief dietary histoi’ies from a sufficient number of patients to provide a clue; third, to find out as carefully as possible the exact method of preparation and storage-of the suspected foods; fourth, to see that the laboratory has an opportunity to carry out a search for the Salmonella group of organisms and staphylococcus on sue suspected foods, feces and vomitus, There is one additional matter on which the Epidemiology Division has too little information and hopes to bo informed by this group, ¥c are interested in knowing how close a degree of cooperation is main-* tained-in-health matters with the Public Health Departments of states, counties, and local communities whore stations are located. In parti- cular, wo are interested in knowing whether problems have risen over the reporting of communicable disease to civilian authorities and the application of civilian isolation and quarantine requirements on mili- tary posts. The time remaining to mo will be devoted to a very brief sketch of the current communicable disease incidence picture in the United States. There, have boon prepared two reviews on Morbidity of the Army in this country from disease and from the respiratory diseases. I have brought along copies of these two reports which anyone who is interested may look over. I do not have sufficient copies for distribution but they may bo obtained if you will leave a request. This.winter, as mentioned before, the incidence of common respira- tory-diseases has been exceptionally low and the average rate for 19hk has been lower than any year since .1938• There seem to have boon two phases of the war so far as its effect upon common communicable diseases is concerned. First, the period from to about which was characterised by a sharp increase above the peacetime incidence of respi- ratory diseases, pneumonia, diarrheal diseases, measles, mumps, scarlet fever, meningitis and other infectious diseases. ' The1 second phase which wo are now getting into is one of decline to pre-war levels or even lower for many of these diseases. There is no doubt that seasoning of troops is a major factor in this transition. There arc other factors to be considered, however, such as the changes in housing conditions; there is perhaps less overcrowding existing now than earlier in the war; differences in the training program; and varia- tions in the civilian incidence of these diseases. Comparing the record for with that for there are certain outstanding differences between the military and civilian incidence of communicable conditions in this country, The civilian incidence of measles was much the same in both years while it declined sharply in the Army, Scarlet fever showed an increase in 19Mj- in the civilian popu- lation and declined in the Array. kk Meningitis fell much more sharply in the Army than in the civilian population. The factor of sulfanamide prophylaxis may have played an important role in the case of scarlet' fever and meningitis.' Certainly the diminished relative number of recruits accounts for at least a part of the fall in meningitis since this’'disease shows the most striking concentration in newly inducted recruits. Variations in these diseases by.service commands have been marked and unaccountable. Respiratory diseases have consistently been high in the Fifth, Sixth and Seventh Service Commands, Scarlet fever has been outstandingly high in the Seventh and less so in the Sixth. Rheumatic fever has shown a similar pattern -- I am speaking in comparison of Service Commands over a period of several years. Measles and mumps have tended to be high in the Fifth, Sixth and Seventh, The differences referred to were quit© noticeable in and but were less well marked in 19hh, A good deal of attention has been focused upon the high prevalence of streptococcal diseases- and rheumatic fever in the Seventh Service Command, particularly in the States of Colorado and Wyoming; however, there is not time to go into this matter now. Among the less common but potentially serious communicable diseases the following showed a decline in as compared with coccidioidomy- cosis; encephalitis; Rocky Mountain spotted fever; and tularemia.. The decline in each of these conditions except encephalitis may be attribu- table to the smaller proportion of troops on maneuvers in this country last year and to the more adequate safeguards taken against, them. While the numbers are so small that not all of the changes are significant, increases wore recorded in diphtheria, endemic typhus fever, paratyphoid fever, poliomyelitis and undulant fever. The 'increase in diphtheria may bo attributable in’part to a considerable number of cases occurring on the West Coast-among troops Just returned from the Pacific areas. The endemic typhus fever increase is parallel to.a.similar Increase among the civilian populations of the Southeaster.and.Gulf States which has been going on for some time. Typhus fever has not, however, become in the military population a disease of any real importance While poliomyelitis increased over ? ’the increase was not nearly as marked as it was in the civilian population. GENERAL BAYNE-JONES; . Perhaps you have many questions. We might start in with sulfadiazine prophylaxis. Has anybody here had any ex- perience with it under present regulations? We had a respiratory epidemic in the replacement’ center, the armored forces replacement center ■which-started the second week in December and the pattern, the first two weeks, was much like the groat increase wo■had last year. It gave us about two weeks‘ warning and then up it wont. In most. of these cases, the rest of the post had:a slight increase,-vith thp..replacement center but mostly cases arose in the replacement center. COLONEL TILLMAN; Wo charted the .roseiratories that entered the hospital on a chart for each battalion and each company and broke it down. From their flow chart in. the replacement center, the time that a company filled and the time they were in the first, second and third week of.training, we , found it took about the'third week in their training before those patients would roach the hospital so to apply this TB Med 112 wo struck a lino ’ ■ • J- : * • »• •• * ■ across this chart that was mounting in certain battalions and gave one gram of sulfadiazine every day for five days. That five days was taken as an arbitrary figure because the TB Med said if you got any results you are going to get it in three days and if you stayed below seven days you didn’t have any reactions so wo struck that figure and tried it out that way. The first group we gave to amounted to-,4200 troops and the curve was beautiful. It wont straight up. In this group the peak rate was 1200 per .1000 per year. In the third day after the sulfa it dropped off sharply to 200, We thought that was the answer to everything. That was fine. Another group started up about that' time and we tried to apply the same thing and taking into consideration this third week affair, we tried to lead one battalion and wo picked one out in the second week just coming up to the third to see if wo could not give them sulfa in the second week and stop this happening. They went to their third week and wont straight on up. Now we are giving a third group sulfa and wo changed from five days to ton days and this one battalion I tried to lead is; getting the sulfa for the second time, because the first five days didn’t work. The second group of 3200 men, wo got a very good response too on our line chart there but at the same time we had a few days of nice warm sunshiny weather and the whole post dropped off so there were other reasons to account for it rather than the sulfa but this affair continued on and started up again. Wo took this third group and tried to give it to them for ten days and see if that would make any parti- cular difference, ■ There was a question of overcrowding, "When this first started we went through the whole replacement training center and made a survey of the housing and so on and recommended that they go to 60 square feet. Of course, the Army Regulation said they only have to go to 50, We had difficulty there.. Then we went hack a week later and checked it again; they would have a hundred men in a 63 man barrack and as soon as it dropped off they wanted to crowd them hack in again. That had some effect on the situation hut the sulfa as far as we could find out, is up in the air. r •There were so many different factors to take into consideration that- except for the first group in which there was a sharp drop-off, when the rest of the camp was still climbing up, so that we couldn’t make any definite conclusion. COLONEL , LEE; We have had a few experiences in the Air Forces with sulfa prophylaxis for various- things. As a matter.,'of fact, I think the first time it was ever tried extensively was-the scarlet fever epidemic at Santa Ana in the late summer of Wo, wo re running a hundred cases a day when wo tried sulfonamide prophy- laxis Ifith rather spectacular rbsuits, The rate dropped to- zero' dn hQ hours. At that time we had about 25,000 rather young recruits. They were all aviation cadets, newly mobilized and of course in the most sus- ceptible period. " , Since that time we have used it in a great many conditions. I have just received a report of the committee who investigagod the.sulfa-pro- phylaxis in the Air Forces, I won’t take your time for the details pf that and if you will pardon me in being a little dogmatic, I can giva, you some of the conclusions which I think arc valid but perhaps spmpi.. ; of them are still open to question. 46 I think, as far as-meningococcus- meningitis is concerned you can say w without any possibility of successful contradiction that'the results are 100 per cent. You can certainly- stop meningococcus epidemics right now. Some of you saw the meningitis in the first war; I saw it at Goat Island in San Francisco when they had 65 per cent mortality among the young naval recruits. As far as meningococcus is concerned, it is 100 per cent. .... For the, streptococcal groups/ particularly scarlet fever, it is very good. I think if your bacteriological work is .done, if you have the'opportunities of checking the strain with which’you are dealing for susceptibilities you can guarantee between 85 and 95 per cent protection against streptococcal infections of that type. There are some strains, IT’s, 18 and alpha strains, that are seem- ingly non susceptible to sulfa and have refractory qualities. That.ques- tion I think is still open. We have not encountered that to any extent. The Navy has to a considerable degree. ‘ As far as rheumatic fever itself is concerned it is also one of the subjects where there is some doubt. There are those who believe with pretty good”figures that by keeping rheumatic fever patients constantly on a half gram a day of sulfadiazine year in and year,out there will be very few recurrences. .1 think that still requires more observation and is not a settled matter yet. In the matter of total respiratory diseases there seems to be no doubt that there is some effect. I just got yesterday the report from the Eighth Air Force in which they ran a very nice series of controls'- and experiments. They had 6,000 patients or 6,000 of their personnel on sulfa and .about 5;A00 off. The next period they had 6,000 in each group. . The total respiratory diseases, you. .can*t” see this but hero is where it started. They are even. " w In the;untreated cases their rate went up to about 2,300 and the' other went "down. At this point they stopped the sulfa and' reversed it . The controls took it and those who had had it, stopped. Those two lines, as; you can, see, exactly crossed. The rate in the controls wont up while in 'those taking the. Army, it dropped. That was for total respiratory diseases'.. Respiratory disease was by no moans abolished and the virus diseases were entirely unaffected by prophylaxis except in so far as the complications occur. The streptococcal complications of the common cold can be materially.reduced by sulfa, prophylaxis . With detachments with a high degree.of gonorrhea, we have made them take' sulfa before they go on leave and after they come . back. The results on that indicate that there is about,30 per cent of bhc gonorrhea controlled in the, groups that take the sulfa prophylactic,ally. They have about.30 per cent as much gonorrhea as those who don’.t.. That is. not finished. Curiously from this report of General Grow in the, .Eighth .Air Force, his control group watches the gonorrhea at the same time, while it was given for experiment in respiratory diseases. They had about 29 per cent of the gonorrhea in the sulfa group as compared to the control group during the same period Of time. That was just an incidental but, beneficial effect they observed. ■ The way in which-it is given for the gonorrhea‘for these Negro troops I don't think is very good. , I think if it were applied quite strictly and over a longer period of time -- the ordinary procedure was to give them three tablets when they went on leave and four,, tablets when they came back. * That"did have a certain.-appreciable effect. 1 might give you the figures we have on reactions. I vent over-Cobum-’s figures in the Wavy. The Navy had a hig experiment with 100,000. on sulfa and 600,000 off. Their experience corresponds pretty closely; to ours. I published a series of 25,000. We gave the two grains of sulfadiazine on one day. I watched those reactions pretty carefully. We got about the same percentage as the Navy. About one half of one half of one perocent of those who got it,, got some sort of a reaction. About one-hundredth of one per cent got serious reactions. There are two kinds. The exfoliative derm titis which can be exceedingly severe. They had a total of about .15 deaths in their sulfa program. I believe that nine or ten of those were derm - titis, I know of six that died of exfoliative dermatitis. Of the ones I saw three,severe cases were exfoliative dermatitis. Those cases can all be saved, I believe, by giving penicillin, Two of our cases were quite ob- viously going to die. With penicillin they made a hour recovery. The Navy had the same experience. They had six deaths from exfoliative dermatitis before they gave them penicillin and I think they have had no deaths from exfoliative dermatitis since that. I believe -- it is a small series not published but I believe the exfoliative der- matitis, which is the most serious toxic effect you get from sulfa, can bo controlled with penicillin. The other coses are cases who come down with an acute fever. I saw one loan with a temperature of 106-y but he recovered and it. took a lot of prompt work with plasma and various: things which I think helped with him. All the cases that we have seen except two with severe fevers, when the history was gone into it appeared that they knew they were sen- sitive to sulfadiazine;,-. They-had fevers before. _ > Following that wo attempted to question each man before giving sulfa whether he know ho was. sulfa-sensitive. If ho said he was, he was not required to take it, he was put aside and subjected to a more... detailed study to sec if wo could determine whether or'not that was a, fact, but it is quite remarkable the febrile cases that we saw, all but one or two or three in all I guess had known and had fevers before from sulfa. So when you are going to give it on a widespread scale, if it is- possible -- sometimes it is difficult to arrange that, the men should be interrogated as to their possibility of sulfa sensitivity. Those febrile reactions can be combatted, I think, by adequate amounts of intravenous salt, glucose and plasma, if they got shock. A good many showed chock* A good many cases will show a little mild delirium. Cases of high fever will show sometimes wild delirium and one case I saw was comatose for eight hours but recovered. ‘ The other group of eases, the half per cent, will ho all cutaneous reactions or mild nausea and, diarrhoa. Most .of those arc trifling. Most of the cutaneous reactions are not severe except in the case of photosensitive individuals.who got,a cun hath after sulfa prophylaxis. That is in California more frequently than in Washington, D.,C., I am sure, and we'had some trouble•from that score. 1 think,that is one precaution that should ho stated, that they should not take any sun bathing when they arc full of sulfa or sulfa prophylaxis. Just in re- sume ,■ I. believe that in diazino-prophylaxis wo have, an extremely import portant preventive medical process. ■ For meningitis certainly; fpr strep- tococcus infections certainly, pneumococcus loss doubtful, gonorrhea almost certainly. That has been in the past, an important group of military disorders for which the sulfadiazine .while by no means perfect, it does give us quite an extra-ordinarily potent weapon, . The full story is not yet written, I think the full facts arc almost in our possession now and all the time that has come in, parti- kS cularly during this last year, it gets organized and published and a resume, I think we have most of the answers as to how sulfadiazine pro- phylaxis should he carried out. GENERAL BAYNE-JONES: ; Does anyone else wish to comment on the administration and- results of this? A VOICE: I believe Colonel Brooks used this at Camp Shelby. COLONEL BROOKS: I know they have used this on a small scale. COLONEL KOGSL: I wonder if Colonel Lee will tell us of the use of peni- cillin on dermatitis. COLONEL LEE; , I think they die because of secondary injection with sta- phylococcus in the skin. I think that it is this from which penicillin saves them. I,think it is the extensive secondary injection that kills the patient. ' . COLONEL MINOR: We have a similar problem of prophylaxis from tho stand- point of tho individual soldier or sailor when they go home, having had prophylaxis and so on or maybe treated at another camp. As far as penicillin is concerned, I am afraid at least in the cases I have observed very closely I must disagree because the patient promptly dies although he had largo amounts of penicillin. That patient had liver damage and uremia so he was not a very good prospect. Ho happened to bo a sailor who had prophylaxis and given by an unwise civilian physician end largo doses of sulfa for a skin erup- tion obviously due to sulfanilamide. Another thing that occurs: to mo is not to complicate Army procedure or papers that soldiers and sailors have to carry. ,. Such a case as-this one I spoke of makes you wonder whether wo would not be Justified in giving prophylaxis in preparing a simple little card Lor a doldicr or sailor or giving him a standard card which says, "I have been; taking sulfadiazine" and so on and thon told to show it to a doctor'll* he goto • sick at homo or goes to another post. You might save,some lives that way. ■ ”, ; '• GENERAL BAYNE-JONES: Wo have been,discussing that. CAPTAIN SARTWELL; The necessity has been realized for those who wore found to ho sensitive to have a record of it made and that is provided for in the now immunization register which Colonel Long mentioned this morning, those. who have reactions' of an a allergic typo or hypersensitivity to vaccines and sulfonamides should he Hated there. It has not seemed necessary yet to have all individuals who have hoen on prophylaxis given a card of that sort. COLONEL MARSH: Ton days ago wo had a transport como in with both sick and wounded and prisoners of war in which there was an outbreak of 560 casco I think of streptococcus sore throat onrouto. The total strength on that ship was around 1900. ■ When they got them into Halloran Hospital they wore all screened alii they found 2k gases at that time, None of them wore very severe, and all contacts wore immediately given sulfadiazine and two or three days later when they entrained for other hospitals that was continued for a period of a week. 0 1^9 The prisoners of war •who were on hoard, of course they were taken off on trains and immediately shot oiit to prisoner of war camps and they were given a gram of sulfadiazine a day for seven days, we were advised. We don’t know what happened to them hut it may he that the epidemic was over hut there were not any more cases following that. COLONEL BANTON: While we are on that case I would like to know if there are any more developments on mumps? Last summer we had some workers down our way and were looking for something to happen. GENERAL What do you mean hy "developments on mumps? BAYNE-JONES: COLONEL BANTON: Whether we have something that can stop this nuisance Cur large posts report this and it goes all winter. Is there anything that will stop it? ; GENERAL BAYNE-JONES: I think you can immunize against mumps. Drs, Enders and Stokes say that you can do it hut it seems an unneces- sary procedure to put it on all troops at present,’ They also had a skin test that was applied in your group. The mere fact that you did the skin tests seemed to protect a certain group of men. Of course, that didn’t work all the way through. Hy impression is that mumps has heen nothing like the serious problem in this war that we expected it to he. CAPTAIN HARTWELL: One of the most striking reductions in comparison with the last war. The Fourth has had more than its share, however. .GENERAL BAYNE-JONES: As.for an immunization program it does not seem to "be Justified at present. I don’t know of any other thing that you might use. Gamma globulin given in large amounts modifies the disease and probably protects but that takes quite a large injection of the'material and also doesn’t seem to be worth while. Are you having a serious problem? Does the Fourth Service Command get a lot of these men all the time? Is that the reason? Is this in- creased induction affecting you? colonel BANTON; Not greatly. We have one or two wards full of them all winter on some of the large posts and that is really quite a few sick men. GENERAL BAYNE-JONES: Speaking about mumps, the thing that interests us very :much is probably the more frequent occurrence of mumps encephalitis than one would expect, No doubt some of these negative reports of spinal fluids that have been sent in were because they .may have been mumps encephalitis instead of some- other things that you may be looking for. If you think the problem is serious enough, perhaps we better go and see what we have and see if we- can help out a local situation, . Captain Sartwe.il had a good deal to say about reporting. ■ Are there any special problems that you have in connection with that? He out- lined a good many of the difficulties that come in to us.in administra- tive epidemics, if you go through and clear out a lot of cases w% suddenly find an epidemic of meningitis due to on accumulation of the records, . , - a 50 V': We would like' to know about these outbreaks of serious food poison- ing as soon as'we can and as Colonel Long said this morning about what you think is influenza, we nay be able to assist you through the Army Epidemiological Board by virus identification. . COLONEL MARSH; Just one question inrrggard to vhat Captain Sartvell spoke of, the disposition of a'typhoid carrier. What are you going to do with a PoW carrier? CAPTAIN SARTWELL; I don’t knov anything other than not letting them handle food. COLONEL MARSH; That is vhat I say, but there is no special place to send them. CAPTAIN SAi\TWELL: That is sonething that can he done soon, I hope. GENERAL : ’ ' BAYNE-JONES; They -won’t agree to a gallbladder operation? COLONEL MARSH; An elective operation --a compulsory operation is for bidden on a prisoner of war. GENERAL BAYNE-JONES: Captain Sartwell asked you for any comments on your rela- tions with' civilian health authorities in the communi- ties in which the post is closely related to a community. Have you any difficulties along those lines? You meant something beyond vhat the liaison officers of the Public Health Service could do? Each Service Command Headquarters has such an arrangement with the Public Health Service and it has proved a very effective plan. CAPTAIN SARTWELL: Apparently there are no problems in that direction GENERAL' BAYNE-JONES; This murine typhus problem in Texas and in the Southern States is of groat interest to us. Colonel Hart of the Eighth Service Command has expressed special interest in It. There is increased troop strength in his region. Havo you anything to say about it? LT. COL. DEWEY: . Nothing in particular. The Array has not, so far, toon affooted by it to -any appreciable extent. Wo have had just a few scattered cases in the Southern part of Texas fTrom the murine typhus problem down there. That is a thing that has toeon there for a considerable length of time. Apparently from reports lit has been increasing in the last ton years. Whether that is a natural increaso or whether it is just an apparent increase, due to bettor reporting and recognition, wo don*t know. I think that that probably has quite a little to do with it. It is quite a terrific problem and ve are trying to handle.•it though the rat control program that has been stimulated in the health departments down there. So far it has not a-ccomplished a groat deal as far as vo can toll. It isn’t working, I think there is a new study going .on in San Antonio this summer in regard to flea control. General Bayne-Jones knows a great deal more about that than I do. GENERAL BAYNE-JONES: Murine typhus* was right sharp around Nashville last summer, or last fall. Then in Florida and in Georgia, 51 it is all increasing. In addition to the reporting, it is increasing among the civilians in communities in those areas. In Texas there is a considerable increase in Lavaca County and the?figures of San Anto- nio show it has gone up iri the last few years. ■' I believe last year in the city they had about ninety-some cases and three deaths. This year so far ninety cases which is considerably above the ordinary inci- dence at this time. The disease occurs among soldiers but I think they don’t get it on the post, In nearly every case wo have run down either a' .soldier who has gone out to a roadhouse or some restaurant or store whore he has teen infected hy rat fleas. I don’t know if you have any rat fleas on the post. Mayhe around some of the grain stores, warehouses• •or freight depots, hut most of the cases among the soldiers, I think this is right, have been contracted hy these men while they wore off the post. That transfers the military problem to the civilian because he would like to have those places cleaned up so the men.won’t got infected but it is a pretty large problem. COLONEL HAEDENBERG-H; I might have more to say on the'. attack of the problem as it has gone on in the pact through rodent control.. As far as I can see it is a fairly slow moving operation to got rat-proofing of houses in the poorer district where the rats are more prevalent and the houses are less suitable for rat-proofing-. It is a very difficult problem. The now attack was begun in,a small way. It probably has already begun in Georgia and I think to some extent in Texas, to see what you can do with.DDT against the-ecto- parasites of the rats, particularly the fleas. Wo have pretty good- information that by sprinkling DDT around the house, on- the floor, rat- runs and ratholes that you can greatly reduce the flea counts. You use the flea count on the rats you catch and fleas in the human habita- tions disappear. At Dakar it looked as though they were able to control plague to some extent and it is true.of Algiers so that what the idea now is, is to take a section say'of San Antonio and dust it, controlling the fleas rather than the rats at that particular time and meanwhile the rodent control problem would be forwarded. It may be a useful thing to undertake to do that from the Army point of view, particularly in the regions from which a large post or large plant draws a good deal of civilian labor. That is one ‘argument put forward, that the labor is healthy and they keep anxiety out’ and it would be good for the military service. • The San Antonio work has not started yet. ' It is.under discussion and may begin soon but it looks like an interesting thing to do, both on murine typhus control and for the information it gives us on plague control. GENERAL BAYNE-JONES? This is the type of thing that you are-familiar with. It wont from the Army Medical Center to Public Health Liaison and’ the civilian system here. COLONEL LONG: With' respect to one or tvo; of the questions that Captain Sartwoll 'raised- about reporting, I would, like to say- one word about some of our activities that may appear to some, of the Service Commands to he in the nature of gadfly activities, I would like to explain why and how we do.some, of those things. 62 Now and then you will receive a telephone pall from us saying, TIWe understand, a certain situation Is going on. What about it?" I bring this up myself because'T am very apt to be the fellow who is on this end of the telephone. There are several reasons why we do that, of course. It is not to try and show you up or to bother you in carrying out of your work but it is because very frequently, more frequently than we like, the situa- tions do come up and you will be surprised how rapidly they get into very high levels. ¥e like to be in possession of information as timely as possible. Not infrequently vre might even get a call from the War Department or from the Hill, so that when ws are calling on special situations to Service Command Headquarters; please don1! feel that wo are being cri- tical and saying, "Why haven't you called this to our attention?" We would like to know about unusual things hut sometimes things are unusual to us that are not unusual on the spot at all and very fre- quently it is a matter of reassurance that we want as much as anything else. In addition we like to have you know and remind you that we are always very glad to he of any assistance that we can. So please feel perfectly free to call us any time, not because we can necessarily al- ways he of help hut if there is any question in your mind, "Is this something that we should get out," why Just give us a ring and also remember that when we call you we are not doing it in a manner to irri- tate you hut Just because something has been called to our attention that we think we may need to have more information on before it will come through regular channels. - GENERAL BAYNE-JONES: I see Colonel Ahnfeldt in the lack of the room now. It is his turn to talk on a number of topics that are listed. We will take a little ten minute recess. GENERAL BAYNE-JONES: Colonel Ahnfeldt is the Director of Sanitation and' Hygiene Division and he has a great deal to cover - in- sect control, intestinal disease control, oiling of floors in respiratory disease control, trench foot and footbaths. I have the pleasure of introducing Colonel Ahnfeldt, LT. COLONEL AHNFELDT; • Mr. Chairman and fellow officers: I am certainly de- lighted to have this opportunity to speak,to you gentle- men and to talk about certain problems in which you have expressed a special interest. The first problem I wish to discuss this afternoon is the DDT con- trol of Insects. Effective control measures must in every instance be directed 'both towards exterminating insects at the places whore they breed, and towards the destruction of adult forms when or where they come in contact with man, or at the places where their presence is a danger to health. Solution of the problem of insect control has been made much easier during the past year with the extensive use of the DDT insecticides. The matter of acceleration and increase in DDT production required our ceaseless efforts during a largo part of the year but now I am happy to say production is sufficient to moot all military require- ments . Nine forms of DDT have been placed on Quartermaster supply tables and are available according to the. ..allowances, indicated in War Depart- ment Circular 151 and a revision thereof to bo published shortly, except for the three newest items added, - the liquid finished spray, the DDT emulsion concentrate and the DDT aerosol dispenser. 53 The following list indicates the catalog name, QM Stock Number, formula, packaging and primary use of each of these insecticides: 1. Insecticide, powder, louse, 2-ounce can, QM No. 51-1- 173 > 10$ DDT in pyrophyllito, packaged W cans to a carton, is intended primarily for individual use in the treatment and prevention of louse infestation. ■ 2. Insecticide, powder, louse (hulk), QM No. 51-1-180, also 10$ DDT in pyrophyllito, put up in 5"pound metal containers and packaged six containers to a box, is for use primarily in mass dolousing with hand or power dusters. Its uses for control of other insects will be described later. 3. Larvicide, DDT, powder, dissolving, QM No, 51-L-120, a-, comma rc.ial grade of puro DDT put up in 10-pound metal containers packed containers to a "box is issued for the preparation in the field of oil solutions for mosquito larvielding, or for making up residual spray and other DDT preparations when the finished product is not available. Larvicide, DDT, powder, dusting, QM No. 51"L-122, 10$ DDT, micronized^, that is, in talc, put up in p’PPund metal con- tainers, 8 containers to a box is designed for use as a dusting powder in mosquito larvicidingp it can be used in place of louse powder for mass dolousing when louse powder is not available as well as for the control of other insects such as roaches, ants and fleas. 5. Insecticide, spray, DDT, residual effect, QM NO. 51- I-305, 5$ DDT in refined kerosene, put up in five gallon metal con- tainers and 55 gallon steel drums, is issued primarily for fly and mosquito control and secondarily for the control of a numbor of other insects, such as fleas, bedbugs, roaches and ants to mention those of military importance. It is designed for application to surfaces upon which insects crawl or rest being applied as a wot spray or with an ordi- nary paint brush, and exerting its effect by the' prolonged residual a action of the DDT deposit. This item probably has the widest useful- ness of any of tho DDT insecticides and gives long-tom control in many instances,- However, it should bo applied by trained personnel. 6. liquid, finished spray, QM No, .169, now containing 1$ DDT and 2-J$ thanite in kerosene and put up in 5-gallon metal containers,, is for use as a general utility insecticide against, all types of insects. It is applied directly to tho insect's In:similar fashion to tho common "flit-gun" type sprays. Stocks on hand of the old formula., can easily bo converted, if desired, by adding an equal amount of refined kerosene plus tho necessary amount of DDT for a 1$ DDT,solution. Labels should bo adhered to indicate tho DDT con- tent. .... * ' ■ ‘ . 7. Insecticide, spray, dolousing, QM No. 51-L-310, con- taining 6$ DDT, benzyl benzoate, 12$ bonzocaine and lh$ Twoen-80, a . hydro carbon solvent, put up in 1-gallor and 5"gallon metal con- tainers, is a concentrate and must be diluted 1 part concentrate to 5 parts water by volume to form an emulsion-type spray. This emulsion is not stable.and must be prepared just prior to use and used within 2k.hours. It is employed principally in conjunction with fumigation or steam disinfestation procedures for dolousing and includes and effect tivo scabicidal agent. 8, Insecticide, aerosol, 1-pound dispenser, QM No, 51" 1-159.? containing 3$ DDT, 2$ pyre thrum extract (20$ pyrothrins), 5$ cyclohexanone, 5$ hydrocarbon oil and 85$ Freon-12, common refrigerating 54 gas, put up in stoel cylinders under pressure, equipped -with a release valve and packed 2k to a carton is designed primarily for control of adult mosquitoes. The DDT aerosol cylinders are finished in olive drat; the old formula which depended entirely on pyrethrum for its insecticidal activity had its dispenser finished in "black. 9. Insecticide, DDT, emusion concentrate (formerly called Insecticide, DDT, louse-proofing, underwear) QM Ho. 51“I“95> containing 2yjo DDT, .10'Jo Triton X-100 and 65$ zylone, and put up in 5- gallon metal containers is issued primarily for impregnating underwear to make them louse-proof. It must he diluted .1 part concentrate in 1.1 parts water to form an emulsion before treating underwear. After dip- ping and wetting the underwear, excess emulsion is squeezed or wrung out so that the weight of the underwear with the retained emulsion will he approximately twice its dry weight. In this way the recommended dosage of slightly over 2°j0 DDT of the dry weight of the garment will he present in the fabric. A great deal of investigative work has heen done during the past year on the relative effectiveness of various insecticides and procedures for the destruction of insects. Control measures for certain insects have heen radically modified and hope of effective extermination is much brighter due to the advent and application of DDT. II will take up first, fly control which has acquired prominence in several theaters. The control of houseflies depends on knowing their habits, ruin- ing their breeding places, destroying their larvae and killing the adults. In this, prevention of breeding is the most effective part of a fly-control program. To control breeding places, all human waste, animal manure and garbage must be disposed of or treated promptly and effectively. Powdered borax for the treatment of pit latrines and com- post piles will likely be replaced with DDT residual spray. The spray- ing of refuse piles, latrines and the like will be of considerable value in reducing the fly population. Neighboring native habitations in poorly sanitated areas are also frequently a major source of flics and should receive careful attention if at all possible, thereby allowing greater opportunity for contact action of the DDT. In treat- ing latrines, the walls, coiling, door and screens, as well as the inside walls of the latrine box, the walls of the pit: and the;.fecal contents should be sprayed. If use of the latrine can be spared until the spray deposit dries, the outside of latrine boxes should bo treated also. Present indications are that application of DDT residual spray is much more effective than the previous preparations used to prevent or kill fly larvae breeding in the focal material of pit latrines when fly- proofing has been inadequate. The use of 2-ounces residual spray per latrine scat hole (-|- ounce per square foot) applied twice weekly at first to the surface of fecal material is suggested. Local experience will determine if larval treatment need be repeated loss often. The exten- sive use of DDf residual spray in areas with high diarrhea and dysen- tery rates constitutes an essential part of all fly control programs. "Whore temperatures arc 70 degrees or higher throughout the day and night, PDB (paradichlorobenzene) has boon found highly effective also in controlling fly breeding in pit latrines. Experimental work is go- ing on in two theaters as well as in the continental United States to compare the effectiveness of PDB with DDT in this regard. You, no doubt, will hear much more about PDB if it proves satisfactory. In mess halls and kitchens whore flics are approblem, it is advisa- ble to apply DDT residual spray thoroughly to the walls, doors, screens, ceilings, cross beams, light wires, light cords and similar places. All food, cooking equipment, eating utensils and table tops must be covered before spraying is "begun. The application of residual spray 55 vith a paint "brush to door and windowascreens alone sometimes will reduce the fly population considerably. However, more thorough applica- tion is advised to include walls, ceilings, cross-beams, light cords and the like. Cloth strips soaked in the residual spray and when dry hung from the ceiling similar to present fly-tapes are surprisingly effective. These should not he hung directly over mess tables for ob- vious reasons. Application of residual spray to surfaces at the rate of 200 mg. DDT per square foot will destroy flies for several weeks to several months or more, the duration of effectiveness depending on the type of surface and the degree of'exposure of the treated area to weathering. At this rate, a quart of 5$ DDT residual spray will cover approximately 250 square feet of surface. The $pray should be reapplied when flies begin to show a definite increase in numbers. ■When immediate clearance of flies from a room is desired, Insecti- cide, liquid, finished spray which now contains 1$ DDT and 2-l/2$ thanite, should be used. This is dispersed by means of the ordinary hand "flit” gun Just as household type sprays in the past:. No special precautions need be taken except to exclude gross contamination of food. Repeated use of this insecticide may in time result in the deposition of sufficient DDT on surfaces to obtain a slight residual action but its use for such purpose would be wasteful. Coming next to the control of mosquitoes with the DDT insecticides, this use of DDT has greatly simplified mosquito control for the Array and is now playing a largo part in keeping the incidence of malaria at a low level in highly malarious theaters. Larvicide, DDT, powder, dis- solving, which actually is pure, technical grade DDT, when dissolved in various oils and solvents makes an unusually effective mosquito lar- vicide, and also an adulticido. The solutions should bo mixed,and applied by trained personnel indoctrinated in the precautions to ob- serve. Solutions varying from 5$ to 0Q5$ DDT may bo used. The con- centration may be varied depending on method of application. The im- portant factor is the amount of the active ingredient, DDT, used. It is recommended that oil solutions bo applied at such a rate as to give 0.1 to O.25 pounds of DDT per acre. A 5$ DDT solution requires approxi- mately 1 quart per acre, and a 0.5$ DDT solution, 2-1/2 gallons per acre at the dose of 0.1 pound DIT per acre. " Since the effectiveness of DDT depends on the material reaching the larvae, sufficient oil should bo used to permit coverage. The minimum amount of DDT solution in oil which can be sprayed on an acre and obtain satisfactory results will vary with the typo and DDT concen- tration of the spray available. The amount necessary will also depend on the density of vegetation in the area being treated. In brooding places where tho larvae are difficult to roach, with a larvicide, heavier applications of DDT should be made. With such heavier applications considerable residual toxicity to larvae from the DDT may occur even after the oil has evaporated. DDT oil solutions can be applied by any of the methods used in tho past for applying oils alone in larviciding. Pouring solutions from containers such as a bottle, can or bucket whore numerous, small, separated areas are to be treated; application by containers of the drip can typo for flowing streams; soaking porous materials such as sawdust, sand or wet gravel and scattering over tho water surface, or placing the porous materials in a bag and submerging in ponds; spraying with various typos of equipment available—all are effective means within their proper limitations for larviciding with DDT oil solutions. Drip- cans should bo checked frequently since some of tho DDT may precipitate out and occlude the openings. Spraying is the best method where large and,fairly inaccessible areas are to be treated,,taking advantage of 56 wind-drift. Nozzles of spraying equipment should he adjusted to give a-fine spray-depending upon the wind velocity and the area to he covered Of the types-of spraying equipment in the field the C.W.S. sprayer (Decontamination apparatus, 3-gallon) if available will prove the best. Knapsack sprayers issued by the Corps of Engineers (Sprayer, insect, knapsack typos, 5“gallon capacity; Stock No. •5“5) are satis- factory but prone to spill solution on the back of the operator unless only partially filled. I think you are all,acquainted with that dis- advantage of the knapsack sprayer. In running streams, open roadside ditches, and pools, a 5$> DDT in oil solution is advised. Applications to•running streams may bo made at widely spaced points along the stream allowing the flow of the stream to spread the larvicidc. The amount and distance between points of application will vary depending upon stream type, width and rate of flow. For places where drip-cans and porous materials soaked in oil have been used in the past suspended over or in streams to apply oils alone, DDT may now bo added allowing a reduction is the amount of oil required. In calm waters a small amount should bo poured on at different points in the breeding places. A squirt-typo oil can will facilitate application where several small places are to be treated. In larger places a lower percentage of DDT and a greater quantity of oil, applied with spray equipment, is recommended. Coverage can bo obtained with smaller quantities of oil in area treatment if a fine spray is developed and advantage in taken of the wind drift as already pointed out. Swaths of $0 to 100 foot or more can bo obtained depending upon typo of spray, vegetative cover and amount of breeze. This technique will overcome any, difficulties that might be encountered caused by the non-spreading of oils. Under suit- able ’’Conditions, area treatment may bo used also whore the breeding is in numerous disconnected places, such as for depressions, ruts and hoof prints. As to effectiveness, an initial larvae kill of 95 per cent or better is obtained from’the recommended-, dosages, One application is usually adequate for-6 to 9 days. Heavier dosages of DDT in moderate to dense vegetation can bo expected to give high residual toxicity to mosquito larvae, continuing even after the oil has evaporated. With the heavier applications, the DDT deposited on vegetation (until washed away by rains) will exert a continuing lethal effect upon adult mosquitoes who rest thereon. Similarly, the larger doses of DDT in oil spread over water also will kill the adult mosquitoes who have alighted upon the water to deposit eggs. Hence, a very effective dual control — larvae and adults — can be achieved persisting 3 to h weeks and longer under suitable conditions. In preparation of new areas for occupation by troops in highly malarious regions the use of DDT oil solutions against adult mosquitoes is an even more important application than their use as mosquito lar- vicides. • For this purpose, spraying of DDT solutions from airplanes has been developed and is ideally suited. This has proven extraordi- narily effective and equipment is continually being inproved. Another item which can bo used for mosquito control is Larvicidc, DDT, powder, dusting, consisting of 10$ micronizod DDT for use on mos- quito larvae as paris green has boon used in the past. This powder is a stock mixture from which to prepare the final larvicidal dust by mixing with any available diluent ouch as pyrophylllto, talc, cement, condemned flour and road dust. A final dust containing from 1 to 5$ DDT is suitable for practical, application, but 2 per cent is recommend- ed for average conditions,. It is applied with hand dusting equipment 57 at a rate of 0.1 pound of active ingredient per acre, and will give practically 100$ control for .1 week. The rotary hand duster supplied "by the Corps of Engineers is suitable for dispensing this item. In thick vegetation, which will prevent shifting of surface dust films from wind and wave action, a residual kill for several weeks to two months after treatment may he expected if larger applications of 1 to 2 pounds of active ingredient per acre are made. Dusts with a per- centage of DDT higher than 1 to 5 per cent may then he used. In open breeding areas with relatively scarce vegetation, however, it is wasteful to apply more than 0,1 pound of DDT per acre since the treat- ment may become ineffective within a week due to this shifting of surface film. The time for additional treatments must still he based on dipping records. The use of Insecticide, DDT, residual effect for adult mosquito control is a highly effective long-term measure similar in effective- ness to that described for flies. When used in mosquito control, it is necessary to spray thoroughly the walls, doors, ceilings ■, screens and other places in buildings, hutments or tents whore mosquitoes are prone to'rest. Dark comers or other portions of sleeping quarters where mosquitoes are seen to rest in large numbers should receive an extra heavy spray application. In malarious regions, native habitations within a radius of at least one mile of perimeter of the cantonment area should receive a residue spray treatment, and this may well pre- cede spraying of military installations to kill infected mosquitoes at the source. Certain species, especially some of the anophellne mosquitoes, also rest in out-buildings such as bams, chicken houses and privies, and fly into human dwellings at night to feed, making it necessary to treat such buildings also. These, as well as mosquitoes that rest on the walls of living quarters either before or after feeding, will then be killed by contact with the DDT on the treated surfaces. An outdoor use is also suggested. For encampments, outdoor theaters and other assembly places surrounded by-dense vegetation in areas where the percentage of malaria infested mosquitoes is high, apply the residual spray to all the vegetation in a °r wider band encircling the area to be protected. Experimentally this type of treatment has been found to cause up to a 95$ decrease in the num- ber of mosquitoes in the protected area up to a week and even longer. Tho duration of effectiveness will vary with the amount of rainfall, since rain will eventually wash the DDT deposit off of the vegetation. The use of a vehicle for tho DDT with greater viscosity than kerosene my prolong its effectiveness.* This barrier treatment is well worth- while trying. Reports concerning its effectiveness under field condi-j t/ions will be appreciated. Tho uso of DDT residual spray offers an officiont and easy proce- dure for continual destruction of mosquitoes over prolonged periods of time, and from the preventive medicine viewpoint is a highly important use of DDT in destroying mosquitoes infected with malaria, yellow fever, filaria and dengue. The aerosol insecticide dispenser has already carved a secure place in tho insect control armamentarium against mosquitoes. This handy, scIf-discharging, dispenser has proved invaluable to troops in highly malarious theaters for adult mosquito control. The addition of 3$ DDT makes this insecticide even more effective. It is suitod for use in all typos of enclosures--barrabks, billets, pup tents, bomb- shelters, trenches, foxholes and the like. : The insecticide is released in almost gaseous form (aerosol) which pervades the whole atmosphere in contrast to the ordinary sprays, and remains in a still atmosphere 5.8 V from. 2 to k hours, thus giving continued protection against additional insects coming into the enclosure after time of application. Due to a scarcity of pyrethrum flowers the distribution of this item has had to be limited to overseas'theaters and ships hospitals. In the conti- nental United States it is used only in disinsectization of aircraft to comply with quarantine" requirements, and a few are made available for training purposes. The item. Insecticide, liquid, finished spray, is a general uti- lity spray and completes the array of DDT insecticides available for mosquito,control. The control of other flying insects such as sand flies, midges, gnats, punkles and dog flies (Stomoxyx calcitrans) whose breeding places, may bo impracticable to destroy can bo controlled by the appli- cation of the DDT residual spray (insecticide spray, DDT, residual effect). Residual spray applied to screens and the outside, of build- ings and tents will usually reduce the number of such insects which may gain entrance. Application to the interior of the quarters as well will further enhance the effectiveness of control. The.spraying of mosquito nets will fortify the protection afforded by such equip- ment.' The control of lice is of social importance, particularly under combat conditions, because of t..o seriousness of the diseases, epide- mic typhus, relapsing fever and trench fever, which they transmit. Due to the development of highly satisfactory prophylactic measures, ,'jfche disinfestation of troops has not presented any groat problem during this war. For both the treatment of lousiness and the prevention of further infestation the application of DDT louse powder is the method of choice. For individual use, the 2-ounce cans of louse powder are avail- able. For mass dclousing of either troops or civilians with powder dusting equipment, louse powder in bulk (10-pound cans) is available. In the latterdisrobing of the individual is not necessary for, appli- cation of the powder. Dusting is accomplished by means of compressed air equipment (Outfit, dolousing, gasoline engine driven) and a special dusting gun developed by the Sanitation and Hygiene Division, This equipment is supplied by the Quartermaster. Disinfestation of head lice or crab lice may bo accomplished by dusting louse powder into the hair of the head or of the body, allow- ing to remain for 2h hours, and repeating twice at intervals of one week. The powder is not effective against eggs -- hence the necessity for re-application. Residual spray is useful in controlling lice if applied to the floors and lower walls of quarters and of conveyances such as trucks, coaches and troop compartments of ships, Seats, bunko and other fur- nishings should also bo treated. Residual spray applied in this way will also be effective against bedbugs, fleas and other non-flying insects at the same time. For use in do lousing o enters such as have loon established in con- tinental U, S. Ports of Embarkation and overseas, there is available the dolousing''spray (insecticide, spray, delousing) which may be safely sprayed on the hairy parts of the body and on the head. This insecti- cide is employed following the bath required in the fumigation or steam sterilization methods of disinfestation. The spray is both lousicidal and ovicidal and is also an effective scabicide when applied to the skin. Detailed instruction for the use of the delousing spray have been furnished ports of embarkation and fumigation and bath units and will also bo included in the forthcoming manual or TB Mod on the DDT insecticides. 59 ■ For sal:© of explanation, 'methyl Bromide fumigation was the first method for disinfestation developed By the Sanitation and Hygiene Division during this way. Later an individual field method with methyl ■bromide using-Bags, delousing, was developed. And'finally, the develop- ment of DDT louse powder "by this Division has largely supplanted the other methods except for special situations. ■ Methyl bromide fumiga- tion or steam disinfestation are used where immediate and complete disinfestation (including lice eggs) of clothing and Baggage is required. A new-model steel fumigation.chamber is, now available on requisition to the Quartermaster to all named general hospitals upon approval of the Surgeon General's Office. Smaller hospitals with a lower admis- sion rate may find it Just as satisfactory to dust louse powder By hand or with a dust gun onto the clothing and into the Barrack Bags of patients requiring same as they are admitted to the hospital and prior to placement in the patient’s clothing room. As an alternate, Bags, delousing,and 20 cc methyl Bromide ampules may Be employed I point this out particularly Because I Believe these items have not Been availaBl© until very recently to the service commands, and now that the service commands are charged with the responsibility of the hospitals as well, I think it would Be appropriate for the medical inspectors to call to the attention of the C.O’s of those hospitals, the availability of these several means of disinfestation. Present directives and those in process of preparation will require complete delousing of troops overseas prior to embarkation, Physical inspections will Be made prior to debarkation and if any lousiness is detected then, further disinfestation will Be accomplished at the port of debar- kation, No disinfestation will Be required, nor should any Be -neces- sary, at inland reception centers, Troop ships are to carry stocks of louse powder which will Be used as conditions indicate. For control of bedbugs DHT residual spray "bids fair to: entirely replace fumigation methods. The application of k to 6 ounces of rosi- dual spray per hod, including springs and mattress, will completely eradicate bedbug infestation for 6 months or more. Approximately 1 quart of the solution should he used for every 5 teds and mattresses. Spraying will he facilitated hy placing mattresses 8 high along the middle of the floor and standing the heds on end against the wall with the underside facing inward. In treating hods, application of the spray should he to the underside, paying attention to favorable hiding places, and allowing the surplus spray to fall oh the wall behind the beds. In spraying mattresses, particular emphasis should ho placed on treating all seams, crevices and tufts, for obvious reasons. For ex- peditious handling a team of two men is recommended -- one to do the spraying, the other to turn ovex- and remove each mattress after spray- ing, If no spraying equipment is available, application of the solu- tion :by means of a paint brush is satisfactory. A slight moistening of the surface is all that is required. The insecticide acts slowly, bub when the above procedure is followed all bedbugs will be dead in 2A hours as a rule. No smoking or fires should bo allowed in the quarters during spraying and the barracks should be aired out com- pletely following the treatment. Operating personnel should be required to wear-suitable masks or respirators while in the barracks being treated. Roaches and ants may Be controlled By the 5$' DDT residual spray or a 10$ DDT powder, A thox-ough application of DDT residual spray will give several weeks’ or more protection from roaches orients. The duration of the effect will depend to some degree, on how quickly the residue is removed By the daily cleaning of the messhall. The residual spray is preferred for roach control wox-k. Because- treatment for control of flies and mosquitoes can Bo accomplished at 60 the same time. It is applied by ordinary hand'sprayers of power sprayers to such resting and hiding places of roaches as under serving tables, sinks, cupboards, refrigerators, around water pipes and hot water tanks, and into cracks and crevices of the wall. It mil be found that the German cockraoch is more resistant that the American cockroach and an increase in dosage over 200 mg DUE1 per square foot when applying the residual spray may be necessary to effect its con- trol . For control of ants residual spray may be applied to nests, door- sills, window-sills, foundations and other places where ants crawl. Lawns or grass plots where ants are prevalent can be treated with re- sidual spray with the liklihood of better coverage and more prolonged action due to improved adherence of the DU deposits to the grass, than when using DDT powder. In that regard,’some of your commanding officers might object to the use of the DDT spray because it may spoil their nice lawns. I understand it stains grass to some extent, but the pow- der will work almost as well as the DDT spray. The 10fo DDT powder (Larvicide, DDT, powder, dusting) for roach and ant control is,applied lightly with an ordinary hand-operated dust gun. Not over 10 pounds of powder is necessary to treat the largest toesshall. Application is made to the same locations one would apply residual spray. The powder is loss desirable than the residual spray because it is more readily removed in cleaning, and also is unrightly. Fleas, important as vectors of bubonic plague and endemic typhus fever, are best controlled with DDT1 by treating infested human dwell- ings as well as the occupants and pets. In conjunction with rodent control programs, DDT louse powder or DDT residual spray may be applied to the floor and lower parts of walls of infested quarters. Dosages of 200 mgm. of DDT per square foot are advised, On earthen floors the ( dosage must be considerably greater. Louse powder should be used for the occupants and pets and may be applied by the same individual and mass dolousing methods applicable in the control of lice to prevent epidemic typhus. As for mites or chiggers, those treed in areas,, of grassy vegeta- tion and feed on rodents at a certain stage of their development. In addition to individual protect’vo measures,; control-should ho directed toward clearing camp areas of low-growing vegetation as well as toward the extermination of rodents. Heavy DDT spraying or dusting of the ground around hods and in the camp area may prove effective in eradi- cating mites hut has not heen fully evaluated as yet. For individual protection the wearing of dimethyl phthalate impregnated clothing A is now used for temporary protection of troops operating in mite-in- fested areas. In control of' ticks the DDT preparations have not boon found to be particularly effective and their use for this purpose cannot be re- commended. The use of tho standard triple-mixture repellent is the best measure available for individual protection against ticks, Tho wearing of clothing, impregnated with an emulsion of dimethyl phtha- late or sprayed with dimethyl phthalate also will give partial protec- tion. . I have felt that tho matter of toxicity of tho DDT insecticides also should bo discussed with you at, this time, if only to Indicate the precautions to bo observed. It should bo pointed out that although DDT can be handled safely it is nevertheless a toxic material. Person- nel should bo trained thoroughly in the application of the DDT insecti- cides and the precautions to observe, and should not bo allowed to dis- 61 regard precautions .recommended. Symptoms of DDT poisoning in laboratory animals are loss of appe- tite, weight loss, hyperpxcitabllity, tremor and finally convulsions. Disfunctioning of the liver and kidneys may precede the onset of ner- vous system manifestations. An increase in the prothrombin time parallelled by a rise in the icterus index were noted in one instance followed by an increase in the urinary output to several times its normal volume. Those findings plus a moderate leukocytosis occurred prior to the onset of nervous symptoms. When tremors first appeared they were coarse in nature, involved the entire musculature, and were particularly marked in the logs upon standing and in the muscles over the eyes. The tremors decreased when DDT was withdrawn for a day. Animals given DDT until a fatal termination show a toxic necrosis of the liver and kidneys frequently enough to be significant. Most of these animals show some evidence of degeneration of•the anterior motor neurons of the spinal cord.. Other organs are essentially negative. Toxicity for man' must be decided from these animal experiments since no- proven case of DDT toxicity in man has occurred. Three indi- viduals, subjected; accidentally or otherwise to extraordinary amounts of DDT in the course of their work were carefully examined and observed for an extended period to note any variations from the normal. Re- peated physical, neurological and. laboratory examinations revealed no symptoms or signs of untoward effect from their exposure to DDT. While these findings were not considered conclusive they did indicate a certain degree of tolerance for DDT on the part of human beings. Any. individual using DDT insecticides in the field and suspected of displaying evidence of toxicity to DDT should be removed from fur- ther contact and placed in a hospital with adequate facilities for making a careful and complete examination including neurological and repeated liver and kidney function tests. Report of such study should be forwarded upon completion to the Preventive Medicine Service, Office of The Surgeon General, to add to the present knowledge con- cerning toxicity for man. If possible, information should also be furnished concerning the following; (1) DPT insecticide employed. (2) Estimate of amount of DDT contacted. (3) Manner of contact -- skin absorption, ingestion or inhala- tion. ' ;- Duration of contact, (5) Any other factor of significance. Dry DDT as used in inert p.owdeys and dusts is not absorbed through the skin nor is it readily absorbed when injected subcutaneously or intramuscularly* The use of 10$ DDT louse powder in conjunction with insect repellent, though * is not recommended* Repellents are sol- vents for DDT Which then can be absorbed through.the.akin. If under- wear dusted with louse powder are accidentally and grossly contami- nated with oil, they should be changed and the contaminated area of the’skin washed with soap and water. Inhalation of 10$ DDT powder as normally used in the field will not produce any toxic effects as indicated by laboratory studies and corroborated by the large scale typhus control dustings in Italy, Yet, it" might be wise for operators engaged in mass delousing or large scale dust larviciding to use suitable respirators or dampened gauze masks when dusting indoors or Under conditions where the atmosphere does’not carry the dust cloud aWay from them. 62 ’ By mouth, DDT is acutely toxic to laboratory animals.' Because of wide variation in individual susceptibility, the determination of a .safely tolerated dose is extremely difficult. The upper limit of tolerance in dogs on daily ingestion of dry DDT powder appears to' lie between 50-100 mg. per .kilo per day; tolerance in some of the other smaller animals is considerably less,' Moreover, when-the same dosages are given dissolved in com oil, tolerance is reduced over 50 per cent. Hence, care should be taken to prevent contamination of food. This is especially important because DDT is a whitish, odorless and taste- less powder bearing a physical resemblance to flour and offers no warning upon ingestion. All foodstuffs, cooking utensilsy eating utensils and tabletops must be covered when dispensing DDT in any form in messhalls. Storage of DDT with food should be- strictly pro- hibited in order to prevent mistaken identity. Solutions of DDT in oils and organic solvents can be absorbed through the sld n making it necessary to avoid unnecessary contamination of garments and sbld Coveralls and suitable gloves should be worn when mixing and dispensing such solutions. Occasional contact is apparently nor. dangerous but prolonged contact must be avoided, When individuals accidentally contaminate themselves they should change their clothes, including DOT dusted or impregnated underwear, as soon as practicable and wash their body thoroughly with soap and water. To reduce the possibility of contamination in dispensing such solutions, paint sprayers and the decontamination type sprayer are preferable to the knapsack type. When knapsack sprayers are employed they should not be more than three-quarters full to prevent spilling. - Continued inhalation of oil or kerosene sprays containing 5$ or more of DDT may produce toxic effects since absorption of DDT from the respiratory tract is facilitated by such solvents-. In this con- nect-ion, it has been shown that solution of DDT in fatty oils in- creases ■its toxicity from inhalation over that observed when dis- solved in'an organic solvent such as cyclohexanone'. While dispensing Insecticide, spray, DDT, residual effect (5 per cent DDT in kerosene) indoors for prolonged periods as for treating walls,-ceilings, fix- tures, beds, matresses and the like, suitable respirators or cloth masks should be worn by the operators. Procurement of a new formula for Insecticide, liquid, finished spray containing 1$> DDT and 2-l/2f, thanite in kerosene instead of the present 5$ thanite in kerosene as mentioned previously was recently initiated. No special precau- tions need be taken in the normal use of this latter spray other than those which will exclude the gross contamination of food. Rabbits were exposed to a heavy mist of Vjo DDT in kerosene U8 minutes daily for four weeks without toxic effect. By mouth, DDT preparations in oils and organic solvents exert considerably greater toxic effect than in powder form. The ingestion of 50 to 80 mg, per kilo per day in a solution of corn oil causes fatal poisonipg in dogs in three to five weeks. Hence, operators should take precautions similar to those prescribed in dispensing DDT as a powder to prevent contamination of food when spraying in mess halls. DDT solutions should not bo stored with foodstuffs. As for DDT in aerosols, the concentration of DDT in the atmos- phere when dispensed according to instructions (k seconds por 1000 cubic feet) in a 1 to 5$ DDT aerosol formula is exceedingly-small and can bo breathed under the normal conditions of its use witnout ill effects. A 3fo DDT aerosol will give approximately 0.06 mg. DDT per cubic foot at the above dofageV Exposure of dogs, rats and guinea pigs to initial concentrations respectively of 12,kk and 6,22 mg, of DDT per liter of air over a period of minutes caused no 63 toxic signs or symptoms. Chronic toxicity studies demonstrated that exposure of monkeys for 2 hours and Ip minutes daily for four -weeks and mice for h-5 minutes daily-for 5 weeks to a concentration of 0.176 mg.DDT per liter of air (5*0 mg. per'cubic foot) produced no toxic effect. Daily exposure of human-subjects for 1 hour to a concentra- tion of 1.0 mg. DDT per cubic foot showed that a 1 to 5$ EOT aerosol offers no health hazard under conditions required for its use. It was further found that tho DDT in the atmosphere settles out fairly soon. Underwear impregnated with a DDT emulsion prepared from Insecti- cide, DDT, emulsion concentrate wore worn in field tests for periods from .1 to h months without toxic effect or irritation of the skin, and retained their lousicidal effect during that time. The only potential hazard involved when they are worn is to personnel handling fuel or lubricating oils.. . Spilling, of oil on the underwear may bring tho DDT into solution again which could then be absorbed through tho skin. Changing to another pair of underwear, and a bath with soap and water will prevent untoward symptoms. Personnel engaged in impregnating underwear with DDT emulsions in the field should avoid dipping their arms in the prepared solutions or handling the wet garments with bare hands when wringing them out and hanging them upttondry. Ladles or tongs of some sort should be provided for im- mersing the underwear, and preferably rubberized gloves for the operators’ hands. The Vjo DDT emulsion used as a dclousing spray to hairy parts of the body and prepared from tho stock of mixture,-..Insecticide, DDT, spray, dclousing by diluting with five parts of water was submitted to toxicity toots and found safe to apply to tho skin. Since tho stock mixture contains 6io DDT, personnel preparing the final solution should take ordinary precautions to avoid contaminating their hands with the stock mixture, Good ventilation should bo provided and ro- tation of operating personnel is recommended when spraying for long periods indoors In a comprehensive statement the toxicity' of DDT may bo summarized as. follows; ' ■ • "• • • "The DDT' insecticides adopted for use'-can be safely employed, but it must not be overlooked that DDT is a toxic material. In general, inhalation of dusts, sprays or mists containing DDT -should be' reduced to a minimum. Whereas-' dry DDT ■'■as used in inert powders is not ab-’ sorbed through the skin, solutions of DDT-in' oils and organic solvents can be absorbed through the skin and, therefore, unnecessary skin con- tach should be avoided. For this reason, use Of repellents In con- junction with DDT louse’powder is not' advised; and garments, includ- ing DDT dusted or impregnated underwear, accidentally contaminated with oils in the presence of DDT should be changed as soon as practi- cable, tho individual washing himself thoroughly with soap and water. Contamination of food with DDT must be prevented. This is especially important because DDT is" a white, odorless and tasteless powder and offers no warning upon ingestion. Storage with food should be strictly prohibited to prevent mistaken‘identity, , Symtoms of DDT toxicity in animals are anorexia., weight loss, hyperexcitability, tremor and con- vulsions. Signs of liver and kidney disfunction may precede nervous manifestations. Pathological findings in fatal poisoning induced in animals consist in some evidence of degeneration of the anterior motor neurons, and may include toxic necrosis of the liver and kid- neys ." • '■ 64 I have purposely taken considerable time to discuss the DDT in- secticides since this is the topic of moot general interest. Now, I would like to make certain remarks regarding measures for intesti- nal disease control. Within continental United States water supplies are relatively well controlled and practically no intestinal disease is duo to contamination of water. The principle cause of diarrheal diseases in this country appears to ho defective mess sanitation in posts, camps and stations. Sporadic cases also are occurring among army personnel who have oaten at unsanitary civilian establishments. It should be pointed out that the control of those establishments located near a camp area is a responsibility of the post medical officer in conjunction with local civilian health authorities and effective measures should bo taken. Outbreaks of intestinal disease occurring within a camp have most often been duo to food infection or food intoxication indicating that examination of moss personnel and supervision of food preparation were at fault. Particular attention should be directed towards the periodic examination of permanent food handlers and towards the daily inspec- tion of all mess personnel when coming on duty. Not only should care be taken to insure the elimination of intestinal disease Carriers, and those having purulent skin infections, but continued training should be given food handlers so as to keep them constantly aware of , factors, involved in moss sanitation. Where sufficient hot' water is not available for rinsing dishes in accordance with AR h0-205, the use of Compound, germicidal rih.se, QM No. 51-G-1606, is advised. It is suggested that oven whore ade- quate hot water facilities are present, a small amount of this material may bo kept in stock for emergency uso. Compound, Germicidal Rinse is a powder, packed in cardboard boxes, which when placed in solution liberates chlorine. When dissolved according to directions printed on the label (one unit in twenty-five (25) gallons water) the resultant solution contains twenty-two' (22), parts per million chlorine upon testing by ordinary methods. The solution is buffered so that the free chlorine is gradually replaced by more free chlorine from the azochloramid in the powder,, as it com- bines with organic material added to the solution. Thus at the end of a dishwashing period, after treatment of tho moss gear of 200 men, tho solution will still show by test between five and ton ppm free chlorine, A wetting agent Is contained in,Compound, Germicidal Rinse which-- lowers the surface tension of water to less than forty (hO) dynes per square centimeter, This insures intimate contact,, of the solution 1 with all surfaces and assists in draining tho solution from moss gear as'it Is air-dried. ' Compound, Germicidal Rinse should never be used in boiling water or oven very hot Water since tl o heat will drive off the chlorine , and inactivate the solution. Neither is its uso advised in cold water (below 60 degrees) since chemical activity is slowed down at low temperatures. For disinfection of dishes at army mosses, the effective temperature range for tho solution probably lies between 60 degrees F. and 90 degrees F. (NOTE: Actual tests wore at room temperature of approximately T5°F.) After immersion of mess goar in germicidal rinso solution, proper stacking of dishes is sufficient to insure air drying, Caro should be given to invert cups so that they do not stand in a pool of solu- tion after draining, and to silverware so that bowls of spoons do not 65 RESTRICTED hold solution. If those items are handled properly, there should he no residue to give an unpleasant odor or taste to dishes. The rinse •with compound germicidal rinse solution is to he the final one. Be- tween 'the washing procedure and the final rinse a rinse in clear water is advised. In addition to its present use for the disinfection of mess gear, where adequate amounts of hot water are not available for their proper disinfection, Compound, .germicidal rinse can he used to disinfect vegetables and fruit that are to ho consumed raw by employing the-, fol- lowing method; •. . . ‘ a. After the removal of visibly soiled or damaged outer leaves (stalks of celery-, heads of lettuce, cabbage, cauliflower, etc, are not to be broken or cut until after treatment), the vegetables (0r fruit) are rinsed thoroughly in potable water. b. - Place the trimmed and.rinsed vegetables or fruit in.a.clean container, cover with.a germicidal rinse solution prepared by dis- solving one unit (one(l) package ■. containing 3*36 ounces) of germi- cidal rinse in approximately eight.gallons of potable water and allow to ‘standi-for -thlfty'minutes , -After removing the germicidal rinse so- lution, re-rinse the vegetables, or fruit thoroughly in potable water. This procedure has been found satisfactory by the National Research Council to kill' pathogenic bacteria, amebic cysts, and schistosomal cercaria. The germicidal rinse solution should be discarded after each use'And1'a fresh solution prepared for each succeeding immersion. It is likely-that there will be no occasion to. use germicidal rinse for the disinfection of vegetables and fruit in con- tinental United States , although it may be. used any time the medical officer considers-it desirable. - The next' item that I would like to talk about i$- the oiling of floors .■ I would like to acquaint you with a procedure which is likely to he standardized soon. During the past year the Commission on Air- Borne Infecti'on; Army Epidemiological Board, has been studying the 'effect of oiling of floors and bedclothing in barracks upon-the inci- dence of acute respiratory diseases. These studies have demonstrated clearly the advantage' to be derived from such procedures in reducing the bacterial count in the air. Moreover, oil treatment of floors and bedclothes appears to definitely reduce the admissions to hospi- tals for these infections among men living in barracks where such oiling has been accomplished. It has actually been demonstrated with regard to bacterial count of the air in a tpst performed at one camp that bacteria were reduced from 3500 per cubic foot to 500 per cubic foot by oiling floors alone and to 75 per, cubic- foot when both floors and bedding were treated, which you can see is quite a remark- able reduction. ■ The first- oil preparation used for treating bedclothes developed some rancidity and unpleasant odor. It was discarded and another, preparation is now being tested. This appears to, be as effective- as the first preparation and is satisfactory from the, standpoint of odor. However, sufficient testing has not been carried out to warrant its standardization at this time. ■ ■ The oiling of floors has proven successful from the start and ;this procedure- has been submitted to ASF Headquarters for standardi- sation. The Office of the Chief of Engineers has requested that standardization of the oiling of floors be delayed until they can test it out on the various types of materials now being used for flooring and also on floors that have already been treated with a 66 sealing compound. While the oiling of floors' may he designated as an Engineer function, it should he of interest to briefly describe the procedure; The oil used is a pale floor oil.' It is applied at the rate of 1 gallon of oil for each 150-175 square feet'of surface. One •application is effective for six months except for'the' center aisle and bathroom floors which will require additional applications at inter- vals of two months, A detail of 6 men require 30 minutes to apply the oil to the floors of a 32-man barracks. In addition to barracks, the oil’treatment*is of value in mess halls, classrooms, dayfooms, offices acrid other rooms where men congregate in numbers. One point to remember is that when a mess hall flooriis oiled, the adjoining kitchen and pantry floors should also bo oiled because men walking from the oiled floor onto the unoiled floors will leave track marks which appear unsightly. ■' I remember that particularly in a trip I took to Fort Bragg. I spoke to one of the mess sergeants and asked what he thought of the oil treatment of the floor in his moss hall. He liked it.’Very much, except for- one objection. Ho said, nLook at my kitchen floor11 and there were track marks all over the kitchen floor that' had been carried in there from the treated floor in that portion of the mess hall where the'mess tables wore, • ‘ •' ” " The essential thing in oiling any floor is that the floor'should ho thoroughly cleaned with soap and water, and as much dirt as possi- ble1 removed from the cracks in the floor. Unless this is done, the oil will loosen all the dirt and the floor will have an unsightly appearance. Mon wa,Iking on the floor With their hare feet then will transfer the dirty oil to their clothing and other personal effects.! Uhere feasible, the floors may he smoothed with a sanding machine* - before the oil is applied. Thin makes a much more presentable'floor in that the oil brings out the grain in the wood. Floors covered'with linoleum, asphalt, tile,- etc,, -which'''are not suitable for this' type *of oil treatment may bp treated daily by-using a sweeping compound composed, of 2-l/2 gallons of the floor oil mixed with 100 pounds of sawdust. In sweeping the floors with this compound, sufficient -oil mil be deposited on the floor to retain all dust. As soon as standardization of this procedure has been accomplished, a War Department Circular will be published giving full details and establishing responsibility for-carrying out the procedure. The method of bedclothing treatment which is now undergoing tests is accomplished by adding oil during the usual process of laundering the bedclothing. An oily, aqueous emulsion is used. If and when this procedure is standardized, it will only be necessary to add an additional step in the laundry process, and consequently; the entire procedure will be carried out in the Quartermaster laundry. The medical inspector’s chief concern in this procedure will be to see that all the bedclothing of a given unit is oil-treated at the same time. Otherwise, the oiled bodclothing will soon become mixed with the untreated clothing, since it will bo difficult to determine which has been oiled merely by looking at or feeling the bedding, I might say that there is no sensation of oiliness in touch- ing either the blankets or the sheets and pillow cases that have been treated in this manner. The ideal procedure is to have the treated bedclothing used in barracks, the floors of which have been-oiled, because only by the use of this combined floor oiling and bedding treatment is the maximum 67 ■benefit dorivod. A War Department Circular aloe will bo '.published when the oiling of bodclothing becomes a standardized procedure. The next topic on the agenda is trench foot. Trench foot has become a tremendous problem this winter in European combat areas. The high incidence of this condition is in part duo to environmental factors difficult to correct, but a great deal can bo accomplished through individual foot hygiene. •The Quartermaster is supplying improved foot wear developed in conjunction with the Sanitation and Hygiene Division and adapted to the conditions present on the western front. The theaters are advised that training programs within .service commands be carefully review- ed so that proper emphasis is placed on foot hygiene in the prevention of, trench foot, and also on the intelligent use of the-'footwear pro- vided, ■ iV- '■-r To dosignato what they are, Shoo-pac,. 12-inch, and heavy ribbed wool socks (Socks; wool, ski) are issued. As an alternate-, the man can. use artic overshoes over the combat boot and various combinations of wool hose, that is, for example, they can use a’pair of light wool hose and a pair of heavy wool hose over same. From the standpoint of: equipment that is best suited for this purpose, however, It is the Shoe-pac worn with two pairooQf Socks, wool, ski> ad we see it- now. Further investigative., work, is going on concerning'this particular problem. , • I can call.your attention particularly to Sec. IV ¥D Circualr 312, 22 July 19M+, TB. Mcd -#8l, h August and alsO-:to aiticlos • .-published.during the past year in the Army-'Medical Bulletin and in the SGO publication, ."Health", I think it is perfectly obvious’that the best of footwear would be useless unless properly worn, and other oppacures prescribed are carried, out;.a.'W' Circular #312 makes the -prevention of trench foot a command .responsibility,- prescribes dii- struct ions to be given-.to the individual soldior and also the foot- wear he is to, wear. .Therefore, training.of. the soldier in the preven- tion of trench foot becomes highly important. WO would bo pleased to have, .you.-give, this matter your attention.. • bb .Ja - The .next thing I. wish to diacuss: is the matter of foot baths, - Aa you all know, this has "been a troversial question in the Army for years; i-anccertain that .all of you have doubted for some time the value of present foot.baths, I can say that skepticism has now been confirmed by. the If at ional Research Council, However, we have been slow to issue specific directives regarding the use or disuse of chlorine foot baths, due to differences of opinion which have existed until recently among authorities on this subject. j / The consensus now is that hypochlorite footebath solutions are not effective in the prevention of spread of dermatophytosis. Failure to prevent spread of fungous Infections by the use -of foot bath solu- tions which liberate free chloring has been attributed to various factors inherent in chlorine solutions. Of chief importance among these factors are the variable rate of decrease in concentration and limitation of range of effective fungicidal concentrations. The former factor is more or less common to all foot bath solutions; the latter is peculiar to chlorine solu- tions, Limitation of range of effective fungicidal concentration is due to the following features; a. The active fungicide, hypochlorous acid, is not formed in 68 effective amounts above pH 8, b. Strong solutions of calcium or sodium hypochlorite yielding 1000 parts per million of free chlorine have a pH above 8 and are too alkaline to form effective amounts of the active fungicide. While the use of this concentration would be practicable as regards main- tenance it would be ineffective as a fungicide. c. Although dilution of hypochlorite solution produces greater dissociation, a lower pH, and more of the active fungicide, an effec- tively low concentration yielding 100 parts per million.of free chlorine would require hourly replenishment when used by as few as fifteen men. The use of this concentration is therefore obviously impracti- cable . It seems probable that any foofbbath solution would be ineffec- tive for the following reasons; a. Even if footbbaths killed all the free spores, a certain proportion of spores are encased in the keratin of epidermal scales. b. Any solution which would dissolve;keratin rapidly enough to be ■ effective •'In killing keratin-encased spores in a foot bath would also dissolve--the horny layer of the sole and produce a severe derma- titis . v •■■■■■ -: v ■■ c. The spores which are keratin-encased are tracked onto floors adjacent to foot baths, subsequently become, freed from the scales, sponllate, and then serve as the main source of reinfection. .. It is therefore suggested that emphasis be placed on the fol- lowing methods of prophylaxis i - a. .Flushing of shower room and dressing room floors with water under pressure, b. Scrubbing of floors with ‘brush and detergents. c. Exposure of flooring or duck-boards wherever practicable to direct, unfiltered sunlight after application of the methods des- cribed above, d. Preventing men from walking around barefooted in dressing rooms and barracks but instead insist on them wearing socks, slippers or shoes. In.conclusion, I should like to thank you for your very kind ; attention, gentlemen, and state that sanitation in general in the Service Commands has been beyond reproach and for this you gentlemen deserve unstinted praise. (Applause) . GENERAL BAYNE-JONES: Colonel Ahnfeldt very thoroughly covered a number of intensely interesting subjects coining under sanitation, I would like to open it up to you for any questions that you -want to ask him. About the DDT paper, Colonel Ahnfeldt has copies that you can have to take with you. COLONEL ABNFET JPG?; Captain Shaffer has a number in the hack of the room. I have enough for everyone here if they care to take one with them. I thought you might like more detailed information on the DTT.insecticides. There hasn’t heen too much published on DDT because of restrictions. MAJOR WALKER; I should like to ask him if these sheets shouldn’t hear a classification of "restricted"? COLONEL AHNFELDT; I -was afraid someone would ask that. This information is the same as we propose to put out unclassified in the revision of War Department Circular 151* I think 69 RESTRICTED ohat that has now been cleared around the War Department, we haven't re- ceived any objection whatsoever and the same applies to this material. As a caution for the timebeing I suggest you don’t divulge the information to any°nQ except to those,to whom the information is important in your own service-commands, - . GENERAL- - BAYNE--JONES: , We are having a great many arguments with the Joint Securi- ;ty Control over the whole publicity and release of DDT. . . Nearly all of it is in the.open now except for security reasons the larvacidal part, and I. hope that that ,will "break down, too, soon. Practically all of it has been in the newspapers, hut it hadn’t "been cleared entirely hy Joint Security Control simply because of the tie- up with larval control in overseas areas. GOMEL KOGEL: I would like to ask one question. From the teaching stand- point; it seems as if there is very little liaison "between . The Surgeon General's Office and the Chief of Engineers. We #will get through talking-to the men against dry sweeping with-respect to disease control- and the next day a student will "bring a-pqster which he has taken off the "barracks wall and it says; ■■’’Preserve-wood;, conserve the floorr dry sweep'1. GEKERAL BAYKE-.JOKES': :'■> >Will you get us one of those posters .and send Tt? COLOKEL AHKEELPT: ■ That might he one of the reasons for the Engineers hesi- tancy about floor oiling. The ostensible purpose is to try it out against various types of flooring. -. . I-, thought we had an effective .liaison between The. Surgeon General’s Office and the Engineer's Office. Colonel Bardenbergh,.isn’t it Major Poilman, Sn.C. over, there who is our contact usually? He has always been very cooperative. But from-what you.say, Colonel Kogel, there ap- parently 'have been some contradictions in policy distributed. A VOICE: Yps, sir. GENERAL BAYNE- JOKES: We are glad you brought that up; Colonel Kogel. COLORED KCWLj> ■- There/is. another similar-thing. We. get through talking to .them .about giving .the. men - the maximum .floor space-and the Chief of Engineers a directive to- us, "In every hit of available space, put as many men in as possible in a particular location." He could;.'¥ord it a.little more diplomatically /• so as not to make, it so hard-, for us-to put some of these points across. (SEERAL BAYNE- JONES; The question of floor space per man.in the barracks has been a subject of intense, anxiety with The Surgeon General for a long time. It was taken up hy the Committee, Dr. Welch and others and we have had it up over and over again during this war. The decision to limit the floor space below original recommendations that were made on the subject is a decision of the Chief of Staff and highest authority, because they felt they had to get all these troops in at the beginning of the war,--that that was more important than we esti- mated to be the risk of infection coming from overcrowding. You may remember in and we sent members of the Army Epi- demiological Board to most of the large posts in this country for a survey of those housing conditions at that time. The recommendations that they made resulted in a little bit more allowance of floor space per man, but crowding continued. They can point with some pride to the military deci- sion because there hasn’t been any extreme respiratory disease incidence in the Army since that time, but what you say, Colonel, is quite right. ... 7P The Engineer is probably acting under a higher directive than the one that would come from the medical side. This is a case, I think, in which the medical advisors very thoroughly educated the military authori- ties, they considered the problem from both sides and-said,,"That is:the risk-we are going to take.” ‘ V.hat is going to happen now with the increased induction rate? I would like, before we get through with this■conference, to.know what is happening in various posts. If they are going to bring in a lot of new troops and new men between now and July, we may have some serious condi- tions. We will try to talk with the Engineers about it, and about this oiling. COLONEL-' AHNFELDT; I do have information recently from the Office of Chief of Engineers that they plan in now construction to provide . 72 square feet per bed-. (NOTE: .proposal altered, later to' 80 square feet per bed including center aisle.) GENERAL BAYrlE-JOIvES: We will be hoping, too, .that they consider ventilation and heating in barracks. This is an enormously important ■ - - problem that- hasn’t been properly investigated. Barracks are not well ventilated and not properly heated. *, COLONEL MINOR: I think that is an important subject. COLONEL BANTON: . This question of delousing, I don’t believe that there is an adequate coverage-of that, When-I came home from France in 1919 I got deloused three times and .one time. I didn’t' need it, but I find people now who have, never ,-been so much as’in- spected that have ,come back from theaters where they had plenty o£ typhus and various other things. One man was coming from Persia, They had a typhus case on the boat.and put into Alexandria, -Men came onto the-boat and dusted about a little powder, When they got to New York there was no question about it, everybody got off the boat. Another instance, a hospital on;the. Mississippi River was .asking for more DDT because they were getting patients over there who ‘Had never been deloused and they..wefe afraid that some disease might break out. I wonder what we;.can do-to cover that point a little better .- GENERAL : BAYNE-JONES >r Colonel., I-know-about; that .shij? because I went aboard it at Alexandria last. April,- General Fox,..I'heeXer. and I and the rest. Whht happened at that time was this: It hap- pened ' to be a navy gunner onthe ship who was taken off, at Suez. somewhere with a very severe ease, of typhus and the boat went around to Alexandria. I would like to tell you about this ship because it will, show the problems. It was the. basis of one of the decisions that Colonel Ahhfeldt spoke about. At Alexandria this ship was in quarantine. The Naval Port Officer and the Army were to hold-that ship there- and not let anybody ashore.. There was.typhus in Egypt the previous year. They had had .33,000 Cases and they had had typhus in Alexandria all.the time, so the Egyptian officials don’t see why you should quarantine a ship against one case of typhus,'-particularly as .long as this crew wanted to go ashore. They had been but a long time, come around from the Persian Gulf and they wanted a little holiday in Alexandria, so when we went out to this ship the Captain was ashore and a great many people were ashore. In addition, there was a boat tied up at the dock. In the brig of this boat there were about 50 more seamen who had been rescued from ships in the - Mediterranean and they were to be put right in this ship, 71 so that there was nothing done at that port to handle the typhus situation on the ship or. keep people from- going ashore and spreading the disease or coining, back infested. That was a fair job of dusting. Everybody on that ship was dusted with DDT and a great many of them were vaccinated. We followed that ship as best we could all the way along throughtthe Mediterranean and I got the report of the voyage after the ship came in. I don’t know whether the people1were deloused at the Port of Debarka- tion, but they had Dewey and in the Seventh, Col. Allen, you are doing about the same thing on that, too. Col. Hilldrup in the Sixth has had probably fewer sanitary engineering problems than anyone else but he has a very good man out there who has kept us out of trouble;, in the Sixth. In the Fifth, Col. Lacock,. I know that they have, had an excellent organization for a long time. And in the Fourth, of course, Col. Banton, we are very proud of what has been accomplished , down there. One of those charts that is coming around covers the Fourth Service Command and another covers the Eighth, in both of which outstanding work in water control has-been accomplished. The Third, Col. Schrader, is another one,:where we have had an engineering organization continually since early in. I believe. I would be very happy to have any comments or disagreements, if they . are not too severe, on this. Well, these may come up later.oh because we have some topics here for discussion, I do hope that we will have well established, programs in all the service/.commands, and I mean' by that a program that is down on paper so, that we will have no cause and no chance for misunderstandings . ■ We have gone along for the last four years, since we started this sanitary engineering program, simply on an unwritten "basis, one idea being that as our preventive medicine program developed we were also making advances in sanitary engineering and we did not wish to freeze • the program in any one place by putting it down on paper too soon. We feel that the time now has come when it should be written out clearly. I sent around wome charts, though unfortunately, I did not have enough of them for everyone, covering the results of water supply control in the Fourth and Eithth,Service Commands. I know some of the other service commands have been doing an excellent Job. COLONEL NORTON; The record for the Ninth is very much like the record for the Fourth. Wo don’t have a chart showing it but is is very similar. 77 COLONEL HARDENBERGH; I have •'been trying to £et the Service: Command. Engineers to get the records together so that we could have- .siini- lar water"quality charts for all of the service commands. It is of interest that during the second half of our nonpotable samples were Just under 2 per cent anfy so far in' 19**i they have run 1.28 per cent non-potable, which is very good. I might say that the young men we have trained and sent overseas have done a similar Job. For the last few months in the South Atlantic theater non-potablo samples have been under 1 per cent. We have had several other theaters where the rates are almost as good. I believe that if wo had.the facilities for bacteriological examinations in overseas theaters we would find that the water .quality is excellent. In other words, we have a good preventive medicine organization in most of the overseas areas now. I certainly hope when you go back that you will remind your sanitary engineers to keep at work on this water Chart for all service commands. Charts such as those I sent around, and as the One showing malaria control in this country, have been of tremendous benefit in selling this preventive medicine program to:;the .Army, to General Kirk, and to others. We conceived the idea some couple of years ago of comparing World War II with World War I. As you see, from the chart, we ran down mighty near the bottom on World War II. Our rate now is, as:l recall, about one-thirtieth yet of what it was in 1919* Getting back to water supply, are there any questions or comments or objections on our chlori- nation policy?- ■ . . . ; ' . COLONEL MARSH; I have two questions; One is, - how do laboratory people rate a specimen as being non-potable because, it has 500 colonies per c.c.? LCOLONEL HARDENBEEGH : Yes sir. COLONEL MARSH; Nevertheless the laboratory sends a report back to the post saying it is non-potable, which entails considerable ■correspondence afterwards. . The second.question, let's take as an example Governors Island, - the-’water supply of which is from the city water supply than which there is probably no better-water supply in the United States or the .world. Every once in a while in some particular spigot somewhere on the post they will; get some gas formers. The question is, should that supply be rechlorinated? You know the New York City water supply as well as I do. COLONEL ■HA.RDEKBERGH: I will answer those questions because they are quite typical of what we get from a good many areas. TM 8-227 is the laboratory manual which prescribes the method of treatment, in the guise of fixing methods of reporting actually, fixed standards of water quality; it was not intended that that should be done but it was'done. Ever since. I have been In the Army, I believe, the TM'8-227 has been under revision. How many more years it; will ‘be under .revision, I don't know.' .In.the meantime, there are technical objections or technical; reasons why we can hot .modify it.-olt-;is a technical manual which is under revision. That stops us from making any marked changes. ’ •: .v ■ •• . : I might say that we have prepared a technical, bulletin, or manual, or Army Regulation on water supply in which we are going bo try to eliminate not only that problem that you speak about, but we are going 78 to clarify the procedure as to what to do when you do get a non-potahle sample. That is, we are trying to work out a system where if the past records of the post had keen good and we get one had sample it is not going to throw the whole economy of the post into reverse, whereas if we get two or three had samples in. a row, then we ought to take some strong measures. This has been pretty well written out hut it is still not very near the publication stage. The second one in regard to chlorination, our policy to cover the point that you bring up. Col. Marsh, is this; If a post is within the network ••of the water system it would not require rechlorination if the sum total of the quality of the water measures up to Army standards, which is a rather vague thing. We wouldn’t require rechlorination on the basis of one or two or three bad samples.' If your water supply were consistently bad in New York, then I think chlorination would be the wise procedure. For instance, in a large city in the South that Col, Banton is' familiar with, out of 686 samples taken before chlorination.by the Army, 10.5 per cent were non-potable. That is a lot. After rechlori- nation by the Army, of samples, l.h per cent was non-potahle. There I believe rechlorination was more than justified. I would like to have some more questions or comments. Maybe Col. Banton would like to tell us a' little about that, if there have been any further developments in regard to the situation that I have just spoken of. COLONEL BARTON: I think it is cleaning up. Colonel Hardenbergh. ''Ihe people there, I think, began to take interest in it and the local Army Commander threw his weight into it, so I don't think there will he any more trouble. This thing which Col. Marsh mentioned about getting reports' from the laboratories, we tried, to control that by a. very close check on our laboratories. We had' a system of rating laboratories, sending them out test samples and things of.that sort. We have eliminated a'great deal of that sort of useless reporting by better training in the laboratories from the Ser- vice Command Laboratory. COLONEL MARSH; The reports I speak of all come from the Service Command Laboratory. COLONEL HARDENBERGH; Col. Lacock, you used to have-some difficulty with that out in the field. Is that pretty well fixed up now? COLONEL LACOCK;. We still'get' some telegrams 'being'sent out about noh~ • ' potable' samples cut we have minimized the danger or importance -of those telegrams, knowing the supply pretty well.-- As was stated, we don't get excited over one non-potable sample on the ••post. ’ 'A ,1 ■ You had a little trouble with chlorination-out’ there, Colonel Norton, in the Ninth? No serious trouble, I mean but your Repair and Utility officer out there get a little flighty. COLONEL HARDENBERG: A lot of these folks get terribly excited about this chlorination before they ever start to apply it. We understand thoroughly that there are some places, some waters, where we are going to have chlorinous 79 tastes or other difficulties in our chlorination program, hut it has been a strange thing that probably 95 per cent of the complaints came before they put the chlcbrinc in the water. Not over 5 per cent, I guess, of the complaints came after they had actually applied the chlorine In other words, it was one of those anticipatory things that do not materialize. How about you, Colonel Carroll? COLONEL CARROLL: No trouble at all. COLONEL HAJ3DENBERGH: Are there any further questions or cements on our water program or on the mosquito control program? From our point of view, those two programs have run so smoothly, that it takes a very small amount of our time in Washington. Wo decent- ralize all of that at the service commands and they have done a beauti- ful Job on it. When I go around to visit the service command head- quarters, it is more In the nature of a vacation than it is in solving any difficult problems. I In regard to sewage treatment; I wonder if anyone has' any problems? We. arc going to consider rodent control and prisoner of war camps presently, so we will discuss at this time the problem of sewage treat- ment, in our camps, posts and stations. Have there boon any problems in that respect or arc there any questions to ask? I am not particularly surprised that there are not, I-'.think we sent out to you copies of Dr. Parran&s letter in which he complimented the Army on the fact that they have received no complaints from state or local health departments in regard to nuisances or dangers to health from stream pollution due to Army sewage treatment plants. We immedi- ately sent copies to the Chief of Engineers and he called back rather happily about it. The Corps of Engineers have done a good job, they seem to be very proud of it, and wo are proud of it, too. • The next thing I have here is rodent control and wo did have a couple of questions sent in on that problem in advance. One was the adviaaoility of building rat and insect-proof wards in case of plague and ether similar diseases occurring in epidemic form. That was from one of cur ports of embarkation. In answer to, I would say: the presence of plague or other simi- lar diseases does not justify extensive building alterations over and above present Army hospital standards for construction. All wards should be reasonably rat and insect-proof and should receive attention if there is any evidence of infestation. Wards should be inspected regularly for defects in vermin barriers and these defects should be promptly remedied. Any building housing patients suffering from insect- borne disease should be treated with DDT and this treatment should be repeated at regular intervals to secure a continuous residual insecti- cide effect. The other question was; "How is it possible to estimate the rat population?" That came from an eastern port. It doesn't tell how heavily they are infested with rats. My reaction if that we ought to get somebody who knows about rodents on the job. About three years ago, in order to bo ready for this situation, we commissioned several men skilled in rodent control, getting them from the Fish and Wildlife Service. They have been very handy. I think the Ninth Service Command has used most of them; the Eighth has used some. Wo sent one over recently to take care of the plague problem in West Africa and he did a great deal of work on the control of fleas with DDT. I would say, where there is any rodent control problem that 8o the thing to '.do is to ask us t ' send someone to you who knows his "busi- ness and have him make a survey and get an answer*' . hotf, if you have to guess at it, yourself, here are the recom- mendations: A crude census may he made hy observing the evidences of rat infestation such as droppings, tracks, runways, burrows, nests, gnawing,-damage done, rat-baiting and observation of the number of live or dead rats; also, from pre-baiting tests. After the species of rat is determined and a readily accepted bait is found, the numbers of rats fed can be figured from the total amount of bait consumed and the average per rat. Trapping will yield addi- tional information if it is necessary to secure specimens, but it gives only very rough information on the numbers of the rates present. , .r'r‘We had another question on rats from another port of embarkation; "Is it possible to deodorize a building other than by removal of the dead rat? If one dies in the walls, what are you going to do about it, put a clothespin on your nose or what?” The answer is this; Most of the commercial remedies, such as chlorophyll wicks, ozone generators and other odor removers have no established practical value.• Dr. Ormsby of the National Research Council suggested recirculation of air through ,an activated charcoal deodorizer which would possibly reduce the intensity of the odor. In the same way,- air scrubbing in an air conditioning unit and improved ventilation will reduce the intensity of the., pollution. Some relief may be obtained by masking the'odors of decomposition through intro- ducing aromatic odors of one kind or another, as by- using incense burners, or dispensers, with creosote or pine wood oil. These ."may bp passed through the wall of the building in-the same general area as the dead rat.;- However, for your peace; of mind,- the death of. rodents ’in walls is ah exception rather than the rule;, as burrowing rodents Usually retire to their burrows when poisoned. . . To minimize the possibility of nuisance, emphasis should be placed on rat-proofing and removal of food supply before poisoning-or fumi- gation, and trapping might well be employed within buildings before the rats are poisoned. I would certainly be glad to have more comments on this rodent business or questions. COLONEL TILLMAN; At Fort Knox we pre-baited the whole camp at the General’s request. Using the pre-baiting method we figured, out that we had 7*5 rats around there. GOMEL HAKDEHBERGH: Colonel Carroll, you might tell about your experience at Camp Edvards or Fort Devens where you areally got a surprising number of rats. GOMEL CARROLL: I don’t recall the exact number obtained but the method there was that of setting baits and having a count to find out how many baits were taken, the following morn- ing, Then the following day, setting more baits and continuing that same process day after day -until we built up to the maximum number of baits taken. When you level off, then they poison the bait and have the big kill. After a time resume that again. There was an officer, Captain Coogan, who was specially trained in rat and rodent control and he carried on that work at Fort Devons. An enormous number was killed but it would be just a guess to state the exact number. That method had been used extensively in the City of St, Louis,. .81.. ,.r COLONEL HARDENBERGH;' As I recall, there was a Mg difference of opinion as to how many rats there ..were at .. .Fort Devons. Some of the really conservative folks thought there might he several hundred there, and you finally got about 4,00Q out of that, one dump, is that right? present, may he rather surprising at times. COLONEL KOGEL; There,. Is such a thing as a .rat pound vhiph is used at times.., , I think they use . it ,in India, and compute the number of rats that are caught in 100 standard traps and then.by doing that, at regular intervals., they can estimate whe- ther there is an increase or decrease in the rat population. That might be used to give a fair idea of the rat population in an area. I am glad to hoar that, I had not thought about the procedure before. I believe, though, that it would atill be desirable if a program be set up initially by somebody familiar with, rodent control and then the post could continue to carry.it on and probably got excellent data. Is there any more discussion on this rat situation? COLONEL HARDENBERGH; CAPTAIN - COOPER; ... Is there any method of keeping rats from getting on or off ships?, Apparently when the-rat guards are used it is quite inadequate.. The method has not changed .any. so far as I know of rats getting on or off ships,, particularly in a port whore the ship comes from plague infested areas..',' Would anyone like to answer .that? . The usual method as .I recall in keeping, rats from getting on or off ships' is the use of, guards> the maintenance of lighted,' gang- planks at night, with a guard.to,.keep fats from going hack and forth, and other precautions of. that, nature. Can anyone' add- to that? • COLONEL ' . HARDENBERGH;, This isn’t my .information. Colonel Hardehbergh, 'hut the Quarantine popnlssibh was working on that problem and they finally recommended the abandon- ment, of the, -rat guard.as, 'being, very inefficient; and as giving false security and their recommendation was that, when a.Vessel entered a plague port or a -known port where the rat population was high,, that the only way to avoid rats was. to tie up. no nearer than three feet from the dock, and preferably not to. remain longer than necessary* If their recommendations were followed, I 'think rat guards and light- ing the gangplanks would be abandoned except where required by law. v- CAPTAIN':.;. SHAFFER; CAPTAIN COOPER: How can you tie the ship with no lines to the pier? CAPTAIN SHAFFER; I know nothing about the practical side of this hut having talked briefly with Colonel Khies; I understood it was desirable to take off the cargo while maintains a fairly accurate watch. Anchoring away from the dock at night would be recommended. I think probably the rat guards are left on the cables because that would be essentials but perhaps some of the two-legged guards can be dispensed with under the system you are mentioning. COLONEL HARDENBERGH; COLONEL HARDENBERGH; They have MP’s always stationed on regular transports hut it is almost impossible to station a guard on any freighter that comes into a port to dock at San Francis- co, we will say. It is also impossible to take up gangplanks as the crew are getting on and off pretty nearly any time during the day or night, CAPTAIN COOPER; COLONEL BAKDEKBEEQH: Lighting doesn't discourage the rats? I have not actually stood guard,, myself, to see if they have teen discouraged. The presence of spmeone there, I think, would he sufficient unless they are. particularly overrun with rats. In San Francisco, particularly, where we have so many ships coming hack from Pearl Harbor, which although it originally was a plague port, apparently is not now, it means the problem of guarding almost every ship. CAfTAIN COOKES; COLONEL HARDENBERGH; Anymore discussion? (Discussion- offrecord,) COLONEL BAEDEKBEEGH: Perhaps, if there is nothing more on the rodent situation, this is a good time to shift Just a little hit and bring up one point in regard to the Sanitary Corps and the utilization of the various specialties within.the Sanitary Corps., As I believe all of you know the Sanitary Corps is now composed of groups of specialists: Sanitary engineers, Entomologists, Bacteriolo- gists, Bio-chemists, Serologists, Nutrition and Occupational Health. . — -.i-A One of the things that you mil have to .-watch out, for is the pro- blem of using each man in his own specialty. An engineer is no .'good ’ in planning a nutrition program. The nutrition man could not he put out on a mosquito project or on the operation of a -water plant) .there he is a total loss without insurance. You have to use a little common sense to put each man in the Job for which he is intended. If you have surplus in any category, we can take him off . your hands. --We don't have to ruin a good nutrition officer hy trying to make a sani- tary engineer out of him and thereby also hailing up your sanitary engineering program. I am sure that that does not happen much any more though we had Just a few days ago an instance of one of our sur- geons changing an M.O.S, on a man, from bacteriologist over to engi- neer, because that is what the Job changed to. We have that come . up from time to time. I don't know that there is any comment that anyone wants to make but if there is we should be very glad to hear it. ' ‘..I: . ’ • ; " . We had • some questions on the prisoner of war camps and that is the thing that I guess is giving as many headaches as any other non-speci- fic thing, that I know of. In regard to the prisoner of war camps, one of- the .problems that come up to us is "What shall we do about chlori- nating the water at prlsoiier of war side ■ camps and branch camps? I believe that the service commands have adopted a fairly uniform policy in respect to that. Where running water is supplied under pressure and is chlorinated by the utility, that' is, the. supply comes from the city or water company, it is not necessary to- rechlorinate, prov vided a reasonable number of the samples are .bacteriologically pota- ble. i :h. Where treatment of delivered water is not adequate or where the supply is procured locally, at:a branch camp, that is, you may. set up a little treatment plant there. Then the water' supply should be chlori- nated, either-with a ' liypochl'orinator or by. .the batch method .of treat- ment, whichever is advantageous to you. If that is impossible to do, then the water should bo chlorinated in Lyster bags.-,- If provision of a hypochlorirator is unduly costly, or if you have to buy how equipment, f would say either use the batch system of chlorination in tanks or make the prisoners Use Lyster bags:. I dop’ t .think that; great cost or purchases of new* 'equipment are Justified: for our prisoner of war camps. Are there any1 comments or questions.- on that? COLONEL ALLEN; Colonel, vhat -if' you have a prisoner of -war camp that has a reasonably large population, four or five hundred, that you knov is going to he operating for a year or. more? ¥e have such a situation in Missouri, The camp has a population 0f prisoners. It has been in operation now for nine months and will be continuing perhaps indefinitely. COLONEL EARDENBERGH; Colonel Allen, -what kind of water supply do they have? COLONEL ALLEN; Shallow w^lls, driven points, in the Mississippi River Valley. COLONEL MRDENBERGH; And you would have difficulty incchlorination there "because your wells discharge directly into your system without any contact? COLONEL ALLEN; Right. COLONEL EARDENBERGH; And "because you have several wells, they go into the-- COLONEL ALLEN; Two wells. Do they go together? COLONEL MRDENBERGH; Yes air. COLONEL ALLEN; COLONEL EARDENBEEaH; I would be inclined;to put a hypochlorinator in that line after they join and not worry too much about the contact period on your shallow wells. In fact, the Army chlorination policy/ where..you have an Army owned and operated well, does not require a contact period. In other words, I would put a hypochlorinator on the line where the two wells join and not worry about the contact period. I believe in that respect some camps are short on.hypochlorinators-and some, have surpluses. I believe if you need any information on your Po¥ camps you should talk to your Repair and Utility officer and ask him to query the Chief of Engineers' office to"see if some hypochlorinators are not available, if they are needed. I don't think it is necessary to buy any more new equipment. Are there any more questions oh the water supply part of the prisoner of war problems? ' * If not, we will go' over to the next question on the extent of malaria controls procedure. That is another thing that some people are not very clear on, ‘ 'Our own feeling in regard to that is covered in ASF Circular 206, 5 duly Section III. In paragraph 3 of "that- circular* it gives the procedures- that will be employed to deal with the malaria problems among prisoners of war. That was worked-up in the SGO between the various divisions con- cerned and I don't think that we have anything to add to it, I might say, in summarizing it, that we do not feel that extensive work around prisoner of war camps can bePjustified. It is a matter of money and, what is perhaps more important, of trained personnel to dp the work. We do not feel that any extensive measures should be required to pro- tect either the civilian populatiph or the prisoners. You may pro- vide a screened recreation building) and,- of course, give them bed nets and require them to be in one or the other of those places after dark. I believe, however, the whole situation is well covered in that circular. We have another question on the disposal of liquid wastes from kitchen and hath facilities at the prisoner of war camps. That is, of course, where there is no regular plumbing and no sewer to carry the wastes off. There we are on the same old problem of how to get rid of wastes without going into very much trouble. It is a difficult situation. About all I can say is to put in your soakage pits and put them in carefully. If possible, send one of your sanitary engineers out to make a test of the porosity of the soil, determine the most advan- tageous place for location, see to it that surface water is drained away and pehhaps you can get by all right. You may have to reduce the water usage; you may have to reduce it down to 5 or 10 gallons, as it will not' be nearly the problem to dispose of the waste as if you have or 50 gallons per person. That might, also, well be a factor in the initial location of your camps. I know that you don’t have very much to say about that. The Fourth Service Command has had an excellent system whereby the location of these camps is being passed on by the surgeon* s office, the labor branch, and the engineer office,.- . Is that right, Colonel Bant on? COLONEL BARTON; Yes, sir, and the requirements of the State Health Department are also considered. COLONEL HPlKDENBERGH; That is an excellent way of doing it and I am sure that by following that method, even though it may not he perfect, you will eliminate some of the worst pro- blems that you have in location. Have you had any trouble up there. Colonel Marsh? COLONEL MARSH; Not materially. We have more or less the same system/ We have to pass on the location before it is used. COLOHEL mRDEKBERGH; How about you, Colonel Dewey? ¥e have the same system, including the State Health Department, hut -we get some very peculiarly located camps in the hinterlands, svamps, and all sorts of places. How they get located there, I don’t knov. COLONEL DEWEY; COLONEL HAJRDENBEEGH; How about you, Colonel Allen)? COLONEL ALIEN; It goes from bad to worse. We have the same system set up on paper but we find that in the- end political and labor pressure rules. Any comments from the. other service commands? Hov about the ports of embarkation? Don' t you. have any pri- soners or haven’t you learned any lessons that you can tell us about here? v • COLONEL HAHDENBERG-H; COLONEL MARSH: I- don't think they use prisoners COLONEL HAKDENBEEGH;- : . , ... Just:the Italian service troops. Then we have another . question here on amoebic dysentery. Col. McCoy, of the Tropical Disease Division of Major Matthews will be hero later on in the program to discuss that matter. All we need to say here is that we feel that with the existing excellent purifica- tion measures for surface water supplies, as practiced in the United States, we have little to worry about the transmission of amoebic dysentery by means of water supplies. We still have one more set of questions that I would like to go into; The Seventh Service Command sent in a question that is of much interest to all of us and it is concerning the effect of sewage treat- ment processes on various ova, Ascaris and so forth. They are now doing some work out there on that, but have not come to,a final con- clusion on the results of drying of the sludge. It seems to be without question that these organisms will’pass - through the sludge digestion process of a sewage treatment'plan and Dr. ..Wright of the National Institute of Health apparently found:'that ;- drying, also, did not destroy them. Would you like to go on from:there, Col. Allen, with a brief resumS, perhaps, of your experience out -‘•■•yu there? . c fro I 'believe I can discuss that tetter, Colonel, by .just reviewing.the queries wo have sent in. The discovery of adult specimens of Ascaris in the tank of the sew- age disposal plant, has raised the question of potential danger in connection with the use of sludge from such sources for fertilization purposes on low-lying vegetables that are consumed raw, such as let- tuce, and radishes and so forth, without danger of reinfestation. COLONEL-., t ALLEN; Available records indicate that the presence of Ascaris at the treatment plant Tfas due to infestation of one American patient in a P6W camp hospital..■ Ascaris or viable ova were found in the tank scum as well as in liquid ’sludge drawn from the tank but were not found in the sludge after normal drying on the sludge .drying beds. This would tend to indicate that the digestion ordinarily accomplished in Imhoff tanks is not effective in eliminating viable forms but that the mere drying of tho sludge after digestion is effective.' Inasmuch as ex- tensive.uae of dry sludge as fertilizer may be expected from irri- gated areas in production of low-lying vegetables, the effect of nor- mal sludge-drying on .the viability of the Ascaris or other ova may be a very important preventive medicine problem. I understand that since this was sent in there; has been a paper, published in which results were reported different from the findings of our laboratory.- ■ COLONEL EARDEHBERGH; That was-only on the effect of drying, I believe. COLONEL ALIEN;;. Yes, on tho drying effect. COLONEL, HARDENBSkOH: I don't see ..why drying, -would have any effect on such organisms. If digestion doesn't kill them/ I don't ; feel that drying would. It is Just possible that by using the higher levels, of heat digestion we might.get something better. I would like to see this tried in some of our sewage treatment plants, • using the upper temperatures, maybe above 100 degrees. There are not very many places where that is done,, -.. . In that connection, last, year we were asked by the Corps of Engi- neers to approve the use of liquid digested sludge as a combined fer- tilizer and irrigation component for certain grass areas around camp. We went over it with them very thoroughly and finally agreed to let them use the sludge in those areas where troops did not have access to the fields on which the sludge was used. We felt that without any evidence at that tine of drying having any effectoon the' ova and other organisms in the sludge., it was no worse to put on a wfct sludge than a dry sludge. As a matter of fact, this sludge dried very quickly in the small amounts that they put on.- However, I understand very little of it was used. Are there any questions or any comments on that part of it? It not, I would like to "bring up the point of inactive installa- tions. There have "been a good many posts put on an inactive status and every time we do that we have a problem in regard to water supply, sewage treatment and insect control. ¥e prepared an outline of pro- cedures which were sent out to the service commands. The Corps of Engineers liked' this so sell that they adopted it practically with- out any change-. Are there any discussions or comments or report on that sutuation, including ‘some1 of the problems that you have faced, maybe even on re- duced personnel? How do you keep your sewage plants, operating proper- ly when you have 5,000 people served by a plant that is designed for '25,000? “'Have you had any trouble in the Fourth, Colonel Banton? No, sir. They have reduced the number of units used at-some plants. C0L0HEL BANTON; COLONEL HARDEKBERJH; What have you managed to do about mosquito control? Have you been carrying that on? COLONEL BANTON; Yes, sir. MCWA is very good down there. COLONEL EARDENBEBGH: That ties in with my next question which is in regard to these personnel centers "being used in the readjustment program. These personnel centers, would normally he some of your existing camps that have "been used hery,little recently. Is that right? Some of them have not been curtailed so much. That is to say that there is simply a change in the function of the camp/ ‘ " ; COLONEL BANTQN; COLONEL mEDENBEEGH: Are you having some of those problems, Col,. Allen? COLONEL ALLEN: The principal trouble we have been having in this con- nection are in the smaller camps in which they want to inactivate the sewage treatment plant altogether. For example,, at a prisoner of war camp, a city of about 3;000 has been dumping raw sewage into the river since time immemorial and the State Hospital for the Insane; one branch of which is located there, have been doing the same thing. The Army comes along and builds a PoW camp and Invests several hundred thousand dollars into a sewage treatment plant. The Commanding Officer being short on personnel, that is the first thing he wants to eliminate, of course. Wo had a terrible fight to keep the sewage plant operating. COLONEL HARDENBEEGH: Col. Lacock, don't you have quite a few camps that were Being reduced in strength. What are you doing with- those? • Closing them up? „,v COLONEL LACOCK: O'Ur two large Division camps, Campbell and Breckinridge, are in sparsely settled areas, and they are on partial operation. #OLOHEL HA-RDEMBERGH; You are not having any trouble? COLOWEL LACOCK; Wo, sir. COLONEL HARDENBERGH; Have you had those problems. Colonel Carroll? COLOWEL CARROLL; No. COLONEL NORTON; ¥e had a few In the .Ninth. One of our men in the Ninth had written a report on his experience at Camp Adair. I thought it was a very interesting report He brought out a lot of problems that they ran into from cutting down from about 5,000 to six or seven hundred. COLOWEL HAEDEWBEEGH; ■ I would like to see that. I hope it cometo the office. ' ... COLOWEIi WOETOW; We will publish it in our next monthly bulletih,. very likely. COLONEL EARDfNBERGH; We don’t always get that .'bulletin. We are about,’ to . send out a letter from the SGO inrregard to these per- sonnel centers, getting ready, of course, for the-- troops who may come back here after VE-Day and wo are' asking you’ to ... make certain surveys of those areas. I presume you have all done 'it1-1 already because we find normally that by the time we get around to . asking you to do something most of you have done it already but we are sending a letter out to you in regard to those personnel centers and their preparation for VE-Day.■ . i.--, • , .The next item I-have'is pest control and all I can say is that it seems to ns that the Army does a hotter joh of that than the com- mercial operators do, and a lot cheaper. That is a kind of hold state' ment to have apyddiscussion or comment on, hut I should certainly he happy ’if someone told Us about that. Have you done much of,that down'in"Camp Blanding,' Col» Coleman? COLONEL COLEMAN; No, sir. Blanding is pretty well filled up with IRC ' troops. , . COLONEL SAEDEIIBERGH; ■■ With reference to pest control - COLOWEL COLEMAW; Yes, sir. ' We have to .keep up a program of pest’ con- tfol) mosquitoes, flies, rodents the.year round. COLONEL" 'V ' ' EASDENBERG-H; You-do ■•that with, your own forces?- .-L > , COLONEL ' ! CDLPliAN; * Y%sy- sir.- *x \ i I, COLONEL HALLLNBERGH; '■ Is Lt, McGahan still there? Yes, sir'/ he -is ' still .-frith. us. COLONEL COLEMAN; • COLONEL HARDENBERGH: Throughout the service commands we have "been holding a good many of these DDT schools. It has been our feeling that the Medical Department personnel ought to know a little more about DDT than any other component of the Army, In furtherance of that, we have tried to send out whatever litera- ture was available to service command headquarters, for re-sending to the posts. We sent, I believe, all of our service command engineers with the exception of one, down to Orlando to take a special course worked out with the Department of Agriculture, It seems to us that Was a very wise thing. We find now a number of excellent schools are being carried on throughout the various service commands and it seems that Medical personnel has been able to take the lead-in that pro- gram which is exactly what we wanted them to do. Are there any com- ments or questions about these schools or any way in which we can help you in regard to them? COLONEL DEWEY: We in our school in the Eighth Service Command would have appreciated a little more information from The Surgeon General's office about what our position is supposed to be in the school because a representative came out from the Chief of Engineers' office and if it had not been that we had a very progressive entomologist in out Headquarters, the school would not Just have come off at all. He took it upon himself to run the thing. COLONEL •: BAKD1NBEEGS; He did an excellent Job. I saw that program COLONEL DEWEY: But he did it without any authorization whatever. It Just happened to work out quite nicely. r COLONEL mHMBEBG-H; Do you think it would he well if the SGO took the lead in recommending these schools and fixing it so that -- -• ... . the Medical Department could more easily provide leadership in them? COLONEL DEWEY: Yes, it would help quite a bit. As it was, the thing almost went haywire because he had to do everything through the Corps of Engineers. . COLONEL El;- HARDENBERGH: It shouldn't be that way COLONEL DEWEY: And they didn't carry out some of the things that our entomologist outlined for them. He didn’t find it out until the last minute. COLONEL 1ASMBEEGE: Did you have something to say on that, Col. Allen? COLONEL ALLEN.;, As you know, Col. Hardenbergh, we 'had arranged for • what we thought was a very good conference. We co- operated with the engineers, the Chief of .Staff approv- ed it and We had arranged at Kansas City a three-day conference for the; latter,,part pf this month. The Air Corps were invited and about 200 of us were going to he present — 170 some-odd'reservations were all ready and Control found out about it. The result is that we are not going to have a .conference. That is based, of course, upon the directive pertaining to conferences attended by 50 or more. Whether we are going to bo able to have a number of smaller .conferences or not,.I don’t, know. This broke Just before I left headquarters Monday morning. . * v ! COLONEL HARDENBERGH; I got the notification just before I left yesterday. COLONEL ALLEN; Yes, air. Now, if we can get some support, from The Surgeon General's office, that this conference is necessary and that these conferences are desired, I think we can go ahead, hut as it stands now, I believe Control has us whipped. ' ' COLONEL BARDEKBERG-H; I think we can get out a notice to you. I think you might have to keep it down to Is there any more comment on this? COLONEL MARSH; We had no trouble at all in the Second Service Command, Lt. Osmun, our entomologist, put on a conference at North Monmouth last summer, a two-day conference for officers, medical inspectors and Air Corps. Then it was continued for another two days for enlisted men. These posts sent down a cer- tain number of enlisted men and they were sent back and all had, •learned how to use DDT. Our Control Branch let us hate it. I think Col. Marsh’s suggestion that a place he pro- vided in the instruction program for, the enlisted men is an excellent one. COLONEL HAEDEKBEEGH: MAJOR HOPKINS: Our conferences -were in the middle part of January, for three states. We set up the conferences in three ci cities of three states. After having had one day of conference, a man spent a second day in the camp mess hall and "bar- racks for actual demonstrations, and the conference was set up for the personnel that were to do the work. The leader took the civilian employee of the Engineer's office, an enlisted man of the Surgeon's office or whoever was actually going to handle that spray gun' and gave him training in the handling of the spray gun and in the handling of his equipment on.that second day. GOMEL HARDENBERGH; We have "been very much pleased with these instruction programs. I am not competent to Judge of their quality beyond the fact that it does indicate that the service commands are trying to and are doing, I believe, a very fine Job in these instructions. Are there any other comments on our DDT schools? .Are there any questions on any subject? • I have reached the end,-except for two items, of the subjects that I was going’to discuss. I wonder if anyone has a ■ problem to bring up that we. might be able to get various viewpoints on from here? If not, 'I would like to hear from the Ports of Em- barkation, which are quite well represented here. We also have . Col, Franklin over here, from- the Second Army and Col,;Primer frqm the Fourth Army. We have quite a group, from the ports of embarkation, I am . sorry I didn’t get all of their names. I think that everyone here would like very much to hear from Col. Franklin and if he would like to come up here and ta.lk we would certainly be pleased to hear from him, ■’ . COLONEL ‘ FRANKLIN; I don’t believe there would he anything of general interest that I have-.to say. COLONEL HARDENBERGH; I talked over a lot of things with Col, Franklin about a week ago and he had a lot of interesting things to say then. COLONEL NORTON; Could I make a comment here? ,I served under Col. Franklin in the Seventh Army over in Sicily and just didn’t want to let this opportunity pass without saying that he certainly has heen interested in the general program of pre- ventive medicine* I am delighted to see him again. I know that he has done a good joh in-the Second Army. / COLONEL HAKDENBEEGH; Col. Primer, how about.it? You have some problems in ■Texas such as typhus and other.diseases that;the Texans won’t admit. COLONEL* PRIMER; Thank you, Colonel. I have nothing,to; add to the conference. I was very interested in these schools on DDT. I didn't know about them. I know that we would he glad in the Army, and in the various posts and camps, if when they put these* schools on locally, if they would he sure and let our medical officer, and the special troops headquarters, know we will try to get as many of the officers in the various units, espe- cially detachments and smaller units, so they could attend those meetings, get all the Information, and learn how to put these vari- ous measures into effect in the field. After all control of a lot of these diseases is going to he a problem of the field forces. I have been very interested in the program as a whole. It has been very good. COLONEL HARDENBERGH; ' Thank you. Col. Primer. I would certainly like to hear from the Transportation Corps folks. Suppose we start off as far away as we can. Is there anyone here from the Seattle port? CAPTAIN GOODNIGHT* I think that most of the points have keen covered pretty- well. We are interested, of course, in rat control programs "because there have "been plague infested fleas on the rats in Tacoma, which is very near to Seattle. They are try- ing to do quite an extensive rat control'program and the newspapers have "been giving pretty good publicity to get the citizens interest- ed in it and that is one of our major things right at the present COLONEL HARDENBERGH: - Thank, you, sir, San Francisco -- I know we have someone here from San Francisco. CAPTAIN COOPER; I don’t have much to add.#.' The question that almost always comes up, particularly on-ships, is the use of salt water for-showers of enlisted men on ships and of late it has "become a particular problem when you have as many as 500 or 600 ships in the hay, all of them loaded with troops ready to go off in a convoy and all of these ships taking on salt water without any methods of purifying it and it being used always for showers and not infrequently for washing dishes. The fresh water supply is limited and the need of a large amount of water for the washing of mess -trays or regular mess gear- has required the use .of salt water. We have been -Installing regular washing machines which use a minimum amount of fresh water and steam which has eliminated the problem but the use of salt water .taken in by the, ships for showers for the enlisted men has apparently been a real problem, es- pecially with the possible contamination of fresh water lines. I am wondering what the benefit of the use of chlorine1 with salt water would be . • ■ - . . , COLONEL HARDENBERGH; Very little. CAPTAIN COOPER; Are any other suggestions for using salt water, as they have "been and always will when carrying as many A troops as our ships are forced to carry, and with water purifiers the only provision for taking care of the military need. ' * There is nothing that we can do for the salt -water that I know, except to prevent it from mixing with the drinking water. Wo have to chock the pipe in- stallations of the ships to see that there are no cross connections and then wo have to safeguard the quality of the drinking water. I don’t think that we can go much beyond that. COLONEL HARDENBERGH; Do you think tho threat of this salt water in the showers is anything to ho considered? A certain amount of that is ingested. Frequently you will find men using it for washing teeth and other purposes. ; CAPTAIN COOPER; COLONEL HARDENBERGH: I would say that much depends on where they take the salt water on hoard.. If they are going to anchor over a sewer in the harbor and take on salt water they are going to have trouble. If they were out in the ocean they would hot have so much. CAPTAIN COOPER; In many places they don’t have sewers hut each ship has a Sewer of its.own, putting out its sewage of 2,000 men on each ship. When you have as many as 2.00 trans- ports and a couple of thousand men on each ship you have as much, sewage in that small area as from.a large sized city. COLONEL HAEDE1IBEEG-H: That is right, CAPTAIN COOPER; Another thing in connection with our transport ser- vice, which I doubt has been considered in setting up your shower facilities for troop's in barracks, is the effect of steam pipes running through the decks below the areas where the, men take showers. In a particular ship, the transport surgeon reported that among the men in one particular compartment, who- used the showers where steam pipes ran through the deck, making that - deck much hotter than elsewhere on the ship, he saw very, very little athlete’s foot. The men in the other compartments had a great deal of athlete’s foot. I wondered if the benefit of increased heat on surfaces has any effect on keeping down.the amount of athlete’s foot? COLONEL HAEDENBEEGH: I would have to ask somebody else about that, I do not know'but I would be glad to hear comments on ft, I think Col. Marsh has something to say, too. COLONEL MAESH: I don’t know why we worry about salt water showers, even if the water is; somewhat polluted. If you go to Coney Island on a hot Sunday. --- COLONEL HAEDENBEEGH; Or Atlantic City, COLONEL MARSH: Coney Island is a little worse/ —and see the people in the salt water shoulder to shoulder* I had occa- sion to make some ‘bacteriological analyses of that bathing water some years ago because of a little controversy I was having and I have forgotten -- I think it was something like.10 billion bacteria per cubic centimeter and nothing but•gas so I am not worried about salt water showers. • •, , COLORED HARDENBERGH: There was standing room only for bacteria in the water, just like "bathers on the "beach. GOMEL MARSH; People don’t usually drink much of that salt water, „ either. .Another thing, in regard to this heat on the floor and the prevention of athlete’s foot, i wonder if the hot floor doesn’t allow a man to dry his feet a little “better? I believe firmly that the best prevention of athlete’s foot is tho- rough drying of feet. CAPTAIN COOPER: I wonder if the Colonel ever tried drying his feet after a salt water shower. COLONEL MARSH: I have. CAPTAIN COOPER; It is almost impossible. COLORED HARDENBERGH: How about the Dps Angeles port? Do we have anone from there? (No response.) ! COLONEL EAEDENBEBOH; New Orleans? MAJOR CAMOH; We have some new problems in New Orleans with salt water "because there are 20 miles of docks and all have access to the city water line. The General has "been very interested in DDT control and we have had excellent sup- port from all sides in the, treatment of the mess halls and "barracks. COLOKEL HAEDENBESGH: You had an 'unfortunate occurrence about two years ago,. I believe, ’ •• ’ V-"1" ■; MAJOR CAMOH; I might mention that in Just a moment. We had,, on one of the ships that was visiting the city., a cross connection between the fresh water line and the river line. The day the ship was going to sail, they had a city pressure on their power line of about 50 pounds and they were taking on water at the same, time indirectly, with a;, difference of about 100 pounds .. pressure. They got back-pressure through a valve and polluted' the city water line with some of the river water. They had, the fol- lowing day, within a 2h hour period, about 75 to 80 cases of diarrhea among the dock workers. • : ; V/.' This is a good example of a cross connection, which is danger- ous, due to the fact that they have difference of pressureiin the fire hose and the city water supply. LT. COL. FRICK; We are Very much Interested in rodent control, but I have nothing to add-, r.; . ■ COLOHEL HARDEKBERGH; : You have quite a flock of Sanitary Corps folks down there at. Charleston, I believe, waiting for your ships to go. ,, , -LTNGOL. FRICK; We have. COLONEL HARDEHBERGH: I hope you are keeping them "busy beeuase if you don’t keep them "busy they write me and I have to explain to them why they are not being used. COLONEL HAEDEKBEEGH: How about Hampton Hoads? MAJOR KEMA: We haven’t much to offer, except that there -was a ques- tion here asked a little -while ago on the relative value of rat guards on ships. Recently I heard Dr. Oleson in Nqw York, in the port-surgeon’s conference mention that rat guards -were absolutely useless and he didn’t recommend their use. What he did recommend was that when ships-cams in from contami- nated ports the quarantine officials should inspect the ships thoroughly and then if the rat population was found to he above a certain figure that the ship was fumigated rather than simple measures I might add al&o that he noticed that on English ships they had their own me- thod of guarding their lines using a burlap bag covered with tar and creosote, which they claim is very much more efficient than the use of our own type of rat guards. COLOREL HARDEIMBERGH; I never heard of that. How about New York? MAJOR BUZZERD: We carry on quite an extensive program of general sani- tation of ships. We are constantly aware of the dangers from rodents and vermin and we helped solve our rodent control problem by sending six non-commissioned officers to the Pub- lic Health Service to train them. These men went out with the Public Health-Service Inspectors and on their quarantine inspection of ships. We continued that training in the office and really we had better in- spectors than the. Public Health Inspectors. They are closer in esti- mating- the rat population of a ship than the Public Health.:Inspectors. We carry on a constant Army extermination program. We are using DDT almost exclusively; however, we have found that sodium fluoride works a little better on roaches; with the DDT residual spray for bed- bugs we; make one application and go back'and inspect the beds and ma- tresses, and there are no bedbugs. We use that as a prophylactic mea- sure. Whether there are any bedbugs there or not we spray ;them anyway. As soon after a ship comes in as possible we have the water ana- lyzed. We have a small water laboratory on Staten Island and a trained Warrant Officer in charge of it. He obtains his own samples, taking water directly from the tank through the manhole. He also takes a •few samples.from taps. We get almost 2k hour service, on water. If it is found non-potable, the Warrant Officer personally takes, care of chlorinating the tanks before the ship leaves. Of course,.-there are a great many of our ships that are equipped with automatic chlori- nators and seme with the super and dechlorinating apparatus which we have really found to be the very best type of water treatment. COLONEL . HARDENBERGH: t We.think that super-and dechlorination are'very_good ' • •’ . MAJOR ■ . ... BtfZZERI);- ' • With,regard to the rat guards, we agree -with Hampton Hoads. We talked to Dr. Oleson, the Chief Quarantine Officer, many times in New York. He does hot Relieve in them at all hut we use them on our transports, and we instruct our surgeons to watch the situation in foreign ports. If they get into a plague port, we recommend that the ship-he moved away from the dock at night and the lines cut so that the rats can not get on the ship. We-have very little disease of any kind aboard the transports, especial- ly in the nature of diarrheal diseases or other communicable diseases. We have been very fortunate, I don't know whether It:.is Just through our own efforts or Just lojr. an-Act' of God "but we have 1)6611 very fortu- nate. ' L.C.; ■ y ■; • - ' ,. COLONEL HA.KDETHBERGH; Thank you, air-. How about Boston? CAPTAIN ' WARD; I have nbt; mUdh’ to add to what has Just teen said. We follow that •pretty closely. I can attest to the ,fact that EDT do.es work very well in spraying for "bedbugs. We try to recommend; with as much pressure as possible; to have chlori- nators aboard ships where the layover is long enough for them to in- stall it. We have recommended the Installation of monel metal units - for dish-washers. They rust rather badly and we find that installation of monel metal inserts serves to eliminate that. At present the principal problem seems to Be in the setting up of. the hospitals for returning personnel. We work rather closely with the veterinarian, who has the policy of putting on enough frozen milk to accommodate the returning patients so that they get about a pint of milk a day. ' Thank you. Captain Ward. Wo arc running a little close to the end of our time period. I -want to give everyone a chance for,a cigarette "before tho next period "but I think we would like to hoar from the representative of the Chief of Transportation if he is .hero. COLONEL EARDENBERG-H; MAJOR NEWMAN: I don't know that I am from the Chief s office. We look at it that way, from our point of view. COLONEL HARDENBEROH: MAJOR; • : : ' NEWMAN: • Unfortunately; Colonel, I have not "been there long enough to know too many of the policies of the Chief's office. • I -was formerly in Boston and Captain Ward has given the : ; report from there. I think ve are all very proud of much of the sani- tary work that has Been done, particularly aboard ships. Capt.-'Ward and the other port outfits have outlined it. It has been well-handled. One thing that has taken considerable attention ; is the contamination possibilities on ships in introducing fresh water and the possibility of getting a cross connection with the salt water. That has been studied thoroughly. I know in Boston that the First Service Command and the Port Sanitary Corps Officer got together and made quite an extensive, survey, checking into it thoroughly. The question of food "being put aboard ships for returning patients has had quite a "bit of attention in our own office "because of the de- sirability of giving these boys an increased ration on returning, oyer what they have been used to in the hospitals.overseas. It has been handled very well and they are giving considerable fruit juices and many of the dietary items that they feel they need. Thank you sir. Col. Walker. (Western De’fense Command); * : :.>0 COLONEL HAKDENBERG-H: COLONEL WALKER: We have no particular problems, Colonel. COLONEL' HARDENBERGH; A happy condition. But I would say that we have an extensive command hut rather small in numbers and that we would appreciate - we are quite a ways over on the Pacific Coast, -- get- ting on the mailing list of The Surgeon General’s office for some of this material on DDT. '■ '• —•J:v COLONEL WALKER: COLONEL ■V EARDENBERGE; I am sure that the Ninth and Eighth Service Command, all of them, in fact, that "border on the Armies or' the defense commands or the porta of embarkation, will,"be happy to Join together, as fay as they can, in thesesschools and'in any kind of help. V. COLONEL SMITE: (Eastern Defense Command) I would like to make one comment. I don't know whether you know it or not/ hut we have arrangements with the first four service commands whereby their sanitary engineers include the EDC in.their routine ins- pections. We feel free to call on their sanitary engineers to make any emergency Inspections, due to the fact that we have no Sanitary Corps officers. We have received excellent cooperation hut it has come via the grapevine to me that there will he a reorganization of the Eastern Defense Command in the near future. As a result of that, we expect to lose some of our medical officers who have conducted ins- pections in the past. I would like to encourage or request that the Sanitary Engineers of the service commands include our units in their inspections and send copies of reports to our office. The Eighth. Service Command now, since we have taken over the Southern Defense Command, is involved in this process and I would like very much if you would include our installations in your inspection. COLONEL EARDENBERGE; Thank you, Col. Smith. Gentlemen, I had intended, aa I said, to give you ten minutes to smoke a cigarette In, On that hasis we are running about seven ;minute late. It takes me seven or eight minutes to smoko a cigarette. Let’s try to get hack on the job about five- minutes after eleven and we will' just have to hand over to those who follow, about five minutes late. (Recess 'COLONEL • EARDENBERGE; Right now, I would like to introduce a man from Carlisle. Col. Kogel has teen in charge of the health training program work at Carlisle. He will speak the activities of the Military Sanitation Division-at,the Medical Field Service -J- School.* ' ' DESCRIPTION OF ACTIVITIES OF DIVISION OF MILITARY SANITATION, MEDICAL FIELD SERVICE SCEOOL, CARLISLE BARRACKS, PENNSYLVANIA. - LT. COLONEL MARCUS D. KOGEL, MC, DIRECTOR. COLONEL KOGEL: Col. Hardenbergh; fellow officers; my' subject this morn- ing is the work of the Department of Military Sanitation. As you probably know., the Department of Military Sani- tation is one of the eight teaching departments of the Medical Field Service School, The Medical Field Service School came into being 1 September 1920 with the objective.of training' Medical Department personnel in their field duties. Since the first class reported in May 1921 the'-principles of disease prevention have been stressed in the training program. • • ■ ’ The Department of Military Sanitation performs two basic functions. First, it teaches students the established/measures' for the preserva- tion of the health and prevention of disease among troops and, secondly, the department performs research in problems of field-sanitation. T Teaching and the -writing associated with teaching occupies most of the time of the department. • At the present time there are three courses offered, at the Medical Field Service School. • . 1. An 8-week Basic Officers' Course which constitutes the main effort of the-School. . . 2. A 5-week Medical and Field Sanitary Inspectors Course. 3. An Officer Candidate School -- this is an intensive seventeen week course conducted for: enlisted men and leading to a commission as second lieutenant in the Medical Administrative Corps. We have also in the past conducted Officer Cadre Courses, as divisional and non-divisional organizations sent officer cadres to us for training for special assignments; and advanced pool courses for Medical Department officers who remained in the pool after having completed the "basic officers' course. Out of a total of 375 hours of instruction for the basic officers’ class the Department of Military Sanitation is credited -with hh 'hours, or approximately 11 per cent. Actually, we give many more hours hut we get no credit in the final tally for the field problems .demonstra- tions, and applications which are put on by the Department of Military Art and in which we take an active part; and for the lectures and ' demonstrations presented by the Department of Veterinary Field Service, The breakdown of the Mi- hours of Military Sanitation may he of interest. Five hours are devoted to the control of droplet and air- borne infections including housing and tent sanitation. A total of :21 hours are given over to the control of intestinal diseases, includ- ing waste disposal, mess sanitation, heating in the field and water purification. Two hours are spent on the ‘subject of venereal disease control. Fourteen hours are spent on arthropod and animal posts,' vec- tors and reservoirs of disease and their control, and two hours are devoted to special sanitary problems, particularly those of the tropics and extremely cold climates. The student gets a practical down-to-earth course in,military sani tation and when he leaves our school, he should know how to safeguard the lives of his men in the field. He is familiar with field methods of waste disposal and water purification. He has been taught recent developments in mosquito control, louse control, rat control, fly con- trol, flea control and mite control. He is abreast of the latest developments in communicable disease control. Wo try more than any- thing else to make him preventive medicine conscious. - When students-' come to us, particularly Medical Corps 'officers, they are not preven- tive medicine conscious. Since the first basic officer class went through the. Medical Field Service School in December, 1940 that is, since the mobiliza- tion -- we have graduated 24,516 officers from,the basic officers’ courses alone and 18,276 of these were physicians; 4;272 were: dental officers; 584 wore voterinary officers; 488 were Medical Administra- tive. Corps and there wore 872 Sanitary 0orps .officers. - •■■■' The' Medical and Field Sanitary Inspectors started on the 2nd of November 1942 with the mission of instructing especially selected officers in all phases of field sanitation and military pre- ventive medicine so that they may satisfactorily carry out their advi- aopy and supervisory duties as preventive medicine officers or assis- tant medical inspectors in divisions or at posts, camps, and stations. While all the departments of the School cooperate to make it a finished a,nd thorough course, most of the instruction is given hy the Department of Military Sanitation. It is a five -weeks course and there is an in- terval of one week "between classes. The next class is scheduled to "begin 12 March 19^5. The Medical and Field Sanitary Inspectors Course is a well-rounded, intensive, practical course in preventive medicine, well worth while for all preventive medicine officers whether already assigned or pre- paring for such an assignment. At first only carefully selected Medi- cal Corps,' officers were designated to take this course of instruction "but a letter, AGO, 21 January added Sanitary Corps officers to the authorization and the first Sanitary Corps officer appeared in the 4 th Class.’ Since then the number of Sanitary Corps officers lias steadily increased and the ration!s now reversed. In the last two classes we had one Medical Corps officer each and the rest were Sanitary Corps officers or Medical Administrative Corps officers awaiting assignment to the Sanitary Corps, Four Dental Corps officers have taken this course; and more, physicians than I care to mention -- who have not the slightest interest in preventive medicine and who seem to have been sent to the School because they had nothing to do at the time candi- dates were being selected. I recall in particular the puzzled and at times pained, expression of a plastic surgeon of considerable ex- perience who was sent through this intensive course in military pre- ventive medicine -- possibly with the idea of improving his techni- que. This course was set up to take care of approximately 5° students each session but only in four of-the 21 classes graduated were there more than 50 officers. Lately the tendency has been for the classes to be quite small. In the 19th Class, only l6 officers were given the opportunity to attend. The last class, the 21st, had an enroll- ment of 33$ This is not economical since it takes as many instruc- tors and as much time and effort to teach 16 officers as 50. Experience in combat areas has demonstrated that training in sanitary control measures is of paramount Importance and it seems reasonable that better utilization should be made of existing training facilities,.-; We have graduated so far from the Medical and Sanitary Inspectors’ Course a .total of 84l officers broken up as follows; 466 MC; 4 DC; 76 MA.C; 288 SnC; 6 PC and 1 CS. The officer candidates receive dur- ing their 17 weeks course 63 hours of instruction by the Department of Military Sanitation. This does not include the hours coordinated with the Department of Military Art and the Department of Veterinary Medicine. ' , In order to keep the Instruction alive and up-to-date we have had. to do considerable writing, both in the form of guides for instruc- tors and issues for students. Our mimeographed material, particularly our issues, to ;the medical inspectors, have become well known through- out all the commands and wo have to fill numerous requests for this material,, 1 have- a good example of this type of material here which you are welcome to take, and if any .of you are interested, if you 'Will write to us we will be very glad to give you all of our memeo- graphed material. We operate an insectorium so that sufficient living .material is available for demonstrations to the student. .Nothing can take.the place--of the officer actually seeing and doing and feeling. At,the present time we maintain colonies of mosquitoes, the house fly and the common bedbug. • There are so many other pests available, readily available in the post that we don’t have to maintain special colonies. We have developed at the Medical Field Service School a most ex- tensive demonstration area, with actual full-size working models of practically every useful sanitary device and appliance that might be needed by troops in the field to maintain the highest possible stand- ard of health. In the matter of research the title of some of our, reports will give an indication of our work; Study of Chlorpicrin as a Delousing Agent for Clothing; Efficiency of Katadyn Water Filter in Removal of Cysts of Endamoeba histolitica; Test on Orthotolidine Tablets; The Diatomaceous Earth Pack Filter; Efficiency of Foot Baths; Japanese Water Treatment Sets; Water Chlorinating'and Dechlorinating Units. The hulk of our work, however, does not appear in reports to The Surgeon General hut is reflected in the instruction to the students. We may spend months trying to get a U - shaped piece of pipe to serve as an effective gasoline burner or make downdraft heaters from 105 mm shell cases and our students get,the immediate benefit of these inves- tigations. I do not intend t6 imply by these remarks that these simple improvisations originate at, the Medical Field Service School. We originate very little. We get our ideas from men who are really doing things in the field and 'at ‘ times we improve on them,' We in the Department of Military Sanitation feel very grateful for the opportunity that has, been given us to serve — we feel proud when we remember that since the present mobilization began we have taught preventive medicine to more than twenty-nine thousand Medical Department officers. Are there any questions, gentlemen? .. . , ,r There was one question presented before this session started, on the use of a preparation on board a ship where suitable, sufficient hot water is not available for the washing of mess kits, I assumed that practically everyone is fqmlliar with the Compound Germicidal Rinse which is available fortrse under those conditions. Col, Ahnfeldt yesterday brought out another very important use of the Compound Germicidal’Rinse, in the washing of contaminated vegetables.. Again, it is used where boiling water is not available, and sometimes it does not ruin the vegetable as much as boiling water would. - There was one other"' question, I believe, about covers for moat blocks. As far as covers for bieat blocks are concerned, I think a very'excellent device was written up in the Army Medical Bulletin and we have nC objection to covers on meat blocks.' The main thing is to keep the cover clean. If you are going to cover the meat blocks to keep the inside of it clean, the idea is not to let flies and animals defecate on your meat blocks and to urinate on them. It is a very important thing. Meat blocks have to be kept clean. Any device that will keep a meat block from being contaminated is a worth-while de- vice. Another question that was brought up concerned the recent ad- vances in field sanitation. We still bury our wastes and still burn them. We now have intriguing methods of burning them and we have an interesting "hot squat" which we demonstrate at the field service school for the disposal of human waste. Under certain conditions where ground water is very high and nothing else can ever he done, we can always put a nice seat and a self-closing lid-cover on a 55-gallon drum and make out of that sort of a multiple shelf type of incinera- tor. You can have a little ramp heading up to it and it makes a very clean latrine that can he used whore you have fuel. I once took a foreign officer through our area. We are very proud of our new demonstration area and he sort of made a face at wery device I showed him. When I showed him a lot of wood, he said, ".Where am I going to got wood to use as fuel?" When I showed him oil as fuel, he said, "I have no oil to use as fuel." Most of our devices use gasoline as fuel. He said, "Gasoline is very difficult to get. We have no gasoline," He was also not much interested in our devices for'human waste disposal. In fact, fecea[is a very valuable commodity where.ho came from and in oortaln places they don’t like to dispose of it. Wo really have developed nothing that can utilize air hy it- self as a fuel. We have gone into the use of the oil-water flash burner considerably and as many of you know, inecertaih installations it works very effectively, '• We have gone into a groat deal of the use of this U-shaped pipe in heating water for mess-kit washing. We have some dandy devices for taking showers in the field, Just an ordinary five-gallon drum with a couple of holes in it. It makes a very effective shower hath. I wish every one of you would get the opportunity to go through our new area,, which goes into everything, including rat control. We have even constructed a stream in that area; we have a rambling brook'that leads into a pond. We have a swamp and everything. Every possible device that can be used in maintaining the best possible health con- ditions among our troops is demonstrated. We would much like to get ideas from the various service commands. 'COLONEL mRDEHBEEG-H: Col. Kogel was a little "bit modest about that demonstra- tion area that he has. It is really a remarkable place and well worth going through. I hope that sooner or later all of you will arrange to go there and see it. They have done a fine job there. I was interested, myself, in knowing that we had passed through some Qj2 Sanitary Corps officers. I did not realize that that many had gone there. .I must say here that- the Training Division of The Surgeon General’s office has done a magnificent job in fitting our Sanitary Corps offi- cers for duty with the Army, In that connection, you may be interested to know that on the 30th of December, we had 2,738 Sanitary Corps officers on active duty. It has to be quite a Corps. Now, changing the. subject a little, one of the bright spots in the preventive medicine program was the initiation and smooth carry- ing out of our occupational health program and at this time I would like to introduce Lt, Col. W. L. Cook, who is in charge of that pro- gram in The Surgeon General’s office. SCOPE OF INDUSTRIAL MEDICINE PROGRAM, INCLUDING RELATIONSHIP WITH SAFETY AND SECURITY BRANCH, OFFICE OF TEE CHIEF OF ORDNANCE -- DESCRIPTION OF MEDICAL OPERATING MANUAL FOR DISPENSARIES - CIVILIAN NURSING PROBLEM -- PURPOSES AND PROCUREMENT OF SET, INDUSTRIAL HIGIENE ENGINEER, FIELD - LT. COL. W. L. COOK, JR., ACTING DIRECTOR, OCCUPATIONAL HEALTH DIVISION. COLONEL COOK; Col. Hardenhergh and fellow officers; That introduction sort of puts me on the spot, I think, "because I am sure that the initiation and smooth carrying out of the activities of the Occupational Health Division are entirely up to the work that Col. Lanza did. Perhaps you all know. Col. Lanza was re- tired from the Army December 6, and I hope not too unfortunately General Simmons decided it would he all right for me to at least stay at I8l8 H Street for a little while longer. One thing that I have Been interested in and mentioned at some of the Division Chiefs’ meetings is informing the people out in the field,of exactly what the Preventive Medicine Service does. I am sure that the officers whom I have met don’t know that the Occupational Health Division does a little Bit more than develop the precepts By which the Industrial Medical Program is run. We have three Branches in the Occupational Health Division, the first and foremost of which is perhaps the Industrial Medical Program Branch. The second is the Toxicology Branch, which is a Branch that we more or less adopted when Col. Stone left The Surgeon General’s office. That Branch deals with the giving to other technical services the O.K. of The Surgeon General’s office on those new products such as water repellents, fungicidal agents creams, soaps, solid fuels etc w which the soldiercuses, When they want to go from steel to aluminum to galvanized ware for kitchen utensils, we are asked whether it is all right. When they wanted to develop the new fuel tanks which when Burning develops high cyanide gas, they wanted to know whether it was all right to use and what precautions should Be used. One comment for instance is that your Compound Germicidal Rinse can also cause dermatitis. We get asked a variety of questions of that nature. The other "branch in our office is what I like to call the Washington Clearing House for the Armored Medical Research Laboratory which is stationed at Fort Knox, Kentucky. That laboratory was ori- ginally set up by the foresight and forethought of General SimmonE. Col. Lanza■arranged to get most of the men who are down there. The laboratory was originally turned over to the Ground Forces, Col. Willard Machie, who is the Commanding Officer of the Laboratory, has insisted that even though it is now a Class installation of The Surgeon General it be used as an experimental laboratory for defining for the Ground Forces, particularly the Armored Command of the Ground Forces, those things which will improve the fighting soldier’s effi- ciency in the use of mechanized equipment and the various types of clothing, food, water and so forth which he has to use in the type of job he is doing. Out of this laboratory at Fort Knox have come the standards for water and salt requirements in various types of climate. They have recently put out some very interesting information on the physical li- mitations of a soldier in various types of environment,. They have changed the ventilation of tanks in order to keep the man from passing out with carton monoxide while firing his gun. They have made the escape hatches escapable -- they have fixed the seats so that the driver.;now has a xjlace for his left foot. They have fixed the hand controls, for aiming guns so that you can really use them efficiently, and I can go on and name a lot more, hut to get down to tile thing that you people arermostly interested in, I will now discuss the Industrial Medical Program. ... The first thing I would like to say is that industrial medicine is. going to stay in the Army. It is not going to he dropped when the present emergency is over. We are at the present time preparing WD Circular No. 198 for publication as Army Regulation h0-220, I think Col. Lanza can he•proud'of the Industrial Medical Program is going to become governed by an Army Regulation, One question that has been asked numerous times is why the ser- vice is limited to those installations which are mentioned in the Circular. I think you gentlemen all know the answer, and it is that we don’t have enough medical officers; we have not got enough civilian doctors who want to work with us and we have not got enough nurses, to include everybody. We originally tried to pick those places which most, needed care for civilians and wo picked our arsenals, depots, inA dustrial plants, and later added ports of embarkation. I think one thing that should be brought out at this time and which has been mentioned over the last two days is that the troop strength has been cut in the United States. But I don’t think-that you will find that industry has been cut much and I would like to make a plea for a little more attention on the part of the Service Commands for ,the industrial medicine program, I think at the present time we can all say that there are buildings, personnel, and ade- quate equipment for running an industrial medical program at those installations which come within the scope of the industrial medicine program as defined by the War Department circular. It is- the belief in our office that the program having now been set up, is hbt work- ing efficiently enough and we want to spend the rest of our'time in making it work more efficiently. You may ask us what we are doing about it. Well, one thing we arc doing about it is getting published, and we have control troubles, too, Col, Allen, a manual which will define for everybody in the in- dustrial medical program Just how any industrial medical Dispensary is .’going to work. This manual has included in it six forms; a physical examina- tion form a report form which goes from the Medical Department to the Personnel or other departments interested at the plant; a record treatment form and an absentee form. The fifth is what we call a dally log sheet of work done. All of these forms will stay at the post. The sixth form is to be forwarded through channels to The Surgeon General’s office in order that we will know a little bit more about what you are doing. I have copies of some of these forms with me. They will not be stocked at AG. depots until the publication of the manual,' which we hope will be soon, I will be glad to let you see them and you may carry any of them home with you. They all at the present time have their AGO numbers and are being printed. There are other things which this manual tells which I think are important. In the introduction it tells Just exactly what we think an industrial medjeal program ought to be and what we expect of any industrial medical program. It also tellsswhat that particular service will do for the installation. It describes what we mean by a pre-placement. physical examina- tion and what someone should know about his plant and his prospective personnel and his civilian job sheet records before he can say that John Jones is fit to be a fork lift operator or that he is.fit to be a machinist.' ■: .- it tells what we mean by a vaccination program in plants; it tells what we mean by a so-called YD program. Should you or should you not take Was seamans on everybody'■and whom should you hire as a result of such a test. It tells how you can get a chest X-Ray survey on all the civi- lians. Sometimes we are asked to get a chest X-Ray survey and we can’t give it to you right away. There is possibly a little bit of fault on two sides, one ourselves and the other, the Public Health Service who, by the way, have been very helpful to us and upon whom we rely for these chest X-Ray surveys. This manual tells what we mean by the reports and records which the plant shall keep and how they shall be kept. It telle you where you can get your medical supplies and how you can gettthem and what are available to you. So much for this manual which wo were trying to get put. I might say it has been our foremost effort;,of the past year and it took us about two and a half years to convince ASF Headquarters that such a manual ought to be put out. In the comments I have heard,:n here, I think that perhaps’we may be jumping the gun on some of the other divisions in the Preventive, Medicine Service, ■Wo have put a request in and are hoping .-to get, the permission to have an MOS number for industrial medical officers. I don’t know'how much- good that will do but at least it is an attempt- on our part to have you keep industrial medical officers working in, industrial medi- cine. •• ■ •; >1 We have, as you know, sent a letter to the. service• commands., „■ asking for assistance in re-editing the supply list for the indus- trial medical dispensaries and we hope that that new list will be published soon. ■,v. I think there is one other way that we, can help the service com- mands and that is by better usage of the Army Industrial Hygiene I Laboratory. I might say that quite a few of the officers of the laboratory are hero today, I suppose they came because they wanted to make sure that there would be at least a small audience, but. they are here, and -I am sure that they will be glad to talk with you ..and discuss anything with you concerning the usage of the laboratory.- I had prepared for me yesterday some information which I think is rather interesting: In the First Service Command in we-did one industrial hygiene survey and in none. In the . Second Service Command we did five in and four in In the Third;.Service Command five in and three in In the Fourth- Service- Com- mand we did four in and one in In the Fifth -Service Com- mand we did two in and two in • In the Sixth Service Com- , mand wo did two in and one in In the Seventh Service Com- mand we have not done any complete Industry hygiene surveys; In the Eighth Service Command-we have done none. In the Ninth Service Com- mand we did none in and five in 19kk. When you look over the list; you find that in almost every place where we were in ve were asked hack in 19kk, except for the Fourth Service Command and one in the First Service Command. When I talk to people in the service commands; they tell me; "We haven’t got enough personnel to do this, we can’t do that; we can’t do the other thing; you will have to assign us more medical officers','. You undoubtedly realize that it is beyond my control. I think you ought to use the Army industrial Hygiene Laboratory more than you do. Another interesting thing; .when you look down this list; Ordnance; Ordnance; Ordnance; Ordnance; all the way down. We have a few C.W.S, Fortunately; this year we have been to every port except Los Angeles; and I would like to know why we have not been there. We have been to a couple of Quartermaster installations and a couple of Signal Corps installations. I am sure there are more in- stallations than those I have been to in my two years working with Col. Lanza; and I wonder why some of these.other places are not ask- ing to be surveyed. When I go out in the field I ask; "What have you got to lose in having a survey? It doesn’t cost you anything," Sometimes I come back and will have convinced two or three out of four or five seen,rthat an industrial hygiene survey won’t do them any harm and can be of material benefit. Later on I -want Captain Postman of the Laboratory to tell us a little bit about his experiences at Frankford Arsenal, I don’t ■want you to understand from anything that: > he says that ve have suf- ficient officers in the Industrial Hygiene Laboratory to assign them for 90 days a year to one installation, which I think comes fairly close to the number of days that Captain Postmanlspent at Frankford Arsenal, one year; however, I do think that he can tell you a little bit about the help that such officers can give the Medical Department and even convince the Command Officer that they have been helpful. •■ r We don-11 want to decry the Industrial Hygiene Engineers or detract from their work at Command Headquarters. We do feel, how- ever ,-• that the Industrial Hygiene Engineer in-the Service Command Headquarters has not got as much equipment to.work with nor does he have a chemistry laboratory back of him which is .equipped and staffed for that type of work. We feel that we; can be of help to those people, do a complete survey for them once, then let them carry on and any time they need additional assistance we will be glad to come out and see if we can be of any,more help. 1 think another thing we have to do in this industrial medical program is to start finding out whether it is being effective. I go around to■■ various places and the Commanding Officers tell me "we think this: Medical Service is a wonderful idea, and we don't know what- we would do without it." .1 ask them, "How do you .know it is a good idea?" -They are a little surprised and taken ■aback by that question. ■ . ;; • •-P think that thebe'is a good possibility that any service com- mand that asks the industrial medical installations within the ser- vice command; "How much does it cost to treat a man per year?", ’How much is this service costing per employee?", "How much is it coating?", wold not be able to receive a satisfactory answer* "There are figures available from which ‘you can get this information. In Washington we don’t know it today, because we don’t know how many people work in many of the plants and we don’ t, kaow how many .people are working in the industrial medical program, lie will when the-new quarterly report starts coming in, h • ; I think you can tell a little bit about the effectiveness of the' program by seeing about the turnover in the plant. Almost every place I go they say, "Turn over 10 per cent a month."' T think we can find out why that turnover is there. If we find that put that a certain number .of people are leaving the plant because they didn’t feel that they were physically fit to work on the Job assigned -t and I think that that is; a combination of the fault of the Medical Department and the Personnel Department -- such individuals may perhaps be. kept on the Job by putting them in a Job where they can do an adequate piece of work.' . . ■ One other thing I think is very important; I don’t like to check • up bn.people too much but I do use the Employees Compensation Commission to find out the .effectiveness of the program and it is, rather discourag- ing to find out that a man was off 65 days due to a tetanus reaction - following a slight cut on his finger. Was he off 65 days due to T.A.T.- or was he off 65 days because he Just went home and nobody cared whe- ther he came back. If at the end of 65 days he comes back and says, "I was sick as a result of that infection.”, who knows the real story? I don’t think it is right to lose an employee 31 days because ho strained his shoulder. There is a diagnosis that is wrong there or else somebody iS not following up their cases. Another case revealed twenty-four days lost time for a laceration of the little finger. I ' -• can mention a lot more for you. I have been to installations, shown : them those figures and they have said, "Wait a’minute, let’0 look," and they always come back with, "I guess you are right. We didn’t follow that fellow well enough, I admit.” , Another thing, when we send people to marine hospitals,, they are : awfully busy and lots of times they don’t want to report to us on,how soon-a man can come back, whether he is hospitalized, whether they have- sent him home, to the clinic, or what the story is. X do know that when the medical officer,gets to know the doctors at the Marine.Bpspital he can get any sort of information he wants, generally speaking.. I . would like to know any time they can’t get satisfactory cooperation : because’after all, General Parran is in Washington. I think General : Parran or one of his assistants might be able to help us a little bit > on that score. • What I think wo have to. tell the Commanding Officer of an iijstalla tion is how he can "move more tons per man" or how he can "produce more per man," If wo can show him that the Medical Department is so assist- ing him, very few will mind when a medical officer makes a suggestion. There is one thing that has been a thorn in the side of lots of people for a long time and that is medical officers assigned to the Safety and Security Division, Ordnance, in Chicago, Illinois. The Chief medical officer there, is Lt.iCol. McConnell who was working with Col. Lanza prior to his coming in the Army and I think there is probably no one in the Army today who knows more Industrial medicine than Col. McConnell. Why did wo assign him there? We assigned him there because Safety and Security, Ordnance, is in eharge of - and when I say "in charge of," from the health stand point I mean it -■ all plants of ordnance Which manufacture, store or process pyrotechnics'or explo- sives. The point is that you can’t put an electric exhaust fan in an explosive plant in.order to cut down the amount of T.N.T. dust exactly the way you would some place else "because occasionally you produce a spark and suddenly have no plant with which to deal. Every recommenda- tion made for the control of health hazards in one of those explosive plants is passed upon "by the Field Director of Ammunition at St. Louis, who is,also the Director of the Safety and Security Division, Col. T. C. Gerber., Col. McConnell works for Col, Gerber. When we do an industrial hygiene survey and I might say that practically all of the Ordnance industrial hygiene surveys mentioned today were asked for by Col. T. C. Gerber, not by the service commands -- the Recommendations are passed upon by the Engineers and the Medical Department of Safety and Security Ordnance before any order goes saying, "This will be put into effect." How much good has this careful check done? I think there is one little story I can tell you, and there are many concerning the effective- ness of their program, and that is this: in the last war over a period of 7*’l/S months in TNT plants in the United States there were some 475 deaths from TNT. I mean acute yellow atrophy and anemia type deaths. I am not speaking of explosive type deaths. These are TNT illness deaths. In this war up to the present time — and I think we are manufacturing maybe a couple ounces more TNT in this war than the last war -- there have been a total of 17 deaths, I think that one little comment is enough to make General Somervell feel perhaps the industrial medical program has been worth while. That is the reason that we have written into the War Department Circular that inspections and recommendations covering the control of occupational health hazards-in those plants assigned to Safety and Security, Ordnance will not be done by the Ser- vice Command but will be done by representatives of Col. McConnell’s office and such agencies as they draw upon’which are two, the Army Industrial HygienenLaboratory and the United States Public Health Ser- vice (the latter for the contractors’ plants only); Wo feel that there are faults on both sides in this arrangement. We know that the Medical Service has to be run by the Service Command, I am sure that perhaps Col, Gerber would love to have us give him some medical officers and let him run his own medical’ show, and control his own occupational health hazards. Unfortunately, that can’t be done and therefore.those service commands that have such ordnance plants must supply them with an adequate on the Job medical service. I know also that Col. McConnell suggests and sends out ordnance letters which direct - that. people working in such and such a plant will have a periodic physical examination every so often, that they will have a red count done, a hemoglobin or urina examined for TNT, and so forth.- I have told Col. McConnell, and I am not talking behind his back, that I don’t think he has been a good enough salesman with the service- commands. I don’t, think they know him well enough. I don’t think- they know What he is trying to do and I think also, that he does not understand-that * the* service command is not looking for work and when they send one of their officers into such plants it is because they have certain responsi- bilities there,. not becuase anyone wishes to inferfere with a Job being well done. One of the things that I want to get from this talk is suggestions from you people as to what I can do to make the relationship between- Safety and 'Security, Ordnance and the Service Caommands a better one. ...We have some questions from some installations as to the nursing problem. Are the nurses going to be drafted? Are the civilian-nurses 106 ■working in the. Army industrial medical program going to he drafted. Hi': We have discussed, this question with the P. and A. ■ and some >of thd" - lower echelons of the War Manpower Commission and Col. Dlanchfi'eTd, head of the Army Nurse Corps, The best information to date is that-the' v nursing situation, should they he drafted, will he handled the same u as the doctors. In other words, if they are of a certain ago and not in an essential position they will he drafted the way the doctors wore, I mean not actually drafted hut subject to rather warm pressure. If they are working in an essential industry from the - standpoint of the 0 7 war effort, they will probably, undoubtedly he able to? stay whore’ they are. I do think, though, that every effort should'be made vif• there arc 28,000, nurses running around loose, -- not hire'the yodngest nurses for our industrial installations but. try to do the same as most of industry is doing today, to get a slightly older group. There is one other point that I would like to mention, and that is this very complicated name that the supply service has given it, "Set, Industrial Hygiene Engineer,Field," This is a compilation of instruments which an industrial hygiene, engineer and I stress that because no installation or headquarters will get one of the sots which has not-got a qualified industrial hygiene engineer to handle it. The' set contains sufficient equipment to permit an industrial hygiene engineer to do satisfactory field studies. It is like the doctor’s bag to the M.D. It costs well over $2,000 and is packaged in two modi1 cal field ..chests. The reason this set was made up was so that if wc got a call to send a man overseas, he would at least have something ■ to work, with when he got there. We also feel that anybody who is doing survey work in the field, such as the industrial hygiene engineer of ;a-; service command, should have one of theses sots# We don’t want you to •••’• write in and ask for three-quarters of it or:one-fifth of it because- — that is like asking for three-quarters i5f the equipment for a 1,000 bed.hospital. They don’t come in that kind of package. If you already have some equipment and you would like to know what the rest of this equipment is, the St. Louis Medical Depot can toll. In requisitioning a complete set, add to the requisition, "We have on hand the following instruments, which wo will turn in upon receipt of this particular group of equipment," Another thing that I want to make plain is this; most of these instruments apparently are slightly on the prima donna side and get out of whack fairly easily. Wc have sot up at the St, Louis Medical Depot at the present time a department which is ready7- to repair these instruments for you, if you will send them. That is about all I want to say. I will see if I can answer some of these questions that wore sent to me. The first question from the Ninth Service Command is 'personnel and supply.problems in industrial installations and remote hospitals”. I don’t know exactly vhat you want -f Col. Norton, the question is: "Person- nel and supply problems in industrial installations and remote hospitals," , The thing I had in mind in bringing that up is that apparently in supply and also.in personnel organizations- all around there is quite a turnover, just as there has been in everything else. A good many of those,'will usually have a sergeant who takes these requisitions and he will put "O.K." or not on -• it. Then we. have to send those in several times because of that. They will look and see that the set-up has so many military personnel. They disregard all the civilian personnel that these:people in these indus- trial (set-ups have to look after.- That is true in the .remote hospital. COLONEL NORTON: Also another problem in remote hospitals is that there they have, the civilian patients and usually they are 75 to 100 per cent’.bed patients, ■whereas the people who are accustomed to consider personnel and supply are accustomed to'dealing with 75 to 90 per cent ambulatory patients, where they can have some help, and it is quite a different problem in these hospitals that have to take care of these people. They heed more equipment and they need more personnel for the same group of patients and also the people that have to do with those...things very frequently do not consider the remote, isolated areas, where they., do have to take care of the civilian personnel in these isolated plants and also have to take care of their families, because some are 50 and 6.0 miles from a doctor and they have to do that, otherwise the workers in. the plants will have to get out and take a Child Or the"worker in the plant will have to take his wife 60rmiles or so to see a doctor, back and forth and that means loss of work. ... .. It is just one of those things. If anybody has .'any good way of getting that"thing across and keeping it across, it is one of the pro- blems that we have to deal with. • .'.C COLONEL 'i 0 COOK: , ,' This much, can be said about it; when ye set up those remote area hospitals, of which there are four in the Ninth Service Command, the Supply Service asked, "How large are they going to he?" I told them and they said: * "If we give you the same amount of supply that we give an Army hospital of that size, will it he sufficient, aside from a few minor addtions such as obstetrical equipment?" I said, "Yes," We haven11 had any official complaints sent in to us. I am sure that the Supply Service will go ' along with us on anything we need. I don’t think that you should do ‘ allergy tests, I don’t think that you should do definitive gynecology, from the standpoint of what the'Mayo Clinic would do, Just because one of the officers at one of these installations happens to he a gyneco- logist, and I don’t think that you should start' doing special bridge-V work for somebody because there happens to be the dentist there. X don’t think you should do definitive ophthalmology Just because there happens to be an eye man there. Those are the things which we will turn down if they come in to us and we usually tell you why. If you have any reasonable request it will, be approved. The next thing is the feasibility'Of. using preventive medicine personnel such as medical inspectors,' T.D. officers and the like on an area basis similar to that already in use for industrial medicine in the three areas of the Ninth Service Command, San Francisco, Los Angeles, and Seattle. I will be very glad to have Col, Norton tell you about this but there is one thing I would like to mention. When Col. Lanza first came to Washington and was confronted with a number of plants which needed industrial medical service, he decided the best' thing to do would be to commission a few fellows who knew a little' bit about such work, send them out where the trouble was and let them go to work. Now that we have gotten down to the bottom of the barrel on indus- trial medical officers the situation that I see in the Ninth Service Command is an excellent one. I grant you that every service command does not have three main locations for its industry, such as Seattle, Los Angeles and San Francisco. However, the way they work it out there I think is very good. They have ono man who really knows industrial medicine, who is the head of a service unit of the service command' located in that area. He is in charge of the medical service for Ordnance, Signal Corps, Quartermaster, Chemical Warfare or anything else that happens to he in that area and he has assistants working for him who don’t particularly have to he trained in industrial medicine. I think that that is a splendid idea. He gets around to see each of his instal- lations once or twice a week and spends as much time as he has to there. I would like you,to tell them anything more that you would like to say about it. I do feel that the situation is very well controlled in the Ninth Service Command. These fellows get to know everybody in the town. They pick up a few odd doctors every once in a while who say they have a few hours extra to work; by going to the medical meet- ings. They don’t have the actual physical examina 11 onc.and treatment of cases to do as much as others. They are sort of junior service command industrial medical officers, if you want to call them that, but I do think that for the service command that* has been cut to the bone on people who really know what the business is about -- and I do think that it is a definite business and has to be looked at as a specialty, that it is a good idea to let somebody be assigned, such as Major Parkinson who has his headquarters at the California Quartermaster Depot, but who also takes care of about seven, other installations, one as far as.50 miles away. Am I correct in that? ' COLONEL NORTON: Yes. COLONEL COOK: He has a command car at his disposal. General Boone of California QM says, "He is my station surgeon hut still he gets around to all the rest of the places" and General Boone understands that he is working, not only for General Boone hut for other installations of the service command. Have you any other comments that you would like to make about that, Col. Norton? LT, COL. NORTON? I have no further comments on that. Tile thing that I wanted to bring up I think can he more appropriately brought up tomorrow afternoon and that was the discus- sion of working out some of these problems on the general area basii for the whole preventive medicine service but I will say that the way that this is working in those three particular areas, for the industrial medical program, is working out very nicely. Major Parkinson has altogether under his supervision lYndifferent • local set-ups and by having a good man looking after that is much better than having two or three at two or three pf the places and the rest of the places being without and it is working out very nicely.' The next question is; Is the' new Army Safety Program, the Surgeon’s part of it, a preventive medicine func- tios? Simplification of the reporting system seems "badly needed. . . COLONEL COOK: I agree with the last part of that statement 100 per cent. As a matter of fact, I happen to be on the Under Secretary of War’s Accident Prevention Committee aq The Surgeon'General’s representative and I have taken two trips around on this accident-prevention business and one- of the first and most obvious criticisms you come across in the field is that the circular describing.the reports that should be kept and forwarded from service command headquarters to The Surgeon General on accidents is, well, from my standpoint, pretty terrible. I think it was a question of the fact that somebody sitting in Washington wrote something without having been out in the field to know how the- field works. .. : " ' I will also tell you that as a result of these two trips, the reporting is going to he changed and you can all sit there and say, "That is not the only thing that has been changed in the adcident-pre- vent ion program." I know, I have had to learn that recently, too. How- ever, I do feel that there are two comments to make one of which is this: Naturally the safety people don’t think the doctor can he of any assistance to them in a safety program. The reason the ddoctor ms brought,into this business was because they felt that the safety man can not be on the spot and investigate every accident'which occurs, : whereas, if an accident amounts to anything, the soldier will bo taken to a medical’dispensary. At that time the safety man may be busy and can’t come out and interview the man and it was the idea that the medi- cal officer in taking his history would also ask a couple of other questions and be able, therefore, to spot for the accident prevention man or the safety officer, the areas and the individuals to be inves- tigated. Whether that is going to be done or not, I don’t know. As I say, it is not working well, as wo know. II don’t know whether I answered the other question which is the coordination of the industrial medical program between the service com- mand and the Office of the Chief of Ordnance. I tried to tell you pretty much about the way it is supposed to work. I would be glad to hear of any criticisms concerning it from you people because I expect to see Col. McConnell shortly and I would like to bo able to straighten out the service commands. It seems to me that the way it is written there should be no argument. However, it may not be clearly enough written and we have tried to rewrite it so that it will be more specific in our proposed Army Regulation. The next question is emergency medical care, the prevention of occupational exposure for civilians employed at combined maintenance shops at posts, camps and stations. That comes down again to the pro- blem that I mentioned earlier, of what individuals we cover in the., indus- trial medical program. We admit that we are not covering individuals who work at. industrial jobs. We are covering all individuals who work at industrial plants, arsenals, depots and ports, and we feel that we ■ have covered the most' essential, perhaps 75 per cent. We know that, we are not taking care of all the people, I talk to the Civilian Personnel Division of the office of the Secretary of War at least once a week and they ask me, "Don’t you think now is the time that we can get out a War Department Circular saying that the service command will take care of all civilian employees of the War Department, and include them in your program?" I keep telling them "no, that is the straw that will break the camel’s back, it is awfully loaded at the present time", so I think we do understand- your problem. We get the same thing from the Air Corps all the#time. I feel that I have been perhaps to fifteen meetings in the Office of the Secre- tary of War, Civilian Personnel and also Industrial Personnel, ASF and we have so far been able to hold them off. Somebody some time is lia- ble to ring in on us a sentence which says, "From now on you.will," and at that time, fellows, I hope I am some place else. Are. there any questions that you would like to ask me? Before we go on. Captain Postman, would you spend a couple of minutes and jiist tell them about the work that you have done at Frankford Arsenal of the Ordnance Department and how it works out? CAPTAIN POSTMAN: The laboratory contribution in the preventive medicine program at Frankford may be best demonstrated by the num- ber of activities with which we were connected during, the past year. Thirty-four active projects were worked on at one time during 19^• These projects resulted from industrial hygiene surveys, made hy our survey team who made field and laboratory determinations, after which the Arsenal requested, through proper channels, either Engineering aid of out Engineering, Design and Development Section dr developed con- trols of their own through their own Engineering Department. : • . - . Up to the present time we have been doing most of the engineering work for Frankford through personal contact. We developed engineering factors which took the skill of a designing engineer, tHe develops draw- ings and specifications, sends them to the laboratory for review and approval, after which the material is ordered, purchased and installed. After, the installation, one of our officers goes to the Installation, adjusts the system and makes a complete check. About six months ago, Col. Foss, Commanding Officer of Frankford, issued a directive after consulting the Post Surgeon, Linder, to the extent that no new toxic materials were to be used in any operation at Frankford Arsenal, no new engineering project was to be 'started or no changes were to be instituted in an existing installatlikinunless Major Linder was so advised. In many instances Major Linder was able to give his yes or no as to the change and the rest of the time we were asked to come up and consult with him and Col, Ross; This has been the most outstanding contribution of our efforts to an arsenal. We have had the most cordial relations with the arsenal and also through Col. McConnell of thS Safety and Security Branch at Chicago, We are available through channels for such engineering services as Col, Cook mentioned to you recently and also engineering aid in the development of any problems which may arise at any of your installations. ' COLONEL COOK: “ Thanks very much, I think that that is a pretty nice compliment to the laboratory, that Col, Ross issued such ' an order, I do know that prior to my coming in the Army, we had such a set-up at Westinghouse and Col, Schrader of the Third-Ser- yice .Command, who also was there, knows how valuable it was to Westing- house to have the Medical Department get in on the ground floor of new developments in any of their industrial installations. We donft, after an installation has been set up, have to go in and rip it out and put in new ventilating ducts and tell the production men that they are going to have absenteeism due to illness, if they don*t improve their working conditions. Are there any questions that anybody would like to ask about the program? CAPTAIN COOPES: We have a particular problem in the port, I suppose they have them at all ports and it pertains to the civilians., usually the employees of the government coming hack from overseas. Not Infrequently we have to go to the Judge Advocate and interpret their contracts which call for medical care, whether they go to a medical hospital in this country or whether we send them to the marine hospital. There are no problems overseas; there are very few civilian hospi- tals and they are always taken care of in an Army or Navy installation but once they arrive in this country we really have a problem. It has been settled in San Francisco mainly because of our relations with the marine hospital there, which is veyy excellent and also tho employees who come back ’as patients are sent there. ■ Occasionally someone will call our attention to a clause in the contract that says he should got there via the Army and insists on go- ing to the hospital we have available, which is the Lctterman,. and then sent to the .marine hospital. He is aomctliifes dlagruntled, 'Perhaps; he has had unpleasant care at some other hospital. He’, does not' f6bl that.' marine hospital available isn't as good as the Army .hospital, 'V'fia/ipr v ■ - | .V.-i .nri„ think, there should ho and can ho some simplification for at least, a consolidation of the various contracts that these civilian employees, get and possibly there should he some explanation to them before they go overseas, as. to Just vhat they are entitled to. COLONEL COOK: . That is an important problem. Fortunately for me it.. is. j. not one that I have to decide. I might say we .have had • numerous comments such as that from various individuals and, particularly technical services and it seems that many of them. stem from the exuberance with which personnel officers promise the civilians, who are going overseas almost anything in order to get them to sign on the dotted line and go, I will taka that up, however,, with .Civilian Per- sonnel and OSW and will see what we can get out, on it. It’, let. (really...., their problem and not ours. Any, other questions? . •. • .. . MAJOR CAKNON: I would like clarification on the point ofr.just how much access we should give personnel officers to the medical records of newly employed people. At our port they seem, to think they should have free access to our medical records and we contend that only should they he told whether a man is suited or able to do d Job physically or not. , . • X V- COLONEL COOK; You are absolutely right in your reaction, I might say that our office, according to War Department. Circular 105, has stated that all medical information will be kept con- fidential by the,Medical Department. There, are many rea- sons for that, one of which, I think, can be mentioned here and that is a new bill which is up before Congress on which we had to testify not - so long ago concerning an overall Federal Industrial Medical Program,— At that time a representative of the CIO stated that he would go along with such a prggram only if the medical records were kept by the Medical Department and not given to other .parts of the set-up, : Col Lanza has been and still ’is a member of the Industrial Health Committee of the AMA. They have had numerous meetings with labor groups and labor--groups are now perfectly willing to go along with pre-place- ment physical examinations on a nation-wide basis provided that the medical information is kept confidential by the Medical Department and also that no employee will be told that on the basis of the physical • examination given him he can not be employed. A prospective employee ;should not be recommended for employment .on the basis of his examination at that time. In other words, they don’t.want these people to feel that they can't ever get employment as-a.result of one physical exami- nation or maybe one or two done within a very short period of time, I think .that that is easily understood, but..if you. have any trouble send your, trouble to us, I think we can straighten that out through Col, Fitzpatrick and Major Newman. I think if there are no other ques- tions, that is all. ... -/cior* *. i •* , , COLOREIc ; • . . HABDMBERQ-H: 0*1 j . ■ • •• * ....... Fortunately, there is not much time left "before lunch. However, the Nutrition Division tells.me if we have any, real gripes, it is'hest to get them off "before dinner so:’, if.vry.OU:',have anything to pomplain about: we would he glad to hear from you. . •• • : ...... .... orkSC rWouldrlike to add just one word-.-about, the meeting this morning. I- talking; about the, organlzation'-pf- preventive medicine service- and ludldnit want-, at- all- to overlook the,.-.magnificent accomplishments for the.last four years, covering only those factors for which I have been measurably responsible hut which have "been performed by the service com." mands. We .must not forget the fine quality of water that the Army is get- ting nor the excellent; results in sewage disposal nor the really out- standing accomplishments in malaria control in this country which are now being duplicated overseas by men you have trained, nor the good luck that we had in addition to fine work of the service commands on the ha- zards that arose through Army occupancy at hotels and colleges, some- thing that might readily have reacted very seriously, nor our modern methods of refuse disposal which are being established in many of our camps' and doing away with the nuisance of the old open dump and the broken down Incinerator. You heard Just now, also, the work of Occupational Health/ and you have had an opportunity to see how it has worked out in your own service command. So while we are looking forward to a better organization from now on and building up a sound organization for the long term peacetime, after-the-war problems of the Army, I think we have much-to be pleased with over the work done by the preventive medicine organization of the Army during the past four years. The program says lunch at 12:30 and I IiOpe It is true. Thank you, gentlemen. (At 12:30 o’clock p.m., a recess was taken to 1:30 o'clock p.m.) 4 : AFTERN00N "SESSI0N - 15 FEBRUARY 19^5 The conference was resumed at 1:30 o'clock p.m., pursuant to noon recess, Lt. Colonel E. S.'A, Robinson, M. C., Chairman. P R 0 CODINGS LT f COLONEL : ROBINSON;. The first speaker this afternoon will he Lt, Col. 0.R, McCoy, Director of the Division of Tropical Disease Control who will speak on the various public health aspects of the introduction of tropical diseases hy troops returning to this country. PUBLIC HEALTH'ASPECTS GE INTRODUCTION OF TROPICAL DISEASES BY RETURNING TROOPS — TB MED 2 EXAMINATION -- POLICY IN DISCONTINUING MALARIA SUPPRESS DTE ■ TREATMENT IN RETURNING TROOPS. : ' LT. COLONEL 0. P. McCOY, MC, DIRECTOR, TROPICAL DISEASE CONTROL DIVISION. COLONEL McCOY; Col. Robinson, gentlemen; The subject of the introduc- tion of tropical diseases by troops returning from over- seas has seized the imagination of the public and has attracted a great deal of attention, not only at medical meetings, but also in magazine articles and in the public press. At the beginning of the war, American physicians, in general, had had very little experience with tropical diseases. Many of the doctors going into the services needed additional training, as well as the medi- cal students who were coming up through the schools to be commissioned in the Medical Departments of the Army and Navy, It was important that they receive training to acquaint them with tropical diseases. To pro- mote this educational activity it was necessary to point out the impor- tance of thes'e diseases in the areas in which we would probably have to fight. Consequently tropical diseases may have been womewhat over-publl cized and the danger ; of introduction of ,these diseases into this- coun- try after the war, 'I- think, in general, was grossly over-exaggerated. It is true that we have , had an unprecedented exposure Uf American people to tropical diseases during this war>/x Millions of men are over- seas in tropical countries, ranging from, the Caribbean to Africa and India, Burma and the'Pacific theaters, .We have. had almost three years now,- in which to evaluate Just how great this hazard has been-for the troops and what the'probable importance of various.tropical diseases will he in the troops as they return home. Of course, it has been impossible to carry abroad the high standard of American sanitation and conditions of living to which, we are accus- tomed in this country, but nevertheless our troops overseas have lived on a vastly better sanitary plane, than have the native populations that surround them. 'Many of the tropical diseases that are scourges among the native populations have been little or no problem to the military forces. For example, there have been no cases at all reported among military personnel of such a disease as trypanosomiasis in Africa, (African sleeping sickness). On the other hand, there are certain dis- eases, particularly malaria, the dysenteries and dengue fever, which- have had widespread occurrence and have been of considerable- military■ importance, ’ : : < " There arc other diseases which have been important in certain local situations/‘for example, scrub typhus, fHarisis, in certain islands in the South Pacific, but.those diseases have affected a comparatively small number of troops considering the' Army "as ‘ a whole. They can not be re- garded as very important from the,public health standpoint when the men: overseas come back .to this country, -id " Next we will discuss certain of these diseases specifically and begin with malaria, because it is by far the most important of the dis- eases which our men have,encountered overseas. In many of the overseas areas suppressive treatment has boon a routine procedure for all troops exposed to malaria. This has boon true, particularly in the Pacific theaters and partially true 'in China-, fBurma and India. These meh have taken the drug for periods or long as a year or more. From experience that has been accumulated to-date we know that the amount of atabrine they receive as suppressive treatment and also as clinical treatment, when they gettsick, has been sufficient to;prevent and cure most cases of falciparum malaria. On the other hand it does not prevent the benign tertian, or vivax type of malaria and it is with this parasite that most of the men returning to this country are infected. During 19AA upwards of AO,OCO .cases of relapsing malaria occurred in the United States, presumably acquired overseas. Practically all of this, more than 98 per cent, was of the vivax type. There is no drug available which will cure vivax malaria with certainty. It is known that a certain percentage, usually about 50 to 60 per cent of cases, will suffer a relapse, no matter what-type of treatment, is employed. Consequently, when men return from overseas with, the .history : of having had malaria we can not be certain which ones of them will subsequently suffer .another attack. From a practical.standpoint the problem has arisen;as to whether these men should-be -segregated in this country. People in the Northern States have, .objected very strenuously to havirig. soldiers ■with malaria sent to camps, in the North,- because they say, '•-We1 have gotten rid of malaria and don't- want it- reintroduced,” whereas the pebpldudown South say, "We don' t, want the.men sent down here because' this is ;the ’climate that is most, favorable- for the spread of malaria; they should be sent up North where they don't haye any." It is hard to re- - cdnclie these. two points of view-, except by..denying both of them, • i ■- As a matter of fact, there is no good, reason to take such an atti- tude in this country. We have never taken it "before in regard to other groups that have come to the United States infected with malaria, We! ■have allowed hundreds of .thousands of immigrants from Southern Europe, many of them carriers ,of malaria parasites, to come .into the country and settle at will without taking any precautions sto see that they were free from malarial parasites. Also we have;encouraged the migration of agricultural workers from the Southern States to, the Northern States-, particularly fruit pickers during the.harvest-season, and we have allowed and.encouraged importation of labor from Mexico and from the Bahamas and Jamaica, “many of whom are infected with malaria. This policy has produced no untoward results. Malaria control in this country depends primarily on mosquito con- trol*/-. Attempts to regulate the location or movement of human carriers of the /parasite not only have many practical difficulties hut moreover do 'hot.!offer the hope of a reel solution that is offered hy a sound pro- gram of mosquito control. This, of course, is easier.to enforce at mili- tary posts and hospitals where good sanitation prevails and where person- nel is available to conduct adequate mosquito control. When the men return to civil life another aspect of the problem is presented which has been of some concern to public health authorities. At one time last summer there was a concerted move on the part of the Directors of the State Departments of Health to require the Army to report the names of Individuals being discharged who had had malaria. As already mentioned, it is impossible, if the man has a history’ of having had malaria, to predict whether or not he will be in the .. group that will subsequently suffer another attack. This question was dis- cussed by some of the foremost authorities on malaria control in this country and the policy was formally adopted at a meeting of the National Research Council in which it was decided that no useful public health purpose could be accomplished by reporting the names, of these indivi- duals to civil health authorities. That policy does not mean to discourage preparation for other methods of controlling the disease. All States should be prepared to conduct mosquito control operations in any area where an outbreak of malaria ’might appear. The U. S. Public Health Service has: established, special units which are equipped for just this job. Before I go on, are there any questions concerning malaria? I know that in some places questions have arisen in regard to segregation of prisoners of war. COLONEL MINOR: I would like.to ask you one question. Are they still following the policy of screening beds of hospital patients in areas where malaria is not prevalent? COLONEL McCOY: •I should think from the common sense point of view, that it would he necessary to protect them only when there . is a possibility that anopheline mosquitoes might hite them. Army regulations prescribe that patients being treated should be protected against insects which transmit disease.: -If .the insects are not there, I should not think that it would be necessary to provide protection with bed nets. That is a common sense interpretation. COLONEL ■ MINOR: I was, wondering if the hospital got a directive to do it. COLONEL McCOY: Is the hospital screened? COLONEL MINOR: Oh, yes. COLONEL McCOY: I 'think when the hospital is adequately screened, and there is effective mosquito control, that it is not neces- sary tb enforce use of hed nets inside a screened ward. Another aspect to the malaria problem which'I want to discuss is the policy in regard to the use of supressive treatment in troops coming hack to this country. I mentioned earlier that in many of the theaters, it is a blanket rule for the men to take suppressive drugs, However, the policy has not been uniform as to when they should discontinue taking the drug. ¥e have been attempting to have the theaters establish a consistent policy of continuing suppressive treatment until these men have reached the United States. A few months ago War Department Circular hkty was published which prescribed that men still taking suppressive drugs at the time of arrival in the United States would continue to take suppres- sive treatment for a period of 28 days in addition. The purpose of this policy is to protect the men from possibly having relapses of malaria during the period of travel and furlough immediately after their return to this country. Also, some people who return by air get back here within a few days from an area of possible exposure to falciparum malaria. In order to make certain that such persons receive at least four weeks medication, which experience has shown is usually sufficient to cure the disease, it is important that four weeks of drug be taken for this purpose also. Have any of you had any experiences as to how well this policy is being enforced? The station at which'the medical processing is done is the place where the drug should be given and instructions offered. The men must be instructed as to just how to take it. I can explain how -we did it there. First of all, troops are inspected and at that time they are questioned as to whether■'they had "been taking atahrine on arrival. If so, they are given a packet' of atahrine sufficient to carry them through for 28 days. On the packet very definite, brief instructions are given as to administration of-the drug. They have a little hit of a problem among the casuals' that-' return in that they go through the staging area,. When they sign in at Fort Mason they are instructed to go to the dispensary, provided they have not taken atahrine on arrival, where they are given their atahrine to take with them on the train trip. CAPTAm COOPER: ♦ Have you any impression as to about what percentage of the men coming through your port are fctill taking suppres- sive drugs when they arrive? COLONEL McCOY: CAPTAIN, ' COOLER: I can only say that o’Ur transport surgeons have been in- structed to continue the atahrine on hoard the ship;,' so that all the troops returning on Army ships have teen given atabi’ino* We have made an effort to get the Naval medical officers on the Navy “boats to do the same thing. I would say that the majority are getting atahrihe on arrival and, therefore, will prohahly continue it..;:, . . COLONEL MCCOY:' Are most of those men from the South and Southwest Pacifici CAPTAIN v' COOPER:' : " Yes, sir. Another problem which is : just .the opposite ;bf the present- subject hut is, I 'think, - quite pertinent, 1' - id just what areas to-which troops are'now going, should the troops be atabrinized. ' For a period of time this .Included all areas, other than the mainland of Australia, I -am suf-e -now that with effective malaria control -campaigns in certain of the Solomon'.groups and the Mari- anas, atabrine should not necessarily be given, although'^we don't.have-.:, recent information bn which areas still have malaria, nuuka . , COLONEL McCOY: Ihpse areas are usually delineated by the overseas theater surgeons. They set the policy in the' overseas' theaters as, to which places shall he on suppressive atahriile. > ' CAPTAIN COOPER; We attempt to give the troops atahrine’4 six or seven days "before they arrive at the port,' We don't know Just what areas are Still getting atahrine. COLONEL McCOY: Are there other questions along this line? Is there any representative from a port on the East Coast? (No response,) COLONEL McCOY; Have you had any experience at all with this policy? We have not had much malaria. I recall hardly any. MAJOR BUZZERD; COLONEL McCOY: Have you had troops returning from India and Burma, for instance, coming through there? • MAJOR BUZZEHD: Not many, a few. - ' -J • COLONEL McCOY; At this season they -would he the- only ones who'would likely he on suppressive treatment. North Africa' dis- - continued suppressive'treatment early in November and of course they have not had it in the European theater area. • '' MAJOR BUZZERD; For the ones who ask for suppressive treatment,1 we con-0:' tinue it hut otherwise we Just disregard it. ‘COLONEL McCOY: Is there anyone from the Air Transport Command who might I comment on this? : COLONEL LEE: I was with the ATC, They were on suppressive atabrine. They‘just vent on last September after they operated in ... India but they don't have a policy of continuing it after they come bach. As soon as they are out of the theater., they stop it after eight days, • ’ • ■ COLONEL McCOY; Are those people, going to stay in this country, or do they go hack? COLONEL LEE.; People who go hack and forth take it all the time. It is ' those ret-urnees, and rotation men, : CQLON&LV • McCOY: I .Of course War Department Circular should apply' to . them, and they should continue to • take it for 28 ■ days-' now. COLONEL LEE; I made this observation before that 28 day ;featule' -came' - out. ta.-itoX.fi COLONEL.-./ :-r,. McCOY: .;!’V "V ■Filariasis Is another mosquito-home disease-that has attracted considerable attention and even some alarm in • r.; h^ewpart of the-public. This is quite unjustified under present circumstances. The Army'has had comparatively fev cases of , , filariasisBy "comparatively fev" I mean several thousand. These have ' all been acquired in’certain islands of the South Pacific. Most ;of the menyere. brought, back early in the course of their disease, so that they received minimal infection. Very fev of them have shovn microfi- lariae in the blood. The life cycle, of the parasite is such that the disease can only: spread from an Individual,' who is carrying microfilariae in the blood. When infected persons are bitten by a suitable mosquito vectors, the larvae undergo a period of development in the mosquito to ah infective stage. Then they may be transferred to another individual when the : mosquito bites again. There are in this country mosquitoes which are knqwn to be efficient vectors of filariasis, particularly Culex quinque- fasciatua and certain of species of Paorophora and Aedes. As long as soldiers do not harbor microfilariae in their blood there is no possi- bility whatsoever that they spread the disease, oven though suit- able mosquitoes are present in the area where they are hospitalized or •' where they are living. In any event, filariasis is not a disease which spreads readily; even in the tropics where conditions are apparently favorable, the dis- tribution is spotty. One village may be heavily Infected whereas a nearby village will be comparatively free from it. In Panama suitable culiclne vectors are present, and over a period of years there have been many people come in from West Indian islands vhere filariasis is endemic and yet the parasite has never become established on the Isthmus of Panama. ; In this country a small focus of filariasis existed at Charleston, South Carolina, vhich apparently smoldered for a good many years but:'-u' never did spread to surrounding territory. Recently it has apparently died out, .even though no special mgs quite- control measures’ vere taken to eliminate it, ■„ that filariasis is a disease vhich. does not spread easily-from-.one individual to an- other. Moreover, military, .personnel, that;, have ;acquifed: filariasis have suqh minimal infections that very fev of them apparently are ever going to shov larval forms in.- thq.-bl.pod> .-;>- vo’i onv ue:- v:C-; Since all text*books of tropical medicine usually Include spectacular pictures of filariasis, the disease, ,is.;.apt tdi seize upon the-imagination. There have been many uninformed people among the services>■ particularly' enlisted personnel, vho have spread rumors about filariasis. Some are afraid that, they might, .transmit the,-die ease, through bodily 'Contact, not realizing, of, .epurse, the.., life.-cycle : of the.i parasito. We are anxious to, ..keep ,-a follow-upoon -patients with'-filariasis that have been returned to this country. During the coming year it is going to be required that a special report be made of any of these patients vith a previous diagnosis of filariasis vho arc admitted to the hospital for any cause.' . The physical findings of Army patients in the hospital at the time of their acute conditions vere minimal, alight enlargements of the lymph glands and epididymis, and transient attacks of lymphangitis. Most of these conditions cleared up completely. Still ve vould like to have a follov-up of a certain number of cases in order to see vhat their ultimate prognosis actually is. We are convinced that almost vithout exception it vill be very good. Does anyone haye any comment to offer about filariasis? COLONEL ; council: We watched for this' particularly in New Guinea in the laboratories and during that tine we found only four cases . in which we were willing to substantiate the diagnosis, one in which we found microfilariae in the blood, one in which micro- filorlae was found in the posterior chamber of the eye and two in which worms, were found in gland biopsies. I know that the laboratory officer’' who,, was bn. duty at Milne Bay made a survey on the natives in that area and found 'A high percentage of them infected but at the time I left they had .na bases in our troops. " COLONEL McCOY: . ' Were these cases -which you did find positive among men , who had had previous service in the South.Pacific? COLORED COUNCIL: Yes. COLOREL McCOY; Did you feel that they had acquired the infection ele?- where or that they had acquired it in New Guinea? COLOREL COUNCIL; We felt that they had acquired it elsewhere in the -South Pacific area. • 03 MAJOR DAMMIN: This matter came up in Puerto Rico* We had a goodly-'nimi- ‘ her of troops down there some time ago and we surveyed over 1500 men who had been on duty in Puerto Rico over' • months. They were selected because they were men who had been oh • duty near Aguadilla and San Juan which are the two cities in Puerto Rico having the highest rate of filariasis. We did two thick films on all ' the men and found not a single positive. If that were done in the Southwest Pacific you would say a lot of these men don't have clrcu- ■“ lating microfilariae but it is a characteristic of filariasis in the • Carribbean. There have’been no cases admitted to the hospital among continental troops diagnosed as filariasis. IIP. COLONEL BROOKS; ' (Camp Shelby.) On Guadalcanal we made a survey among the troops there and found a relatively high rate of infection. However> there was not a'single case of filariasis admitted to the hospital on Guadalcanal which we could say was actually picked up there. There, were.a number of them there but they came from islands further east. „ COIpNEL * "MeCOY: • ' Public feeling about fllariasis runs rather high. The Public Health Service ■wanted.to conduct some experiments to test the susceptibility of local species of mosqui- toes to filariae and they wanted to bring into this country a Puerto Rican Vho carried just, the right number of microfiloriae in his- blood, enough to infect the mosquito and yet not so many that the mosquito would die. They had difficulty bringing him into this country, mainly because they asked some .one's permission to do 'so. In fact, their, own marine hospitals in several localities 'did not want a patient with, filariasis brought in, and yet we admit Puerto Ricans into New York City without question. , -• = There are perhaps a quarter of a million there, a good many.of whom are carrying microfiloriae. But as soon as you make a public issue of filariasis, and it comes to the attention of a public health official, he regards it almost In the same light as leprosy is regarded in many places. There is ho reason for -such an attitude, whatsoever. '--A;; Schistosomiasis is another tropical disease which is causing some trouble overseas. Early in the war a good many troops were serving in Puerto Rico and the northern part of South America where schistosomiasis is endemic. According to the records in the SGO only one case was acquired "by a continental soldier. North Africa and Egypt, of course, are noted as endemic. centers of Schistosoma mansoni and S. haematobium. In spite Of "-the fact that'.many men were in these areas there were only-' a few cases of schistosomiasis acquired by our troops in the Middle East or North Africa. ; .v " Our first real experience with the disease has occurred since the invasion of the Philippine Islands, It happens that Schistosoma Japonicum is endemic bn the island of Leyte. A good many of out troops had to fight across the island of Leyte, wade through the streams and canals and build bridges across them. Through such exposure apparently quite a few men have become affected with.this type of schistosomiasis. So far they are being, treated in the. overseas but' it is probable that many will be returned to this country for further treatment. The question wij.1 come up as to whether they may be a source of danger in the spread of this disease in the community. The intermediate host of the schistosome parasite is a fresh water snail. There are no representatives of the species of snail which act as the vectors in the Ear East in this country. Tests have been made in the laboratory as to,the susceptibility of other species of snails in this country to Schistosoma mansoni and S. haematobium. So far non© has been found which is a suitable vector for the schistosome parasite. Similar tests are now being made with Schistosoma japonicum -- the Oriental species. From what we know of the other two species a fairly safe guess can be made that a suitable snail to spread this parasite does not exist in this country. If- this is true, even though infected men are brought back there will be no chance whatsoever for them to spread the to others. Is there any question about schistosomiasis that anyone wants to raise? • MAJOR ' - WYLIE:' (Ninth Service Command) I can report a case of death from schistosomiasis in a Puerto Rican soldier who to';. admitted to the Pasadena Regional Hospital. He-was cri- tically ill. I don't know all the details of the clinical findings ex-, copt that the X-Ray picture resembled, an area of tuberculosis. The patient died of shock and the case was so puzzling that it had everyone, fooled. Following the autopsy the parasite was found in the liver and diagnosis made.' That case was a- Puerto. Rican soldier. COLOREL MqCOY; Of course there have "been many thousands of cases of ;’ schistosomiasis among Puerto Rican soldiers. Recently A it has teen a cause-for disqualifying them for Army ser- vice. This policy was not adopted-for a year after Selective Service was in effect down there and even after it was in effect many light cases of the disease were not detected hy a single examination. Conse- quently there are many thousands of Puerto Ricans in the Army who harbor the parasite. Most of these infections-, of course, probably were acquir- ed before they came into the service.- Continental troops who have served along with them have not picked up the disease. * COLORS! KOGEL; I would like to /know on what "basis the diagnosis of schistosomiasis was made? A man can really have miliary tuberculosis and also parasites in his liver and still‘v die. of miliary tuberculosis,- •MAJOR WYLIE; I can. only say there was.no military evidence found to establish a diagnosis that he died, of IS. I am not sure what tests.were carried, out and I don’t know whether IS was completely ruled out, COLONEL McCOY: , Amebiasis is another parasitic infection which has attracted some attention, particularly in the Ihdla-Burma theater where a fairly high rate from the disease has occurred. As you all know, amelias is is endemic in all countries, including our own. It is reliably estimated that from 5 to 10 per cent of the people in this country are carriers of Endamoeba histolytica. That is a general average. The rate varies greatly in different sections of the country;1' in big cities in the north it is probably less than one-tenth of one per cent and in some rural communities in the south it may run as high as 30 per cent or more. Consequently, we have not been able to get excited about the Army contributing very much to the problem of amebiasis from a public health standpoint in this country. It is realized that when soldiers come back, a higher percentage will probably be infected than when they went out. Still, from the,standpoint of the overall mimber of carriers in this country there will not be an appreciable Increase. However, from the standpoint of certain units it may be an important problem to be reckoned with, particularly in relation to food handlers, I think that among units which are retinmed from the China and Burma- India theaters, this problem should be kept in mind particularly in rela- tion to members of the unit who have to do with the handling of food. The same is true in regard to bacillary dysentery, although wide- spread use of sulfonamides for the treatment of dysentery has greatly reduced the number of carriers. Even though the incidence of the disease has been quite high in some units, sulfonamide treatment has meant that ■ very few of them have remined as carriers. Hookworm is another parasite that might be mentioned. Many of the troops serving in tropical countries, particularly the combat troops in the South Pacific, Southwest Pacific and in Burma, have acquired hook- worm infection. In the majority of cases, the number of worms acquired' has not been sufficient to affect appreciably, the health of the men. However, there my be some individual cases in which the blood loss ’a ■ caused by these parasites has been siifficient to produce anemia and other signs of infection. Hookworm is already endemic in this country and the public health danger of these men coming back carrying a few more worms probably' is not very great. But wherever patients are hospitalized I think a'rou- rj- tine stool examination is indicated so that if Endamoeba histolytica or hookworm parasites are present, the patient my be given proper - treatment. An interesting phase of this problem is that Ancylostom duodenale, the so-called old world hookworm, has been the predominant species acquired by the men in the Southwest Pacific. The ordinary hookwom found in this country is Necator americanus, the so-called Hew World hookworm. There is a possibility that individuals infected over- seas might bring back and Introduce a type of the hookworm parasite which has never .been established in this country and which is somewhat more severe in its effects. There are certain other acute diseases such as scrub typhus and dengue, fever which do not have a carrier stage, as far as we know, and- consequently do not present the. public .health problems that many of the other diseases do. Dengue has occurred from time to time in epidemic form in the Southern states and there is always a possibility that -some- one in the incubation period of the disease might return to this country and serve as a focus to start up an. epidemic. This is all the more reason for enforcement of adequate mosquito control programs around airports and at all Army posts, camps and stations. To summarize what I have had to say, I. hope I have emphasized that although there are certain problems connected with the presence of tropi- cal diseases in troops returning to this country, , on- the whole the danger of their spread in the United States has been exaggerated. We believe, if proper precautions are taken, the prevailing sanitary safeguards in this country in regard to water'supply and sewage disposal, our general scale of living and our environmental1 situation will minimize the spread of.exotic diseases. The danger of extensive epidemics or outbreaks of these diseases is not considered very great. There may be occasional small outbreaks which ought to be controlled properly if proper mea- sures, are taken without delay. I will be glad to answer any questions that have come up in your work, specifically in regard to these diseases. MAJOR TUCKER: I would like to ask since ve are going to have patients , coming hack from overseas; what you would consider to he adequate tests of whether or not they are infected with parasites? Our experience with patients in a hospital for a few days, prior'to evacuation to a general hospital has heen that one or two negative stool cultures or stool examinations in which no parasites are founcl are not adequate -- because sometimes; in many of the cases; when we have heen able to keep them for a longer period of time for other reasons; wc have found that maybe the fifth; sixth or tenth stool would show positive. Is it a safe procedure when a patient arrives with a diagnosis of amebic dysentery to get a stool that is negative and then to send him right oh? The conditions on the trains which carry these men'.'from the port areas inland is such that unless rigid isolation technique is carried out with regard to segregated dishes and food, it is easy to see how one carrier can contaminate the food of other men because they do swap food and change utensils and so on. It is usually estimated that where well-trained laboratory personnel are making the examination, a single- stool exami nation will detect not more than 50 per cent of the ■ carriers. Additional' stool'examinations will, of course* disclose the rest. Usually five stool examinations on different days will he suffi- cient to disclose say 95 par ctent of those that ultimately could he proved to carry the parasite. COLONEL McCOY; From a practical standpoint three negative stool examinations on different days are usually considered Sufficient to be fairly safe in ruling out the disease; that would probably-take care of nearly 90 per cent of the cases. - •• As far as rigid precautions to be observed-are concerned, we have to remember that these peoplepare traveling on trains on which probably 5 per cent to 10 per cent of the other travelers are carriers, of amebia- sis and are just as dangerous' as far as the spread of the disease is concerned. The important' thing is to have good sanitation in the wash- ing of dishes and handling of food. Known carriers ought to be given special instructions as to-’the necessity for observing strict precautions in personal hygiene, particularly in keeping the hands clean. MAJOR. TICKER: I would like to ask, also, - what yotir 'opinion is -with respect to finding'1 the active trophozoite in the stool s. and whether such a patient Is infectious and why there ane no cyst's? It has "been my experience that as soon as a: case of amehiac dysentary comes in and we find the active trophozoite, everyone hccdmcs very excited and wants' that patient isolated right.away, although the'reports I have read indicate that there has "been no experimental evidence to show that they .are infectious during that'.stage.: COLONEL McCOY; It has been found that the trophozoite stages will not withstand the normal' acidity of -the gastric juice. Consequently, it is generally accepted that there is no danger of the spread of the disease "by the trophozoite stage. It- is only the cyst stage that can withstand passage through the stomach and thus it is the cyst which serves to spread the infection. COLORED NORTON: I would like a comment on the possible introduction of Japanese B type of encephalitis. : ' OOLOKSL McCOY: Presumably we have mosquitoes in this country which could serve to transmit the disease. The problem is how the disease might he introduced. If someone, were brought back to this country while still in the incubation stage,, -it' might happen. There is also the possibility that certain people, mightharbor .the virus after recovery. It would have to be present in the blood stream so that it would be accessible to mosquitoes. I don't think anyone can give a good answer on this possibility. .. From a practical standpoint, our attitude is that all types*:of moS' quitoes should he controlled around airports, not only.anophelin.es hut also all species of culicines. The culicines mosquitoes may serve to transmit dengue as veil as certain of the encephalitides. COLONEL ■BANTON; ’ v/;The diagnosis of filariasis seems to be one "of the big problems at Moore General Hospital where they are getting _ these men back. It is a question whether or hot we can call it filariasis when we have no laboratory support. Whether it should be called .filariasis on a clinical basis, I don't know. The idea is being set forth that the men don’t show evidence of microfilariae in the blood, certainly none in the peripheral circulation for a year or maybe a longer period after infection. I think that the question of Just what con- stitutes the diagnosis of filariasis enters into our public health problem. Are these men going to become a problem in future years? GOMEL • Me COY! ’The diagnosis has actually been proven in only a minority of cases. Microfilariae have "been found in the Hood in a few instances. A somewhat greater'number have had the diagnosis proved hy gland biopsies in which adult worms have been found.. It is believed that there has been sufficient evidence to estab- llsh this syndrome as actually being caused by filariasis. ¥e have been willing to accept the diagnosis of filiariasis in those individuals who have characteristic changes in the lymph glands, characteristic lymphangitis and the history of exposure in those particular areas where we-know other proved cases have been acquired. I think all of these factors must be taken into account, particularly the history of exposure in,; one of the islands whoro ve know soldiers have acquired the disease. ¥e have got to accept the diagnosis of filariasis in these, individuals, eveji though it is not proved by actually demonstrating the parasite in all, of them. £1:: As to follow up on patients, that is exactly what is hoped; to be pbtained from the special report which is now required on these indivi duals whenever' they are hospitalized at a later date from any cause whatsoever, j . (:: t'COLONEL •;■•••• >nr. v;:POBINSON: IO .'/oil y.;-: ; Any more questions for Col, McCoy? (No response.) You might save your questions and spring them on Colonel Dieuaide -when he is here, ’ I think we can go on now to the second speaker of the afternoon, Major Dammi-n,- Director .of .the Laboratories .Division of The..Surgeon General’s Office, who will talk about laboratory service in the Service Commands. •Major-Dammin. , . ... ./ ‘ LABORATORY SERVICE IN THE SERVICE COMMANDS - ■ EPIDEMIOLOGICAL FUNCTIONS OF THE LABORATORY LABORATORY. EXAMUJATIONS' SUGGESTED BY TB MSD 2— THE ASSIGNMENT OF. LABORATORY OFFICERS MAJOR G. J. DAMMED MC.,. DIRECTOR, LABORATORIES DIVISION, MAJOR DAMMIN: Col. Robinson and gentlemen: There -were no questions submitted for consideration by the Laboratory Division and this discussion will be rather general, I believe the informal atmosphere that has been created in the early meetings should be continued because I think it will help to accomplish the pur- pose of this meeting. .. . , We depend very much in the Preventive Medicine Service on information which we get from Preventive Medicine officers, from service command laboratories and other installations which submit reports to the Preven- tive Medicine Service, I hope everyone will feel when this meeting is over that we have among us a good number of representatives from really the Preventive Medicine Service of The Surgeon General’s office. It is not possible for Laboratories Division or any other Division to maintain intimate contact outside. For us to understand your pro- blems and for these Divisions to carry on their own work in conjunction with other services in The. Surgeon General’s Office, we depend very much on-information which you send us. The Laboratories Division wants to act as a coordinating agency for the Service Command laboratories. It will become evident, when I describe the integrated laboratory system which we are striving for in the Service Commands, that the Preventive Medicine Officer will play a very important part in that arrangement and will also derive a lot. of helpful information from the, laboratory arrangement as we plan to see it set up. The’ only information which the Laboratories Division in the Surgeon- General's office gets from the Service Command laboratories is that contained in monthly reports. We. find these of variable value, I shall’ not mention any specific Service,.Commands. Some tell us exactly what • the laboratory is doing and give us the information that we like to have, so that we can carry on our work with other agencies, . , We are especially interested, in knowing how well the things we recommend are working out in the' Service, Command laboratories and in .... the hospital laboratories. It .is true that personal visits could ’ ‘ * 'h accomplish that for us. As I mentioned, it is almost impossible to maintain contacts with Service Command laboratories and hospital labora-, ... tories in Service Commands by this method. Wo want to know about the .. .... evaluation of technical methods which have been authorized and approved by the Laboratories Division. There are no set channels except through" the monthly reports to tell us about those things and as a coordinating agency, if we can get this information from the Service Command labora- tories we can make the profitable experiences of one Service Command .... laboratory available to the other Service Command laboratories. There are very few critical evaluations of apparatus, reagents, tests or technical methods included in the reports we get Just now and ... we are considering a standardization of that monthly report to help.our. *y Division and to help other Service Ccinaand laboratories. The Service Command laboratory realljr.is,the Army counterpart of a public health laboratory or a State health laboratory. It is our aim not to have such a laboratory intimately connected-with any hospital. It has a function to fulfill in the whole Service Command. I realize that this discussion "borders on the ideal many times "because there are few Service Commands who have their laboratories operating as they are expected to operate under AR 40-305. These regu- lations are worthy of periodic consideration because they provide an excellent description of exactly how a Service Command Laboratory should perform in the Service command and exactly how it should function in helping the Service Command Surgeon and this new officer arrangement whereby each service command has a preventive medicine officer. It is the indirect responsibility of the Laboratory Division to see that Service Command Laboratories do function that way. This respon- sibility was simpler to fulfill when Service Command Laboratories were what we now call Class 4 installations. ¥e knew more about the person- nel in the laboratories and we could make changes from The Surgeon General' office according to the needs in each Service Command Laboratory It is more difficult now but we try by recommendation of special offi- cers for assignments to service in service Commands to see that Service Command Laboratories and the service commands do have properly qualified officers. Actually the Service Command Laboratory should be regarded by the Service Command-Surgeon and preventive medicine officer as a special staff of assistants. There should be an intimate relationship between the Service Command Surgeon, preventive medicine officer and the Commanding Officer of the Service Command Laboratory. Before the appointment of a preventive medicine officer, the Com- manding Officer of the Service Command Laboratory had very much the same position that the preventive medicine officer has now. It was stipulated that the Commanding Officer of that laboratory have.a broad training in epidemiology and very much the same background that the present preventive medicine officer has. We hope that this ideal can be obtained, that the Service Command Laboratory and its staff will act as a consulting staff to the Service Command Surgeon and the preventive medicine officer. We gather from monthly reports that the-Service Command Laboratories are not making themselves felt widely enough in the service commands. There are labora- tory officers in general hospitals and smaller hospitals outside who feel that they have no superior to whom they can bring their problems. We hope that in the near future we will see this integrated laboratory arrangement set up so that in the smaller service commands, the.Ser- vice Command Laboratory can act as the consulting agency for all hospital laboratories. In the larger service commands, the Service Command Laboratory should be allowed to. set the policy whereby certain general hospitals will have definite functions to fulfill in smaller hospital labora- tories in a certain area. These laboratories can act as coordinating agencies for smaller hospital laboratories',' . ■ In one short visit to hospital laboratories; in one of the service commands; it was found that the laboratory officers were very competent; that they all, according'to their own interests, had found modifications and developed new techniques which with some coordination could have been made known to more hospital laboratory officers. As I say, in the small service command, the Service Command Laboratory might act to bring these hospital laboratory officers together and to pool what- ever modifications and whatever experience they have derived from their work in the hospital laboratories. I might cite a few special instances in the use of the spectropho- tometer. Somo laboratories have found a very wide use for this instru- ment, , Others have used it for one or perhaps two tests. There are special modifications, special vhli>h make It more versa- tile. These things should be liadW known to .all laboratory officers; and we hope that through- the-broader functioning of the Service Command Laboratories throughout the 'service command that that can cone about. The other report which occasionally, comes to the Laboratory Divi- sion is the medical consultant1s report. .It is helpful to have the medical consultant’s opinion of the Laboratory Service. The laboratory may be doing, its job particularly well and to what extent the labora- tory cooperates with the clinipal services we. get from the medical con- sultant ’a report. Wo realize' that ho can not.critically evaluate the officer or officers in the laboratory, ", He can not, always evaluate methods; but his opinions’ about Laboratory Service are welcome. Wo hope that the Service Command Laboratory staff will send us evaluations ;of hospital laboratory officers; otherwise we have no information about their performance. I have been going into this in-some detail because anywhere in this integrated system of laboratory the preventive medicine officer must be able to step in and expect.the help of a general hospital laboratory or the Service Command.Laboratory. . ■ - There is just a word to be said about the TB Med 2 examinations. Those have been variously interpreted at the reception stations. Some stations that had laboratory facilities were, very, enthusiastic about the amount of information they were going to get from them and they started off on surveys but soon found that, the volume was too groat and moat of these projects were abandoned. The routine of. the reception station; itself; is not conducive to survey studies and; again, the value of survey studies done by personnel who have perhaps had only moderate training in the diagnosis of these diseases would bo of questionable value. About the assignment of laboratory officers, the Laboratory Divi- sion since Jrily, has' recommended for commissions about 250 Sanitary Corps .office# candidates. That procurement objective is now full and there will net bo any more commissioned until further notice. These men arc commissioned, then arc sent out for training and later to laboratories. - We have no direct way of knowing about their performance except by an arrangement we hope we can make through the service command laboratories. We hope that the preventive medicine officer in. his use of the laboratory service will help evaluate that service-for us. •• ■ - We hope in the assignment and reassignment of medical "and Sanitary Corps■laboratory, officers, both officers returning■from overseas and newly-commissioned officers, that wc can arrange training periods for them in service command laboratories, in general hospital laboratories and in general hospitals which arc histopathological centers,. Some training these men do obtain in the pools but wc hope to make bettor use of the time the laboratory officer often spends in the pool. If this can be [arranged, the training will more certainly be in the form of a refresher period for'these returning,offleers and the newly commissioned Sanitary Corps officers. ' ‘ Although there was no question submitted for consideration by the Laboratory; Division, - the three of us in the Laboratory Division do hope that wc can establish some contacts with whatever laboratory offi- cers are .here and with'all prevent ivc medicine officers... We must depend on you for information which wo can use to help you in your work and for information which will aid us to carry on ,our work; with other ser- vices of The;Surgeon General's Office. Perhaps.some questions have occurred during this discussion of the work of’ the Laboratories Division 126- 'COLONEL' ROBINSON: Are there any cornnients? COLONEL BARTON: Is there a T.O. f or-'the Service Command Laboratory? That is one trouble now."'- An organization having no T.O. is in a way helpless. It has to function alone and it can't even feed its men. I am wondering if there is a plan for such things? COLONEL ROBINSON: ; I think I can answer that. That is a question that came up before Major Dammin came to the Laboratories Division. There is notT.O. and it is essentially impos- sible to set one up simply because the size of a Service Command Labora- tory will vary so much from one service command to another. There was a manning table drawn up, I should say it was the better part of a year ago, or possibly more than that. At that time each Service Command Laboratory was considered separately in terms of troop strength in the service command, particular needs and so forth and so on and the manning table was drawn up showing not only how many officers but what particu- lar specialty should be represented. As I remember now it varied all the way down from a minimum of about four or five officers up to a maximum of somewhere, I think, around ten officers. We can look that up and see Just where it stands now, if you would like us to. colonel MINOR; I would just like to say a word for the medical consul- tants, "being the only one here. I think that if the Laboratory Division would stimulate the reporting by the medical consultants in the laboratory evaluation that they make, they will probably get a great deal more help than they have already. Actually many of the medical consultants have had suitable laboratory experience. Some of them may have gone into internal medicine, from laboratories, which is a good thing to do, and they have been evaluating laboratory methods and while they differ quite a bit I think it can be found that they will be of greater help than in the past. I just want to put in that word for the consultants. MAJOR ; DAMMIN: We appreciate your remarks on including the Laboratory in the medical consultant reports. As I say, just now, ; - or very often, it is the only. comment we have on the laboratory performance'. , COLONEL ROBINSON: If there are no other comments, I,.think we might have a recess for let us say, ten minutes. (Recess.) COLONEL ROBINSON: The next discussion is by Col. Dieuaide on questions in internal medicine of interest to preventive medicine officers. QUESTIONS IN INTERNAL MEDICINE OF INTEREST1 TO PREVENTIVE MEDICINE OFFICERS - LT. COL. FRANCIS R, DIEUAIDE, MC, MEDICAL CONSULTANTS DIVISION. T COLONEL DIEUAIDE: Col. Robinson and fellow officers. The questions appear- ing in the title of this discussion are supposed to arise from the audience. There are very few. .Irhave picked up some disjointed subjects which I thought might be of interest to you and I shall do my best to answer such questions as you may have now. I thought I might refer to the existence in The Surgeon General1 s office of the Professional Divisions in case some of you are not acquaint ed with the organization of the officeThere at one'.time was a Pro-o fessional Service, as many of you know hut at the present time:;' the . professional.subjects or professional aspects of problems dealt with by The SurgeOri General’s office are divided among the Preventive.Medicine Service with which you are concerned, the Proffessional Amlnistratiye Service, and'‘‘several Independent divisions, which are hot part of any "service." These indenehdent divisions are devoted to Medicine> Surgery, and Neuropeych The Professional Administrative Service is concerned with rules about physical qualifications fbr entering the service., about medical discharges and retirements from the Army and similar questions. There .has been reference' made today to the group of professional consultants who in spirit are associated with these professional divisions of The Surgeon General’s office. I-say in spirit, of course, because in the command sense they have no direct connection with,-The Surgeon General’s office. These consultants, however, have been practically all selected by the related divisions of The Surgeon General’s ;offlee. The service commands have found them helpful,il believe.. Consult- ants have been left almost entirely with professional duties, dealing with administrative problems only in the way bf^*making suggestions or recommendations Occasionally. I think everyone who has watched the development of this system has felt very strongly, that they should not acquire important administrative duties. v /. . In. regard, to.the history of consultants, of course, there were such officers in; the last war, both in this country, and overseas and I suppose in some Senbe or other there were physicians and possibly scientists associated with the Army for this purpose long before that, ’it is true, nevertheless, that the assignment of selected officers for specific professional purposes has gone very mucin further in this war than, it ever did before, Obviously,, in many -ways the .functions, of consultants is parallel to that of preventive medicine officers. Pro- fessional consultants are also assigned to most of the.oversea theaters, but not to the" smaller base commands. In the cases -of the largest theaters there are several consultants in each field-.- • ''V "Major Dammln: referred to the' desirability of association between laboratories and medical services or professional services in hospitals up to a certaih point,: 1 think perhaps we might be willing to go far- ther. Most of us would like to see the closest possible association betwc.epi-preventive medicine activities, laboratories, and the so-called clinical services. These different services cannot function satisfac- torily as'independent units. So much for generalities. •1 understand that yesterday you had a discussion of diphtheria, I am not going to go into the- general problems of diphtheria, but it may interest you to hear a'little more -about cutaneous diphtheria, with which I happen to have had some experience. .This is a subject of con- siderable epidemiological interest, "When the subject of infection of skin lesions with diphtheria organisms comes up, it has a tendency to cause the raising of eyebrows and shrugging of shoulders. Many officers jump to the conclusion that non-pathogenic diphtheroids are being in- terpreted as virulent organisms. Scepticism is healthy, but in this Sthe attitude in question is unjustified and may cause serious le. • .'!i"';. • • • •; In the early part of an epidemic Of jcutaneous diphtheria occurred in the South .Pacific' Area as it at that time- In the cases of a large number of the patients in 'this epidemic- the -;diagnosis was proved by-virulence determination of the organisms that were isolated from their lesions. '' -lb-" Since then, diphtheria outbreaks of varying size, none of them very large, have occurred, centering around cutaneous diphtheria in practically every warm weather theater. I have heard of no outbreak in the Caribbean Defense Command, but have occurred everywhere else, Including the Southwest Pacific, the South Pacific, the Central Pacific, India, and the Mediterranean. Similar epidemics occurred among British troops earlier in the war, particularly in the Middle East, and more recently in India. As same of you know, we were struck early last year with the occur- rence of an undue number of cases of faucial diphtheria among prisoners of war. It is very Interesting that these cases were diagnosed origi- nally "by the ohserration of a number of instances in the same camp of partial paralysis at a time when diphtheria itself had disappeared in the individuals concerned. The type of skin lesion which is most often found infected with virulent diphtheria • bacilli is that commonly known as the "tropical ulcer," "jungle sore," or "desert sore," I do not mean to imply that all ulcers that bear those names carry virulent diphtheria bacilli by any means, but merely that this is the morphological typ>e of lesion which has most frequently been found so infected. Such ulcers conform fairly closely to a characteristic appearance. They are often moderate- ly deep, are frequently well rounded, have rather clean-cut edges which are not often undermined, though occasionally they are. The edges are often rolled up and are surrounded by a small area of swelling, edema, and redness. The base of the ulcer may be surprisingly clean. The base of the ulcer is occasionally covered by an eschar, if we may use that old-fashioned term which has come back into use largely through scrub typhus, a crust which is dark in color and which has underneath it a grayish or somewhat greenish pus instead of the yellow- ish pus which is more commonly seen with other infections. These ulcers may be single, but they are frequently multiple. They are especially common on the legs, but may occur on the trunk and on the arms, VJhile many of these ulcers are infected with other orga- nisms, this, is not always the case. In some instances, pure cultures of diphtheria bacilli are obtained. The feeling that we have at present about these ulcers in connec- tion with diphtheria is so strong that we believe that when it is known that an epidemic of diphtheria exists, patients with such ulcers should be regarded as having diphtheritic infection until it is proved other- wise. Many other kinds of skin lesion have been found to be Infected with diphtheria bacilli as well as these ulcers. Among them are eczematoid dermatitis, exfoliative dermatitis, epidermophytosis* and paronychia. At the Lottorman General Hospital, virulent diphtheria bacilli were recovered from skin scales off the floors under the bed of a patient with exfoliative dermatitis. In the skin ward where this took place, an epidemic of faucial diphtheria broke out. In addition to the proof supplied by the virulence test, it is an impressive fact that among these patients there have been a rather largo number of cases of peri- pheral neuritis and a few cases of myocarditis, as shown by definitely abnormal electrocardiograms. In the Mediterranean area, the death of one patient was attributed to diphtheritic myocarditis. In several theaters, a rather large number of cases, of peripheral nearitIs; have occurred, -with no adequate explanation. Various diagnoses aro;madp which are not convincing. Including malarial neuritis. It seems likely that many of these cases are post-diphtheritic* It must he remem- bered that the- organisms may have disappeared’ from the skin lesions hy the time the patient is seen. Indeed, the lesions may have healed en- tirely, Wo know that diphtheria bacilli disappear quickly from skin lesions when the patient is'put to bed, cleaned, and local care given to the skin. It has been shown, though perhaps not with conclusive finality, that penicillin hastens the disappearance of the organisms,. From the epidemiological point of view, diphtheritic skin lesions are very important. The epidemic in the skin ward of .the Lettcrman General Hospital was traced to two or three patients with skin...diphtheria who had been received from the Southwest Pacific, In two instances of epi- demics in the Pacific, the infection was undoubtedly spread while the men wore on transports. One well studied epidemic involved a largo organization which returned from combat - experience in the Western Paci- fic to a rest base. In this organization over 100 patients with, diphthe- ria were found, when the troops were debarked. Most of those patients said thatythey had had only trivial sores which they thought wore of no consequence when they embarked. . . It should be remembered that surveys show that ho -to 50 per cent of our soldiers' are susceptible to diphtheria. If any of you have any questiohs*that you care to raise about skin diphtheria, I will do my best to answer them. COLORED ' MARSH: Are these cutaneous cases given anti-toxin? COLONEL ' DLEUAIDE: '**' Patients have usually "been given anti-toxin when the ' diagnosis is made. The clinical diagnosis’ is difficult, 4, hut as a group of patients is studied and medical officers get-more experience and are more sure-of themselves, they come to feel that they can make .a clinical diagnosis,- Of course, laboratory proof of the diagnosis is always desirable, but it imay be unwise to await such proof. The best course is to*give a dose of 20,000 units of anti- toxin in any case in which it is believed diphtheria Is present. Fur- ther treatment must depend upon the circumstances in the individual case. A great many, patients do not need more anti-toxin. The outstanding reason for, giving anti-toxin, of course, is the prevention of complications due'to diphtheria intoxication. The sooner anti-toxin is given, the more chance that it will b© effective. .Anti-toxin is useless after neuritis or other complications due to intoxication have .'occurred. COLONEl. MARSH: What I had in mind was the possible prevention of this neuritis. . oil .... . COLONEL DIEUAIDE; That is "the main reason for giving ’anti-toxin,1 CAPTAIN , .COOPER: .. I have, cm .luosticn.'' Vho'n' returned on allies 'these patients are scattered. in troop c6:upar+^ori:ii, J si"Containing .. as many, as.a Irmorod or two hlridro'd meneaciu ■ 'That- same ship ten days later .will .load h :mit going overseas, ’ Thus- 'far- we have seen no difficulty in troops going overseas and; apparently from what I understand it would hardly he nececaary to disinfect those';compartments. COLONEL ROBINSON: You know you have had diphtheria in the group coining hack. CAPTAIN COOPER: Yes. COLONEL ROBINSON: How long a time to return? CAPTAIN ■ COOPER: Not less than ten days, necessarily. It may he two or three weeks, depending on the amount of repairs necessary to the ship and so forth. COLONEL ROBINSON: Certainly, theoretically you ought to clean up those com- partments, that is, if you are taking active diphtheria cases out of a compartment, "but just how thoroughly you can do that, I don't know, "because I have not gone into the set-up. What you would "be doing would "be moving people into quarters that were occupied "by diphtheria cases.—'-It would certainly "be highly desirable to clean up as thoroughly as possible. How great the actual danger is rather a gam- ble. If the people you put in are immune to diphtheria it won't matter. CAPTAIN COOPER: These compartments of course house as many as 350 'men and they are.pretty veil scattered throughout the ship,' It might entail cleaning the vhole ship vhich is not very practical every time it comes in. They have teen on practically every ship that comes in and the patients are ambulatory patients and in most instances have the liberty of the entire'-ship.* • COLONEL ROBINSON: It would be very easy to give an answer on a high academic plane but practically, I don't know. MAJOR TUCKER: I might make a statement with regard to practical solutions hut I don’t know anything about how and when the ships are cleaned up after the patients have disembarked. We do know that the diphtheria bacillus,- a great deal will live in the dust on the floor and maintain, its virulence for about six weeks. We also know that diphtherias bacillus is pretty -susceptible to the common disinfecting agents. We tried two or three of these-and we find that the general consensus of opinion is that diphen solution which is a cresol preparation will kill the diphtheria bacillus in a one to ten dilution in about 15 minutes so that it would not be any great job that would require too many personnel. The simple solution is to clean out the compartments, at least the floors and the lower parts of the walls of the compartments, which' is done by taking one to ten diphen solution which has a phenol coefficient of about five and using a wet mop. That is the procedure that we use and are using in all the diphtheria wards and diph- theria rooms at Lette.rman General Hospital, Twice a day an enlisted man goes in with a one to ten diphen solution all the time the patient is there. No wax is used and floor polishing as seen in all the linoleum covered floors in hospitals, but the baseboard around the wall and we will say up to a man's shoulder, Is mopped with this diphen solution, 'I think that that is a practical thing but I don't know how long it takes to clean a ship but if it is going to be in for ton days it does not seem like too big a problem. The susceptibility of the new soldier who is going to occupy that ship has acted in favor of not getting any new cases, I am.sure. r COLONEL ROBINSON Would that be a practical solutidn? A VOICE; I think that is practically being done at present. I knew in Boston ports it has to some extent been done in this way. All the ships have to be clean thoroughly because they are in port. You have to change the bunk bottoms and spray the compartment with a cresol solution so to a large extent that is already being accom- plished. Any ports where it is not being done it can be very easily done. • COLONEL DIEUAIDE: To turn to another disease and make a single remark about it. It may be worthwhile to call1 to mind the importance of patients with meningococcus infect ion who do not have . :: meningitis. I refer to cases of so-called meningococeemia, such as those which were fairly numerous in These cases have special clinical and epidemiologic significance. They may be overlooked for a time. It : is important not to think of meningococcus infections only in connection with the physical sign of a stiff neck. There have been a few indications that there may be an outbreak 70 •, this winter and spring of severe streptococcus infections, including streptococcal pneumonia. There is an article in the last Aimy Medical Bulletin referring to the possibility. Streptococcus pneumonia is a . >.£ * disease with which many medical officers may not be very familiar. The clinical picture is quite different from that of pneumococcus pneumonia/} so that the-diagnosis is often missed, until it has been demonstrated post-mortem. There are some questions in connection with some of the so-called tropical diseases which Col. McCoy went over that I might refer to from the clinical point of view. Amebic infections raise many practical problems. What individuals with amebiasis should he isolated. When does an epidemic of this disease exist? Should all individuals with amebic cysts in their stools receive treatment? In answering these questions one has to stay within the bounds of practicability. Cyst passers in general cannot bo Isolated. They should, however, be restricted so that' they are unlikely to infect:: significant numbers of other persons. The number of cyst carriers, known to exist depends entirely on the time and effort expended on stool exami- nations. Even though a survey shows a rather large number of•carriers, one would not on that basis say that an'epidemic exists. Such a state- ment must depend on the presence of an undue number of patients with symptomatic colitis, or amebic dysentery. The treatment' of large num- bers of cyst carriers in the Army raises many difficulties and is time- consuming. On the other hand, we know that it is individuals who {.pass . cysts who are of epidemiological significance. b . COLONEL ROBINSON: The question that was asked this morning was essentially-, how many stool examinations do you have to make before • you can say yes or no -- rather, before you say no? COLONEL DLEUAHE; It -would appear that different routines have to he ac- cepted in different circumstances. In a routine general examination, probably only one stool examination is prac- tical. We know, however, that such an examination brings to-'light only a fraction of those infected with amebiasis. As the number of examina- tions is increased, the percentage of those infected, who are found, rises. But in any case, the results depend upon the training of laboratory -technicians and the care they rise. In some hospitals in regions like the Far East whore technicians are plentiful, as many as IQ stools arc routinely examined for all patients. It was estimated that such a rou- tine disclosed 9Q to 95 per cent of those infected. The routine adopted for a given set of oircumatenoos must represent a, compromise to some extent. ' "": ■ Would Colonel McCoy care to add anything? COLONEL McCOY: Three stools examinations usually expose about 80 per cent °f "the cases and five or six probably over 95 per cent. One stool examination is pretty reliably estimated to disclose only about half. COLONEL DIEUAIDE: Col. McCoy spoke of schistosomiasis Japonica, a problem that we are facing in a moderate number of troops. The early symptoms are important, since it is only by knowledge of them, together with epidemiological information, that the problem can be attacked in time to do some good. If you put the history of exposure and a certain combination of symptoms and findings together, you get an impression that means some- thing. In connection with Japanese schistosomiasis, the history of ex- posure is extremely important, because of the fact that the distribution of the disease is fairly well known and relatively limited. The most Important or most suggestive events that occur following infection are fever, which is often slight, and itching with urticaria which may sist of small or of giant lesions. In one recent case, the whole of one side of the face was involved by urticaria. Cough, without sputum, is a common complaint. There are in even the early stages of the disease transient bouts of simple diarrhea which is not dysentery-like. Patients complain of pain in the back and in the legs, and of malaise and anorexia. A most important finding is rapidly increasing eosinophilia which reaches 40, 50, or 60 per cent of the total white blood cell count. It is most important to know that all of these symptoms and signs are transient. Sometimes they are only present for a day or two. They occur at variable times from the end of the first week after infection through the eighth week of infection. During the fourth week and there- after for four of five weeks patients begin to have dysenteric symptoms and the so-called second stage of the disease begins. From this time on eggs may be found in the stools. The earliest symptoms are apparently reactions of an allergic nature to the presence of the worms. The later developments are due to physical and chemical effects of the worms and their eggs. Most of the eggs are deposited in the intestinal wall and in the liver. But a few eggs are deposited in various other parts of the body, even relatively early in the disease. We have already had two patients with central nervous system symptoms due to schistosomiasis. In this connection we would like to have it known that it is really important for patients with schistosomiasis when they come back to this country, to be sent to the Moore General Hospital which has been desig- nated for specialized treatment, of tropical diseases. The chemotherapy of schistosomiasis is not altogether satisfactory. Hence, it is neces- sary studies be carried on to be sure that the best methods arc used. For many reasons, the management of patients with schiotomiasis should be concentrated in the hands of a group of officers with special quali- fications. It has already been decided that patients with schistosomia- sis will be evacuated to this country. , Beyond question that is the right thing to be done. Patients will be given, however, .one complete course of treatment in the theater before they are evacuated. One aspect of malaria deserves emphasis. We have published Recently a technical bulletin in which we have, done everything we can to encour- age medical officers to give suppressive medication to individuals known to have vivax malaria, who have not passed through at least throe months without an attack of malaria. In other words, we are recommending that following treatment for an attack of vivax malaria,1' suppressive medication be instituted and carried on for two or three months. There is no doubt of the desirability of this plan. It is realized "that there is no guaran- tee that administrative arrangements will be made' 'which will ensure that medication is taken. There are no units in this country that are taking suppressive medication and we are not going to have any fcuch units. Never- theless there must be a good many men With enough intelligence to rea- lize that it is to their own advantage to avoid the disturbance of going through repeated attacks of malaria. Such men will take sufficient sup- pressive medication to avoid attacks. I would like to emphasize that in making this recommendation we have no idea that the use of atabrine or quinine for a period of say three months is going to cure patients. In other words, we are merely1 stres- sing the disease, 'Nevertheless, the advantages of a period of three months free of attacks are great, • Individuals who receive suppressive treatment under these- circum- stances are not to be kept in the status of patients. It is interesting to note that about 80 per cent of the relapses of malaria which are seen in the course of nine or ten months occur in the first three months. • / A small point that I thought might entertain you, was recently called to my attention. In and we were all doing everything' we could to Convince medical officers that the yellowness associated with atabrine is not jaundice. Apparently we have gotten now to the point where anybody Who'has been overseas and is yellow, is considered to be stained with atabrine. This premature conclusion has resulted in overlooking cases of Jaundice, some of which are associated with serious disease with no connection whatever’with atabrine or malaria. In regard to "filariasis, studies have been made and are in progress, in the effort to clarify the early Clinical picture and to gather infor- mation abCut the course of the disease in infected soldiers. We must acquire a basis for predicting what'will happen to these men. An A.S.F. directive has recently been issued which requires that certain informa- tion be added to reports of patients with this disease. There, informa- tion will be subjected to statistical analysis. At Moore General Hospital in * the last f ev months they have handled about 800 patients with diagnoses of filariasis, The’process has been to observe patients for three months, following them very closely. A graduated program of exercises is used. , When patients go through a period of three months without symptoms, they are'returned to duty. For various reasons, the policy has been to retain in the service men who have, or are supposed to have filariasis. These men aroepro- tected against further infection with filariasis and excused from com- bat duty by restriction to service in this country. It is believed that they arc bettor off in the service from a medical and a psychological point of view than they would be in civil life. It will interest you to know;that: there is no report of any Army patient developing a permanent pathologic change that could bo called elephantiasis. There have been in the Army a number of cases of general/* ized leishmaniasis or kala-azar,' The majority of these cases so far have originated in the Mediterranean’ area,; A minority has arisen in India. It may bo expected that there will be many more from the Far Eastern area, - ■ i o'" y ; : ’•* Kaia-azar mimics a- great many diseases, including typhoid fever and malaria. In the early stages, it Is often very acute. The diag- nosis, may, he very difficult for those unfamiliar with the disease. The history of exposure is very important. The outstanding characteristics, in addition to the fever chart,. are rapid and progressive enlargement of the spleen and leukopenia. Anemia may develop quickly. The globu- lin fraction of the plasma proteins Increases at an early stage? all of these changes are often very severe. One of the questions which was turned in related to the immuniza- tion of patients against hay fever. This is an individual problem. It cannot be handled from an epidemiological point of view. Whether or not a given patient should be immunized against hay fever at the begin- ning of the season, should be decided in.terms of the history and condi- tion of the individual patient and of the region in which he is. There was also a question about the management of mycotic infections, especially epidermophytosis. This is not a field in which I am at all expert. I have been greatly impressed by the divergence of opinion among doctors who specialize in the subject. If there are any other questions,; I will be glad to do the best I can to answer them. MAJOR TUCKER: I would like to ask a Question about the so-called aty- pical pneumonias. Ad out two, years ago we had several cases at Letterman Hospital which were thought to he, cases of pneumonia. We expected more this past winter hut they did not show up. I Just wondered if there was anything new in the way of treat- ment other than putting the patient in an oxygen tent. The reason I asked that is that I heard there was some work being done on the use of immune globulin. COLONEL DZEUAEDS: I have no information that I can give you about that .COLORED EDGED; Is any work going on on para-aminobenzoic acid in the treatment of atypical pneumonia? COLONEL DZEUAtDE: Yes, work with it is going on, I am not in a position to tell yqu about it. Perhaps somebody else who knows more of the details might. COLONEL KOG-EL; In the matter of pneumonia; that you -wore asked about, in the Air Force Hospitals, between 65 and 100 cases were treated with convalescent serum in the midst of that large epidemic we had. The reports on that wore rather favorable. Fifty per cent of them had a subsidence of fever within 2h hours after the convalescent serum was given. COLONEL ROB UTS ON :' Does anyone have any comments they would like to mako on thbse last couple questions? GENERAL BAYNE-JONES: The treatment of atypical pneumonia with globulin in- Sections is 'being tried out by the Respiratory Disease Commission at Fort Bragg, They have not had anything to report definitely on the subject. The use of paramino-benzoic acid looks rather hopeful, A paper has been published with members of the Commission working at Cairo and perhaps the A.M.A. will give us some information on that, I can get you a reprint and send it to you. You may have seen that paper of Dr. Pinkerton in the Journal of Experimental Medicine on the use of para-aminobenzoic acid and its effect on egg cul- ture, Col, Plotz did some work on that before that. It looks as if enough is given early enough it has a beneficial effect; so-much so that we have sent a group of naval officers from the Naval Research Institute to a hospital in Burma to try it out on scrub typhus. They are also taking -with then methylene "blue. Both the para- amino-benzolc acid and methylene Hue used on mice with scrub typhus or epidemic typhus has given enough evidence to warrant the trial in human "beings, It is a new kind of a cheno-therapy, in a way. ‘ ¥e are trying to get at the parasites that are intra-cellular and •perhaps affect their metabolism. AM VmmK CORPS MEAT, meat-food and dairy products INSPECTION SERVICE - BRIG. GENERAL RAYMOND A. KEISER, USA, DIRECTOR, VETERINARY DIVISION COLONEL ROBINSON: The next speaker will be General Kelsely uho will talk about the inspection service for meat, meatT.oods, and ‘ dairy products. General Kelser. V* ! BRIG. -GENERAL KEISER; (USA, Director, Veterinary Division}.:',' Colonel Rot ins on and gentlemen, as most of you undoubtedly know, the" *• functions of'the Veterinary Corps fall into-two distinct categories, one, those having to do with the professional care, treat- ment and hospitalization of sick and wounded animals and everything • that goes with that and, two, those pertaining to the inspection of meat, meat-food and dairy products procured for the subsistence of the troops * The first has some definitely preventive medicine aspects inso- far1 as those diseases of the lower species which are communicable to man are concerned, but this afternoon we will discuss.briefly the food side of the Veterinary Corps.' functions, because that is a large-part of the duties of the Corps at.the present time and it has a wider pre- ventive medicine aspect than perhaps the animal service function, espec- ially within the United States. Of the soldier's ration, about,.38 per cent consists of meat,, meat- food and dairy products. That represents about 60 per cent of; the total cost of the ration. ■ It is apparent, I am sure, to all of you that while these products are very important items of food, at the same time-.,they are, because of their nature, the type of food stuff that lends,itself to,spoilage and contamination with the ability to produce disease in men consuming it. After”all, it is animal tissue, subject to all of the changes that such tissue can Undergoif not handled properly* ; ■ I will later take up a few subjects that will probably be more interesting to you, but I will, first, try.to outline the mechanism by which the Veterinary Corps performsRits function with regard to, the inspection of meat and food and dairy products. Prior to the present emergency most of the inspectional work wap done upon receipt of the. foodstuffs at a post, camp or station. The contract was let by ,the lo- cal Quartermaster and upon delivery of the item, or items to the post thpy were inspected and if found either spoiled or not complying with contract specification requirements as to quality, that is type ..and grade, they could bo rejected and replaced locally by the contractor or purchases made against his contract if he failed to promptly supply replacement. That worked all right under conditions of a normal army in peacetime. - : .T It will be readily apparent.to you that with the enormous quanti- ties of food stuffs procured for ‘the subsistence of the troops that if inspection was delayed.until the,.items reached the. post qr station and then they -were found not to comply, it would he impossible, because of the amount, to replace them locally and in addition there would have been utilized critical transportation in getting the shipment to the post and replacement bach. To overcome these difficulties the Quarter- master General's- Office, early in the emergency,, organized throughout the country, in desirable places from a standpoint of availability of certain types of food items, so-called markets or market centers. They are.located ip. areas where, for example, packing centers are located or.where large quantities of food stuffs of the type that the army buys are prepared or are available. ’ ‘ ‘ These market centers, some 35 or 37 in number; are all. closely hooked up with a Field Headquarters of the Quartermaster General's Office in Chicago and they procure all perishable subsistence supplies for the Army, the Navy and the Marine Corps. * . Nhile inspection has always been important to Insure that a dealer does not deliver, on a contract, foodstuffs that are deteriorated or actually harmful, it is important, that the inspection also Include the type, grade and quality of the item. This latter is particularly important at the present time because, as you will at once recognize, with ceiling prices essentially setting a uniform price for certain items, the element of competition is largely removed and the range-of profit may frequently be considered by the contractor as rather narrow, Consequently the -unscrupulous individual will try to increase his'pro- fit by supplying items which are inferior in quality. It, therefore,■ is very important that inspection be made to determine that the Govern- ment gets not only a safe, wholesome, food, but precisely what it con- tracted for as regards quality. Those plants, as you will readily recognize are In many cases over- worked. Their facilities are‘over-taxed and the type and training of much of the personnel, in many instances is not comparable to what they had under normal conditions.. As a result,, it would bo possible, in the absence of adequate inspection,, for a foodstuff, especially canned moat products, to be prepared and shipped out, later to find that it had been improperly processed and had spoiled.- Under such circumstances not only would there be ' a risk of detrimental results in the individual consum- ing ft, if consumed, but a false sense of adequacy with regard to what is on.hand and, also utilization of critical shipping in transporting a worthless item.' ’ The Veterinary Corps conducts largely what we term 'point-of-ori- gin inspections". Those inspections are made at the point pf origin or-at the location of the plant or market. Inspections at those points make - it possible to conserve transportation, and assures that the pro- duct, when it reaches-the post, ,camp or station, will bo acceptable if good condition is maintained, thus giving assurance to the contractor that when he makes shipment, it will be accepted at the point of receipt provided .good condition has been maintained; The greater part of our inspections are these so-called point-of-origin inspections. In addition to inspection at the time of procurement or at delivery, food-stuffs are inspected in a aeries of subsequent inspoctional activi- ties, while in storage, when shipped, and when Issued. Those inspec- tions are of particular importance, especially in seme of our overseas stations where climatic and other conditions are such as to make it a difficult to maintain food supplies over protracted periods without spoilage or damage to cans and containers which later make for spoilage. It is important, therefore, that these in-storage and other inspections bo made and they have resulted in considerable savings to the Army. Very frequently changes which have started and which will later manifest them- ) 137- selves as spoilage are often detected and the foodstuff salvaged through early issue or reconditioning. The Quartermaster market centers pur- chase all of the perishable subsistence and the Quartermaster Depots all of the canned and cured products. I will mention several of the items which are of importance'from the standpoint of our inspection and comment as I go along on some of the things which have come up in connection with the inspection and the handling of these products. One of the largest subsistence items of animal origin is, of course, beef. Prior to the emergency, most of the-beef procured by the armed forces was in the form of quarters or sides. At the present time, with very few exceptions, that procured is so-called boneless beef. That method of putting up fresh beef was developed some few years ago and has proved of inestimable value in conserving transportation and in facilitating handling in messes. Certainly under the circumstances incident to the present war it has been a very excellent thing especially because of the critical shortage of shipping space. Boned beef is prepared by removing all the bones- and cutting it up in commercial cuts. It is then frozen and in that condition is very compact, stores well and can be shipped and handled with-'facility, It has proved a very popular way of handling beef.'- ;• t; The boning of beef, it you are not going to mutilate it•beyond- recognition, requires expert butchers. "While most of the packing plants, prior to and in. the early days of the war, had qualified personnel to do this, the demand has become so huge that it has"not been always easy to obtain the necessary expert, competent personnel, .to carry out the boning of beef. The Quartermaster Corps, within the last ten days, initiated action to bone beef, which they will procure.as carcass beef, at a number of military posts, utilizing military personnel and priso- ners of war labor.- , - . -r: •• l-'-l '■•- Smoked products-have always been important from the: standpoint Of the military establishment, . Those items, as prepared for the. Army, are often processed in a manner different from some of tho usual commer- cial practices. Smoked hams and bacon as ordinarily prepared won’t stand up under high temperature conditions, and handling, such as the old long-cured ham. You will all recall tho old long-cured ham that you could hang in your basement or in a commissary and it would stay there for weeks•without deterioration. You can’t do that with the hams prepared under present commercial practice. These so-called artery pumped or tenderized,hams contain more fluid and are given a shorter euro than the old hams, ■ They are much more susceptible to deterioration. The army, in the" case-of a number of process-cured meat items, has prepared its own specifications to produce foodstuffs that will have better keeping qualities than some of that made according to usual com- meroia.1 practices. .. . ■Aside'from cured, products and .smoked products, wo have, of course, all of the various canned meat products, especially things like canned §omed beef. We have had considerable trouble with canned corned beef from certain places. It is put up in rather large cans and contrary to ordinary belief, these products arc not bacteriologlcally sterile," The processing does destroy most bacteria but often they do contain viable organisms. Ordinarily in the medium they are in, usually with a high salt content, propagation of the organisms does not take place. In some cases, especially under adverse conditions, swcllcrs develop indi- cating spoilage. I have seen in a lot of stuff, especially some of the foreign meats, that -was not thoroughly processed, that -when stored in places like India and Burma, there were rather high losses. The army, of course, utilizes large quantities of cheese which we inspect. You will he interested, as most of you undoubtedly know, that within the last year or 10 months, there were several outbreaks of ty- phoid traced to cheese, largely Cheddar cheese. Ordinarily cheese is aged for several months before it is consumed, but the demand has been so great that much of it on the market is not aged as long as usual. If it is only several weeks old, there is considerable danger of spread of infection such as typhoid, as in the breaks that I mentioned, and likewise Brucella infections. Fortunately, back prior to these outbreaks we had issued instruc- tions thatno cheese would be issued for military use unless it had been stored for at‘ least 60 days, ¥e upped that to 90 days after these out- breaks started and that has proved sufficient to insure against the out- break of anything like typhoid and Brucella infections. The changes incident to ripening over that period of time will destroy E, typhosus and species of'Brucella. The outbreak in California, due to short- h ripened cheese, became so serious that the legislature, in a special session passed an ordinance that requires that cheese be made from pas- teurized milk or that it be aged at least 60 days. It is almost impossible to get cheese prepared from pasteurized milk, because, as many of you perhaps know, it is a common practice with cheese companies to collect cheese from a large number of small pro- ducers, sometimes actually from housewives’ homes.' It would be impossi- ble to have all of that milk pasteurized, so the safest procedure is to be sure that it is aged. We think that 60 days is perhaps sufficient, but to give a little wider margin of safety, the army policy is 90 days. We have had considerable trouble with canned milk prepared for over- seas shipment. There, again, contrary to common belief, canned milk ■ as commercially produced is not invariably a sterile product. It is not bacteriologically sterile. The number of viable organisms is small, but if you culture enough of it in a sufficient number of cases, you (can almost invariably isolate some of the large spore-bearing organisms. Sometimes these arc very proteolytic and will split the casein and you will have a decomposed milk. That doesn’t usually happen under good conditions of storage and reasonably prompt use. However, it should bo remembered that canned milk is not invariably sterile and that if wc buy large quantities of it and store it over a period of several years the losses will bo relatively high. Canned milk, ought to be used within a year. Powdered milk -has. boennan. item of great Importance -in this wary, both from the standpoint•of its keeping qualities and the lessening of bulk for shipment. Hugo quantities have been procured and shipped overseas. It is usually put.up not in the form of a while.milk powder in the presence of an inert gas, nitrogen, and it will keep for a consi- derable period of time before oxidation and rancidity occur. Usually it can be reconstituted.with very little' difficulty and makes a pala- table type of fluid milk for beverage purposes. As you all know, we have had considerable experience with dessi- cated eggs in the present war. Prior to this emergency, dried eggs were used almost exclusively by the baking industry end not to any large extent, so that when we got into the present war and developed the need or desirability of shipping eggs.overseas, the dried variety became Important. It was found very difficult to get shell eggs overseas and have them in edible condition for any period of time under storage con- ditions that would exist in places like North Africa., for example. The powdered egg* industry, therefore, has developed markedly in this coun- try as.a.result of the present emergency. It has developed with it several problems of importance. Of course, there is no egg powder made that is sterile. It all contains a variety of organisms, most of them saprophytic, hut in some instances, perhaps somewhere between 5 to 10 per cent of all egg powder produced in the United‘States, organisms of the Salmonella group are found. Fortunately, powdered eggs put up under army specification and contract requirements are not and have not caused any known extensive outbreaks of food poi- soning. There has been a British Medical Research Councillstudying of several outbreaks of food poisoning in England in which powdered eggs supplied on lend-lease were incriminated. They were considerably concerned be- cause apparently there had been introduced in England several species of Salmonella which heretofore had not existed there. The presence of Salmonella organisms in dried eggs is one of those things we don't like and work is being done in an effort to produce an egg powder that will be free of pathogens. If we could pasteurize the fluid egg before it is spray-dried, it would probably accomplish the purpose. However, there are some practical difficulties with regard to putting an egg through a sprayer after it has been heated and that will have to be overcome. We have every reason to believe that within the next few months, that at least a good portion of the dried eggs will be produced from fluid eggs that have boon heated at l4o or lh-2 for seven minutes. That is sufficient to destroy Salmonella organisms. We have had, as you might well appreciate, considerable trouble with butter. We have to reject considerable quantities of butter under various circumstances, particularly in certain localities, because of high mould counts resulting from the use. of stale',, old cream, heavily con- taminated with mold. The enormous demands for butter are such that some dealers will try to obtain supplies from sources that they wouldn’t ordinarily think of using under peacetime conditions. If- you have tried to get chickens lately, you will realize that this is a very critical item from the standpoint of food supply. All chickens in plants in certain sections of the country have been frozen for the Armed Forces. Perhaps the thing that will ho of 'most interest to you in conjunc- tion -with dairy products is fresh fluid milk. It often has "boon a head- ache ■with us. Early in the war, the War Department decided that as a matter of morale it would ho desirable to retain fresh fluid milk a S’ an item of ration and that has hcen done and in the United States today wo are averaging a little hotter than a half a pint of milk per soldier per day. That runs into very, very large figures. We have had considerable difficulty with the local supplies as received by pasteurizing plants, . Very frequently a milk company will con- tract to supply a so-called grade A milk, produced in accordance with the specifications and requirements of the U.S, Public Health Service Milk Ordinance and Code and yet if you check the raw milk, you will find that there is often a breakdown. Very often it will bo found that the character of milk going to the pasteurizing plant is not what it should be. We disapprove many plants. There are several reasons for it. First off, the dairyman or the dairy faimer producing miIk for beverage pur- poses has a coiling price just a trifle better than that of the indivi- dual prodticing milk for manufacturing purposes, that is for dried milk or for canned milk. The fellow that is producing fresh fluid milk must have at least a minimal amount of acceptable equipment and he has to meet certain standards in handling, cooling, delivery and all of that in order to get his milk to the pasteurizing plant in satisfactory con- dition. The differential in price is certainly not such as to offer much inducement to the dairy farmer producing fluid milk for beverage pur- poses, especially in view of the serious manpower shortage and the question of critical items of dairy equipment. As you know, we buy milk under an Army specification. In connection therewith is a point worth stressing because it has gotten us into trouble through ignorance on the part of some of the people having to do with the control of milk supplies in towns and municipalities. We buy, where it is available, a so-called Type II grade A pasteurized milk. "Type II" is an unforu- nate classification because naturally it carries with it the inference that this is a grade B milk. However, the federal specification, start- ing,back some 15 or 20 years or more ago, classified certified milk as Type I and the top grade of pasteurised milk, which was the so-,called grade A quality. Type II. ; ■ ■■. • With the emergency it has been necessary for us to go to Type III milk. Now Type III milk is, really, a good "3 grade milk. Bacterlolo- glcally it meets all the requirements of a grade of milk which is com- parable to the grade B milk produced under the Public Health Service Standard Milk Ordinance and Code, However, when contracts are let by the army for Type III milk, we find a lot of health departments saying the army is buying a grade C milk, which is cooking milk. It is well to bear this in mind because it will come up and some of our own people have not been clear on that particular point. We do not buy any grade C milk. • Another thing with regard to milk which is of importance is the phosphate tost to indicate whether or not proper pasteurization has been accomplished. We make considerable use of this test. In general, we place great emphasis on proper pasteurization. We have had to go to a lower grade of milk, an acceptable, grade but lower from the stand- point of the raw products, simply because of a lack of availability of the higher grade milk, but there has been no let up in requirements with regard to pasteurizing plarlts and,methods of operation, equipment and so forth. We are sure that if we relax with regard to pasteurizing plants, we would be headed .for trouble. You may find that the methyl blue reductase test is utilized by some of the dealers to determine the quality of raw milk prior to pas- teurization. That tost has been considerably abused. As you, of course, know, the test depends upon the utilization of oxygen by the bacteria present in the raw milk and if it is not set up and done under proper conditions, there is likely.to bo considerable variation between the results with the methyl bide test, - the standard plate count, or the direct microscopic count, so that a milk that wodld ordinarily pass on the basis of methyl blue reductase test might not necessarily pass on the basis of the standard plate or' direct microscopic count. Another point that has come up in connection with milk is the ques- tion of bottles and capping. For a long time The Surgeon General has „ consistently adhered to the policy of requiring, wherever possible, that milk be put up in bottles,, which are capped with a- cap covering the bottle lip at least to its greatest pouring diameter*. That has a very definite public health value. You have all seen milk 'coming out of ice'box cold and if it has a plug cap, the well formed by the lip of me "bottle and, the cap, when the milk expands results in the milk exuding into, that well. This small amount of milk is subject to contamination and will often enter the "bottle when "the cap is removed. If milk bottled this way is delivered to one family and somebody sneezes in it and is a streptococci carrier or has any.of the other throat organisms, you may have as. a result of that one bottle of. • • milk, one or several cases of disease in that one family. If the same thing happens in the mess hall, that one can, of course, be the source of infecting the entire group. So we are rather insistent that these bottles have a lip covering. The cap doesn't have to come all the way down and it doesn’t have to be wired. This type that is crinkled and 0 protects the lip through its greatest pouring diameter is.entirely satis- factory. ■ Overseas' we are operating not only from an inspectional standpoint, we are operating a number of slaughtering establishments to provide fresh meats. Especially is this true in India and it has been true over in the North African or Mediterranean theater. ,. , To give you an idea of the extent of this inopectional service performed hy the Veteranary Corps I might state that we are dally inspect- ing about 23 million pounds, of meat, meat food and dairy products. Rejections run about A.5 per cent. Aside from the protection afforded the health of troops it should be apparent that the potential monetary saying to the Army, as represented by the difference in value between what is offered for delivery and what is accepted following inspection, runs into tremendous figures. ' • . ? I have rambled along to try to give you in a relatively short period of time the overall picture and touched on a few things that might be of Interest, I will be glad bo answer any questions. GENERAL BAYNE-JONES: Someone is of. the, Expression that fresh neat in the Pacific area is' very rare--1 don’t mean rare hut hard to get/ in the Guinea region and in through there. GENERAL REISER: Lend-lease in reverse is the order of the day and in ■ the early days of our troops over there it is true that they vore getting very small quantities of fresh meats. This has "been improved considerably and we are getting out of New Zealand large quantities. .on a reverse lend-lease basis. We are also,* getting large quantities from Australia. In the India-Burma theater, when I was over there several months ago, there.,was essentially no'fresh meat supply issued, except that produced at those, establishments that wo were operating. However, they arc now. shipping frozen boned, beef over there. It would have gone over earlier except for. the fact that they didn't have the refrigera*- tion facilities to take car'e of it. Any other questions.? What is your, opinion of dispensing milk by the modern type milk dispenser? • MAJOR BUZZERD: GENERAL REISER: We have consistently discouraged that.' There is a lot of pressure, being exerted right,.now .on, the Secretary' s office-to. get; in some of these dispensers. First off,, the milk is put"up-in 5-gallon cans and they are inverted. That is one type of dispenser. We felt that if operated properly you might get hy with it, hut that it certainly does not afford the safety of the indi- vidual container, The Wavy uses it and, also huys hulk milk. The Army does not huy hulk milk. • MAJOR BUZZERD: I have another question, also, With regard to the dis- posal of ocean-going ships ', -.garbage. they are in many cases apt to separate it and it contains meat scraps. How should’ that he disposed of? : - v : '• GENERAL KEISER: The only safe way is to incinerate it. It is not always done, however and, as you probably know, Australia was one of the countries very much disturbed about having trichinosis introduced as a result of pork going in there and pork scraps being fed to native pigs. We possibly produced an outbreak of hog cholera in Iceland as a result of pork products that went to local pigs from soldier meases in Iceland. They had never had cholera there, so far as we know, but after we got our base up there, and they obtained garbage from the messes hog cholera made its appearance. We may or may not have Introduced it,. The virus of hog cholera is carried in some of the tissues and it is a very common mode of spreading the disease. As a matter of'fact, it has been well known that hogs that have been continually fed bn garbage are immune to cholera because of the constant exposure. There, of course, are a number of methods for handling garbage . but it isn't always an easy thing to do, but that is a long story. We have had foot-and-mouth disease introduced in the United States as a result of it and improper disposal is responsible for swine erysipe- las, hog cholera and trichinosis. It is certainly best, if it is going to be used as feed, to cook it and if that can't be done and there •’ isn't, too much of it, and it isn't much of an economic problem, why they incinerate it. In some places they bury it rather than incinerate it if they don't have'the proper facilities for incineration. COLOl'IEL “■ ROBINSON: Any other questions? (No response) COIOIIEL ROB BISON: Thank you very much, General. (Applause) We will recess at this time. MORNING SESSION - 16 February 1949 The conference convened at 9';0C' o'clock a.m,, Colonel T.B, Turner, Chairman. --•••• COLONEL TURNER: Gentlemen, we’d "better get going on the last day's session. The first topic this morning will he ■ presented "by. Colonel Sternberg, a study on venereal diseases. COLOHEL : STEEKBEHG: • . Mr. Chairman, gentlemen, I do not have a paper, hut there are a few points that I would like to cover of general interest and a few points that we are particu- larly anxious to try and put over in the field. After that I hope that you Will feel free to ask any and all questions which you may think of in connection with venereal disease. I suppose it is hardly worthwhile to mention that our trend in rates of venereal disease has heen upward' quite sharply for the past year. Starting January 1, 1944 the total venereal' disease rate for the continental army has heen steadily upwards, rising from a rate of 26,3 in to an average rate of 3*4- la 1944. The rate beginning at this period of time, January 1, 1944 was at the same level as the previous year, 26,3. The year ended with.a" rate of 40- for for December 19*44, The rate for January now appears to be .in the neighborhood of 48, ■ ' ' - .: . " The breakdown by disease, however, presents a far more encourag- w ing picture. The increase was entirely in gonorrhea.' As' a matter of fact, we have a very definite decrease in the incidence ofisyphilis.and the minor venereal diseases. The total overall rate for syphilis dur-. ihg lS4-J--Was A.8. In 1944 the overall syphilis rate was 4> ■ • The minor venereal diseases had a rate of 1.9 in 1943 and in 1944 they had decreased to 1, so that the total for syphilis and minor vene- real disease had decreased to 5 in 1944. We feel that that is quite encouraging. We do continue to have a decrease in syphilis despite a markedly rising rate in gonorrhea and we feel that it indicates that we should continue to drive at syphilis as hard as we can. We feel it is much more important to obtain adequate contact histories, follow-up and so forth on your cases of syphilis and that progress is being made in this disease. The incidence of gonorrhea has almost doubled at the present time and we feel that there are a number of factors that arc responsible for this rise in rate, some of which are out of our control. Certainly we are getting better reporting with the repeal of the loss of pay, removal of punitive measures. The rapid and excellent treatment we now have which encourages men to report rather than to go to a private phy- sician, so that we feel that the gonorrhea rate represents a much truer incidence of the disease in the Army today than it did a year ago. Further, the character of troops in this country has changed marked- ly in the last year and a half. The well-trained, highly disciplined units have, most of them, at least, gone overseas, and we are left in this country with a higher and higher percentage of troops which for many reasons were removed from ground force and air force units, dis- ciplinary cases, low I.Q.’s and so forth, troops which invariably do have a'higher venereal disease rate. are a-numCb©rv Cf other fad-tors ' involved. One, of course, is that there ’appears tC-’be an increa.se in gonorrhea in the civilian-popu- lation. I say "appears", "because this is certainly not proven on the hasis of any statistics which have "been presented by the U. S. Public Health Service or any other civilian agencies and yet there are some-- during 1944 at least, some 30,000 or 40,000 more cases of gonorrhea re- ported in civilians than in the previous year. This increased Army rate•has been accompanied by a very important thing, that is a decrease in the number of days lost per thousand men per year from-venereal diseases. In 1940 this figure was 1,280 days lost per thousand men per year from venereal disease. There has been a marked drop ever since, to 800 in 1941; in 1942 there were around 600 and at the present time the lowest days lost per thousand men per year in the army that has ever been experienced, under 300 per thousand men per year* That has been a steady decrease and, of course, it lias been brought about by better and improved treatment methods. Furthei} the days lost per case of venereal disease has shown a-similar decline and is almost unbelievable; in 1939 it was some 42 average lost days per case of Venereal disease* At the present time it is around 4,9 lost days per case of venereal disease. v - This■decline in days lost is actually a better measure of the importance of venereal disease to the army than incidence rates,- so that the rising rate, while we are concerned about it and anxious that it should be chocked, nevertheless, is not as significant as it might have been if bur treatment methods had not improved. This' leads into the whole question of treatment, TB Med jf96 does away with sulfonamides and institutes penicillin initially in gonorrhea. The course recommended includes 'five injections of penicillin, a total' of 100,000 units covering 8-hour period. We recommend where possible that gonorrhea he treated on an out-patient status. We are quite anx- ious that as many of these individuals as possible he treated on an out- patient status. We feel that with the high cure rate'-which we get with penicillin, which incidentally is being maintained-pretty-well, that the disease does not justify hospitalization at the present time except under circumstances where dispensary or out-patient treatment is- im- -,:- practical. We feel that that is one thing that can be accomplished in the field to the great advantage of the Army and to the hospitals which arc how greatly overcrowded, namely, the treatment of gonorrhea on an out-patient stabus. We recognize that the present treatment schedule is purely ar- bitrary. It is almost impossible to misuse pencillin provided at least 6 hours is covered by the treatment schedule and 3 or A injections com- prising a total of 100,000 units are given. Under these circimistances acure rate above 90 per cent is obtained. The new developments in the treatment of gonorrhea which I think you are all aware of are the methods of prolonging penicillin blood levels by delaying absorption. The most important is becs- wax-peanut oil preparation. He :has treated some 200 cases with a, single injection of 150,000 units of penicillin with beeswax-peanut oil and has had remarkable results. His last series of 100 patients have all been cured with a single injection using this dose. This material is now being made up by several commercial laboratories but it is still in insufficient quantity to put it into the field for general use. In other words, it is still in the research stage, but it does offer a very promising one-shot treatment which we hope can be made available some- time this year.' v V" - The treatment of syphilis was completely revolutionized:-last November when we put out TB Med. # 106. We hope that this can he Improved fur- ther. At the present time, with the 7-1/2 days of'treatment-with peni- cillin> plus the initial diagnostic day or so during the hospital stay and a day or two after, the average hospital stay is around 10 days and should not he longer. The treatment schedule, itself, appears to he very satisfactory. The percentage of failures will prohahly he in the neighborhood of 5 to 10 per cent. This is not serious provided these failures are- recog- ; nized and are treated satisfactorily as early as possible. There are a number of new developments in the chemistry of peni- cillin in,which I think you would he considerably interested. -' In the first place,"it is now apparent that the crude penicillin"that we got a year ago had a certain effectiveness which does not seem to he pre- sent to the same extent in the more highly refined pure penicillin that we are getting today. '• A year ago the penicillin potency averaged from 30° to -4-00 units per milligram," Today it averages between 900 and 1,200 per milligram. There are developing very definite indications that the impurities contain substances which are at least effective against the Treponema pallidum and perhaps against the gonococcus. The work that has been done along this line indicates that we have in crude penicillin, first, the pure penicillin products-and there are. a'number of them which I will discuss in a minute—and secondly the im- purities which, are also metabolic products of the mold and have a defi- nite therapeutic effect. Work is now underway to try to isolate these impurities and determine what they are and which ones are effective V against the Treponema pallidum. ■ , The penicillin products, themselves, consist of a number of chemi- cal compounds which have been given various names. The most common are G-, F&X. Also, they have now isolated F’ and F". These are- all,"' differentiated -under chemical names by the addition or subtraction of certain side molecules. It is very interesting and complex. "G-" comprises a very large per cent of our present penicillin, around 80 per cent, and pure synthetic "G-" has very little effect against Treponema pallidum. In vitro it has no effect. The solutions of peni- cillin "G-:! can be put with spirochetes under the microscope with no spirochetocidal or splrochetostatlc effect. In vivo . "G-" still does have some effect in rabbit syphilis, but not as good an effect as crude penicillin. ' "X", as you know, has a very marked effect against gonorrhea, much more so than the crude penicillin or penicillin "G-". Studies are now being undertaken to determine which of the various organisms F' and'-F" are-most effective against. There- are also two other penicillin products or penicillin extracts which are being isolated or have been isolated. One of them has been given the name of "Q" and very little is known about it now. The indi- cations are that there will be five to ten more types of penicillin found in crude penicillin, so that it is perfectly obvious at this point that we are just beginning to find out something about penicillin and we don't know too much yet and in the next year or two we will see a lot of revolutionary changes in our thought on this whole business. In the meanwhile we must make every effort !to see that the patients with syphilis who have been treated with penicillin get their monthly exami- nation and follow-up and the failures are identified and properly re treated. The question of prophylaxis is one -which always creates quite a discussion at any meeting of this type. The value of the various pro- phylactic procedures has teen questioned "by many. One of the most ques- tioned is the fixed prophylactic station upon which the army has always placed the greatest dependence. ¥e feel that only about 30 per cent of the existing prophylaxis stations today are Justified. The Justification of any fixed prophy- laxis station depends entirely on its utilization. It is quite difficult, of course, to arrive at any definite minimum number of prophylactics; which should be given in any period or time to Justify the existence of a station. It is possible to determine the cost of the individual prophylac- tic given by averaging the number who go to the station monthly, figuring the upkeep of your station, plus the time, the commutation, quarters and so forth of the personnel running it. It is found that in many stations it costs as high as $50. 00 per prophylactic, ranging’ all the way down to a few cents in some of the larger, border stations where many pro- phylactics are given. It is our feeling at any prophylactic station where costs run over $1,00 to $1.50 per prophylactic that it is hardly Justified unless it is a "leave1'-town where it is essential that a prophylaxis station be located from the standpoint of public opinion or the satisfaction of the commanding officer, ¥e feel that many of them should be closed after careful surveys and evaluation. ¥D Circular has set up an entirely new system of distribution and utilization of Individual prophylactic materials in this country. First, of course, the most important change is free issue through medi- cal supply channels. This has been slow getting into effect, but I be- lieve that now it is becoming pretty well adopted throughout the zone of the interior. There are still some areas where many are apparently unacquainted with this circular published the 19 of October, 19^-• That is one of the Jobs that has to be done on visits to posts, camps and stations. That is to check into the method of distribution of individual prophylactic items and see that they follow the provisions in ¥D Circular iflO, The unit commander must see that the items are made available in the barracks rooms, company quarters or any other con- venient .places to the soldier. ■ ¥e are quite anxious that the new "pro" kit be publicized as much as possible and we have gotten out a lot of educational material cover- ing the new "pro" kit which Captain Larlmore will say a few words about, ¥e believe that this kit can be a very valuable aid to venereal disease control program, but that it is necessary, of course, that the men be made acquainted with it and its proper use. That leads to the next question and that is the type of: prophy- laxis now given in the standard prophylaxis stations. In this circular we have made it possible for surgeons to requisition the individual, chemical prophylaxis to place in prophylactic stations either for use in regular prophylactic stations or for distribution therein. These items can be requistioned on service command level or any lower echelon where it is desired to use it. It is good advertising of the "pro"' kit -if they are used in prophylaxis statiOP-S, After the men have been given a prophylactic with the "pro"' kit by S trained attendant they are then acquainted with the kit and with its use and will he more apt to use that kit in other circumstances where they can not or don t care to come into a regular prophylaxis station. The further recommendation that this circular makes is the setting up of distribution points for prophylactics he established. Many of these have been set up in various service commands, through arrangements with fire stations, U.S.O. and other places where service men come and congregate. I have a number of questions and I think .1 will ask Captain Larimore to say a word about venereal disease in Negro troops. CAPTAIN LASIMOKE: I don't think it is necessary to point out to you what a problem control of venereal disease is among colored troops. The Negro venereal disease rate runs consistently from 6 to 8 times the white rate. It has done that since practically the onset- of the war. In fact; the trend recently has teen such that the proportion is even higher. You might ask why. I will attempt to" give you some of the reasons for this difference in rates. All of the studies that we have made, including the confidential surveys and other studies indicate that the sex exposure rate of Negro troops is many times higher what it is in white troops. In other words, all available evidence seems' to indicate that sex exposures per thousand troops over any given period are greater. The second reason is that the risk of infection is greater. The • population to which the Negro troops are exposed has1a higher incidence of venereal disease, so the risk of disease per exposure is greater. The final factor is that there is evidence to indicate that Negro troops are less likely to provide protection for the sex exposures that do occur. in short, Negro troops are much more prone to avoid prophy- ■ iaxla than are white troops. One of the chief reasons for this break-’ down of our educational and prophylaxis program is that 71 .per cent of all Negro troops are in class k and or semi-illiterate as far as edu- cation is concerned. Many of them don't understand:the educational program which has been designed primarily for white troops. They don't understand about prophylaxis and many have long-standing superstitions about YD and the use of prophylaxis, which include inherent objections to certain types of prophylaxis. All of these things add up to the fact that the Negro Venereal disease in the army rate runs between 6 and 8 times the white rate. .... ■ * Next is the Question of what can be done about it. Well, a great a .. i. ■ deal can be done. The Negro venereal disease rate at certain posts in this country is comparable to that among white troops. For example, Tuskegee Army Air Field has maintained a Negro YD rate for the past three years which is comparable to the white rate of any post in that area. Another post., Fort Huachuca, Arizona also has maintained a com- paratively among fts Negro personnel low rate. Similarly at Indiantown Gap Military Reservation, Pa. there is a low rate among the Negro troops. Thus, it can be done, and when you begin to investigate to find out why some of these posts have low Negro rates as compared to the overall Negro army rate, a number of things become apparent. First is extent of the suppression.of Negro prostitution activities. At the start of ■ the war there was very little, commercialized Negro prostitution in the communities ajacent to army posts. That has changed in the past few years 'until now in some of these cities there is a great deal of, commercialized Negro prostitution activity, particularly in the south. All too frequently the local police are. reluctant to do anything about Negro.prostitution conditions. In posts -with low Negro VD rates ye usually find that an effective attack has been made on the local pros- titution situation with a resultant reduction in the sex exposure rate. The second factor is the community recreation facilities for these troops.. All too often they are frankly not on a par with those, for white troops. 'When Negro troops go off the post they gravitate into the Negro section of the towns and practically the only thing for them to do is to go to some juke-joint where within two or three minutes they are likely to be approached by some prostitute or charity-girl. Hence in such an environment they are almost continually bombarded on every side with opportunities for sexual exposure, both free and for pay. The third factor is that on these posts where a successful Negro YD control program is carried on, one does not find commanding■officers with the attitude that there is nothing you can do about high venereal disea.se rate among the Negro troops. You don't hear the defeatist dog ma that the Negro VD rate has been high and is always going to be high, and that there is nothing that can be done about it. In the posts with low VD rates the command has not just washed its hands of the problem but has given complete support to the venereal disease control program among Negro troops. This command support is the keystone on which any successful control program must be based. The final thing is education. Since our VD educational program for the army is as I pointed out to you, directed primarily to white troops, it has been less effective when applied to Negro troops partly because of. the fact referred to above that,71 .per cent of the Negroes have an AGCT classification of 4 or 5 • Further, one of the basic factors in the effectiveness of any training aid or health education material is that the individual for whom it is intended must bo able to put himself in - the place of the subject depicted’in the material. Hence, in general VD' educational utilizing white characters, elicits a poorer response from Negroes. Health educational material for Negroes, such as posters, etc. should employ Negro characters for maximum effectiveness. We have been unable to obtain permission to produce graphic material with Negro charac- ters, although we do have a film on VD control, with a Negro cast, in pro- duction at the present time . One of the reasons for the success of VD control programs at all Negro posts such as Tuskegee is that the educational procedures are carried out by Negroes for Negroes with a full consciousness of the pro- per educational level, the proper language and the proper appeal that will effectively reach the group. These programs placed a major emphasis on the use of specially trained non-commissioned officers to get the pro- gram down to the level of the men and to carry the VD control campaign into the barracks and the orderly rooms. These and other irinciples of VD control among Negro troops that are embodied in WD Circular 88, 1$'44 which was a restricted War 'Depart- ment Circular. Apparently it was very much restricted because, frankly, from our observation it doesn't seem that anyone so far has paid too much attention to it, other than during the first few weeks after it came out. I think it would be fair to tell you that we have been informed that the Inspector General's teams who visit posts for the purpose of rou- tine inspections will check into the strict application of this circu- lar to all Negro outfits. You might pass this word along to your posts. This circular, if you are not familiar with it,. provides, essential- ly for-a venereal disease control program for Negro troops "based largely experience oi those installations which have "been successful in maintaining Negro YD rates approximating those for white troops. It provides for an officer to "be designated as venereal disease control officer for each Negro company or unit of similar size and it also di- rects that this YD control officer will employ the company non- commissioned officers as nls assistants in carrying out a YD. control program for that unit. Circular 88 also outlines other general principles concern- YD education, suppression of prostitution, and provision .of adequate prophylaxis facilities. We feel sure if these principles that have “been successful in lower- ing the Negro venereal disease rate at some posts were intensively ap- plied to the army as a whole a drop in the venereal disease rate would result just as it has at these isolated posts where they have "been ap- plied, so it is our hope that you will familiarize yourselves, if you have not already done so, with this circular and see if we can- "bring about a better application of its principles, and thus bring down the Negro venereal disease rate from the peak it now presents. Now, as to venereal disea.se education, the Army in had the most intensive venereal disease education program in its history. About 15>000,000 pieces of graphic educational material were issued and our training film audiences totaled approximately 10,000,000. Among the materials we prepared were two pamphlets, 21-15 and 21-16 both of which were for general distribution to all troops. Pamphlet No. 21-15, "You Don't, Think" is a new departure in Army pamphleteering, employing the child's book technique of make-up and typography. The other Pamphlet; 21-16, "So You've GiotA.Furloiigh?", is intended .to meet the furlough problem. This pamphlet is also unique in that while it, was put out by The Surgeon General's Office and paid for out of venereal disease educational funds, there are, only four pages on venereal disease out of the 20 pages in the pamphlet,. This was done because wq. felt that a pamphlet, containing general information of value to the soldier with the material on venereal disease sandwiched in between, would bo more valuable as YD educational material than would a pamphlet devoted entirely to venereal disease. Experience with the pamphlet thus far bears out the advantage of: this type of material. We also put out other YD educational pamphlets for special purposes or to meet particular needs, for example, there is as you all know, a pamphlet for WACs, There is also a. pamphlet,, "No Tiene Cuenta", for Spanish speaking troops in Puerto Rica. Another, "Even SNAFU Knows", was put out for the Burma-India theater. The latest of these special pamphlets is one .called "Yenereal Disease Overseas" ... to bo given to all troops going through ports of embarkation.. With respect to posters, The Surgeon.General's Office, under WD Circular 28, which designated it as the War Department agency concerned with the selection, procurement, and distribution of venereal disease materials, undertook in a YD poster program with.a monthly poster to bo distributed 'directly to all posts by The Surgeon General’s "Office on the basis of one poster for each 100 menW In some instances, we have made distribution on a higher ratio than that where' such was. Justified because of local need. At the present time we are purchasing around 50,000 posters a month which are shipped directly from the printer to each installation of more than 500 strength in.this country. If any posts are not receiving their allotment of posters, or if_the allotment is not satisfactory, it can be corrected promptly by a communication., ■!", to'the Preventive ■Medicine Service, Office of The Surgeon General... * ' . A somewhat different situation exists with respect to pamphlet material. While we select and procure YD educational pamphlets the dis- tribution of them has been accomplished by the AGO since that distribu- tion-gets into the millions--( we distributed 5,000,000 copies of 21-15 alone). It runs into bigger quantities than we are equipped to handle, in fact, 5,000,000 copies of 21-15 occupies about 10 freight carloads, so you can see it is a. tremendous Job. The Surgeon General's Office is not equipped for such distribution and we requested the Adjutant General’s Office to get these pamphlets into the field. Reports reaching us indicate that, by and large, the pamphlets and other material have been well-received and the distribution system has been generally satisfactory. However, if there are any suggestions for improvement of content or method of dissemination of any of the YD educational materials we would be glad to have them. In regard to future YD education plans we expect to continue the poster program, on the same basis in 19^5• With respect to pamphlets we plan to revise the War Department Sex Hygiene and Yenereal Disease pamphlet which is given to men in reception centers and possibly to pro- vide another pamphlet, probably about the middle of the year, for generalized distribution to all troops. In all of this material you will note that there is a consistent "plugging," to use the radio term, for the PRO-KIT. Not neglecting, of course the value of continence as a YD preventive. All of our material contains a reference to or a picture of the PRO-KIT and instructions for its use. This theme of individual chemical prophylaxis runs through all of our educational material and stresses the use of the PRO-KIT. If you will look at the PRO-KIT package you will see that the name is registered in the U.S. Patent Office as a trade-mark by the Army, or rather to be more accurate, it is registered as a collective mark, which covers not only the name but also the method of distribution and use. This collective mark was obtained by the SGO in order to prevent any drug firm from taking undue advantage of the amount of effort and money which we put into VD education material, containg reference to the PRO- KIT, and similarly to prevent the exploitation of an inferior article under the same name, by same unscrupulous commercial establishment. As General Bayne-Jones told you., last evening, there has Been set up in the Preventive Medicine Service a new Health Education Unit, which has "been formed hy combining the health education branches of the Tropi- cal Disease Control Division, the Sanitation and Hygiene Division and the Venereal Disease Control Division. No changes, however, are contemplated in the venereal disease education program and it will be carried out in the same manner in the future just as it has been done in the past. I will be very happy after Colonel Sternberg is through to answer any questions about the venereal disease education program or about the venereal disease education program or about the control of venereal disease among Negro troops. Thank you. COLONEL TURNER: I would like an awful lot to discuss, this subject and to get discussion from the floor on these questions. COLONEL STERNBERG: I have some questions that have "been asked. Some of these have already teen answered. One of them is, has peni- cillin ever "been used as a prophylaxis agent against gonorrhea. It has "been on a local level. There are some posts that have used it, purely experimentally, and it has hoen used in animals. Unfortunately, as you know, it is difficult to infect animals with gonorrhea. Dr. Miller at the University of Chicago has "been able to _■ ■ ■ ’ ’ '• ‘-v' •'• *; - ’ Ci i.: tl: jn.rxi/0 WX'-, M ■:> to. . - * infect the. anterior-.chaiubeE .of .dhejley#- in rabbits. It is Very difficult to, eyaluate any .l 1943• Its main stated functions are two: 1. Proper preparation and serving of food 2. Elimination of waste These are important functions which contribute to optimal nutrition among the troops and the Food Service Program. In general they do their job well. However, ASF Circular $45 and the Food Service Program as practiced neither supersedes nor rescinds any of the responsibilities of the Medical Department. The Quartermaster has no authority to act in nutrition, health or sanitation. Those are your jobs. Where they overlap the same sort of cooperative activity should be worked out as exists between ourselves and the engineers in sanitation, or between ourselves and the Quartermaster in veterinary functions. Proper food, feeding and the health of troops are command responsibilities. In nutrition and all matters pertaining to it which may affect the health ox troops, the Medical Department is the commander's advisor. In the matter of the mechanical and economic handling of food the Quartermaster Corps is the commander's advisor. No conflicts need to exist, and where they do exist they should be corrected post-haste for the benefit of the troops. To assist Surgeons and their medical inspectors in carrying out their function, a group of officers have been carefully selected and trained. They are known as Nutrition Officers or Nutrition Specialists. They are Sanitary Corps men with special backgrounds in nutrition. They are competent to appraise and give advice on the nutritional as- pects of food and feeding and to assist in the development of an ade- quate nutrition program in the various commands. They are thoroughly trained in menu analysis, dietary survey techniques and the nutritional requirements of an adequate diet. They have had instructions in proper preparation of food to retain its nutritional value and are constantly supplied with the newest factual information on such matters. 'They should be used in all service commands and in the larger camps. Fre- quently one may serve more than one station if stations are small. These officers will be of inestimable help to you Preventive Medicine Officers in properly discharging your responsibilities for the nutrition of troops in your commands. There have "been turned in three questioils, two of which are essen- tially the same and to a large extent have "been dealt with. They are the following: What,.is the relation of the service command nutri- tion to the nutrition program and to the AAR nutrition program? What is the status of the Medical Department in the nutrition program with sjjecial reference to the duty and responsibility of the nutrition officer in relation to those of the food supervisor? Both of those questions, of course, are about the same and they both deal with mat- ters that I have already discussed. The relation of the nutrition officer and the relation of the surgeon and the Medical Department, to the food service program is es- sentially what the surgeon.makes it. As I have already said, by in- stituting a food service program you can not escape the responsibility for nutrition. You may be able to employ the food service program and should, as an aid to the control of nutrition, but it is essentially, at least for the present, a command function. The surgeon has a definite respon- sibility and he can work with and through the food service program .. and the nutrition officer to the extent which he feels advisable and necessary. The same thing applies essentially to the AAR food service program They have set up their own, as you probably know. At the present time they have an organization in Washington to which we have contributed two or three nutrition officers to provide technical help and informa- tion and assist in organizing the program. They also maintain very . close liaison with our office, with our laboratory and the Subslstance Laboratory in Chicago, with the Quartermaster, with the Air Rorce Quartermaster and with other agencies that concern nutrition. They are planning to put Rood Service Directors, using that term in a general sense, throughout the commands, similar to the Rood Ser- vice Directors which are used in the Army Service Rorces. To date they have not completed the program and there has been no full-scale employment of it, as far as I know, as in the Army Service Rorces-at present, but again, the relation of the Army Service Force surgeons and Class III installations is essentially up to the surgeon. He has a responsibility for nutrition. He can cooperate and work with them on that program to the extent that he deems wise. There is a third question which is not primarily one of nutrition. It is the -question of permitting German prisoners to eat uncooked meats such as ham and bacon. You can see that that is not a nutrition problem but one of disease prevention. I inquired from Col. Long about our relation to that and he says, with which I am in accord, that it is a fundamental matter of the protection of health. We are held to protect the health of the prisoners jiist as we protect the health of our own troops and if wo think our own troops should not eat raw moat because of the possibility of trichinosis, we should take the same protection for prisoners of war. As a matter of interest, as you probably know, there has been reported, an infestation of tri- china from this source. COLORED TURNER: I would like to have some questions from the floor, some discussion. ■ ■ COLONEL ALLEN: Although the last question which you discussed, Colonel, did not come from the Seventh Service Command, we have had that very thing to contend with. In inspecting the Prisoner of War Camps we find that unless they are scrutinized very closely,, that most of their cured hams., meats and ha,con are eaten with- out cooking. I recall .one' ramp' where I inspected four messes one after1 nopn, during the. hour ■ when. they were putting the fopd out - on the ta- hies, and,in three of those four they were serving the ham and hacon uncooked. It seems as though it is a custom of theirs and they pre- fer it that way, and they save it up throughout the week for a delicacy on Sunday. COLONEL YOUMANS: I "would Just like to use that as an example of what may occur in relation to nutrition, although it is not primarily a nutritional problem. Nevertheless, varia- tions in food habits, variations in the preparation of food, variations in the serving of food, may have a significant effect upon nutrition, as I indicated, and for that reason, that sort of thing -- not exactly that ca.se, but that type of thing,-variations, substitutions, local variations in cooking, things of that sort-are significant as far as it affects nutrition and health. I might make this point in regard to it. None of these things are drastic, especially in the Zone of the Interior. There is no dra- matic change in nutrition by any ordinary occurrence. • They are accumu- lative. It lasts over months hut they are cumulative and in the end will have an effect. In the Zone of Operations, of course, you get much more acute pro- blems, the more dramatic aspects of nutrition appear, hut if you look at it from the viewpoint of preventive medicine, the correction or pre- vention of these minor errors over long periods of time are important in the prevention of deficiencies in nutrition. LT. COLOKEL TILLMAN: . (Fort Knox) As you probably know, ' in the Fifth Service Command, the food service program was very energetic and at one time they got through a program that since 80 per cent of the patients: in hospitals were fed the regular, diet they should go on the master menu. We carried that .through to The Surgeon General and it came back that the Medical Department•is responsible for feeding patients in hospitals; we got that far and it has straightened out and the Quar- termaster backed down a little'bit. Now we are in another phase of wastage i . ..... . 1 , • ’ ' • " . . .. . • We have a great program on wastage and they are getting down to a point where we have a new .Commanding Officer who came in for - Breck- inridge ..and at Breckinridge, on the monthly progress report the. wastage of a whole Division for one day could b>e put in one garbage can. We feel that that wastage is getting down so low now that it would in- fluence the nutrition.of the-troops. ■■ They are starting the same program at Fort Knox. They have trans- ferred the food supervisor who was in Camp Breckinridge.up to Fort Knox to show" us how to do it, just bring this figure down and make it look good, on paper and we are up against a tough situation there. How can we convince these people that you can go down too low on your wastage figure where the nutrition is really going to be inferior? COLOKEL YOUMANS: I would like to comment on this and add a little more to it. That is not the only place it is happening. From the Seventh Service Command we had the same report. We have the strong feeling, in fact we have some evidence to sup- port us, that the over-zealous attempts to reduce waste have resulted in actually Linder-consumption of food among patients, which interferes with their.health and recovery from illness and disease. That he-, comes all the more important when you think of new developments, new knowledge.of the influence of nutrition on recovery from disease; when you realize that you can put some four and five thousand calories in a patient following disease,, 200 grams of protein, 30 to 35 grams of nibrogen and get "beneficial results and when you realize that, unless you make a positive effort to do that you can’t accomplish it. "When you over-zealously try to reduce food waste without discrimination, thus results an actual under-consumption, one "below the ordinary level and you can see the "bad influence of this type of program. In the Third Service Command we have seen some efforts of civi- lian dieticians to influence unduly the type of nutritional care of the soldiers, particularly in the case of hospital patients, "but not altogether confined to that. They should not take over responsibili- ties for nutrition. That is exactly the point I was trying to make about our respon- sibility. We are still responsible for those things. As a matter of fact, one of the reasons why I said that the nutrition officer should' not divide too much time or too much responsibility with the Quarter- ... master is that you should not have a person both as prosecuting attor- ney and Jury. You must impose some control there. CAPTAIN DYER: Before we get too far away on this point from the feed- ing of German prisoners, I would like to say a few words. 1 A recent survey conducted by a nutritional consultant of one of the service commands at a prisoner of war installation revealed this; First let me make this explanation, that the prisoner of war menu, as you well know, may,have certain substitutions, based upon the de- sires of those prisoners of war. When this nutritional consultant got through making his survey of the PoW mess, he found the prisoners of war were actually getting more food than American troops at that same post. I wonder how much investigation you people, you medical inspec- tors, have actually made in the feeding of prisoner of war troops? A recent directive from the War Department indicated and deals Just exactly with this thing that I have talked about. If you have not seen it, you will see it in a very few days. The Medical Department, I think, needs to take some thought and study on this matter. Getting "back to this point, this, question of supplying milk in a' certain plant in the Fifth Service Command, there is one more thing that I would like to add to Col. Youman1 a discussion about it. Based on all the endorsements, it went to every place except the Service Command Surgeon in the Fifth Service Command. He never saw the commu- nication. We feel this: Commanding General of a service command should know that the Medical Department does have responsibility in the feeding of troops, and he should bo made very much aware of this. We personally feel that somewhere along the line the communication from this plant should have gone to the surgeon for some consideration in the Fifth Ser- vice Command but h£ had never seen it. -~ Getting back to this wastage -- and I am glad ,he said "on paper"- for the whole emphasis.and the whole advertising program has been'to show how many dollars worth of food or how many tons of food have been RESTRICTED saved. Well, if you feed 1,000 troops and still end up with only ten pounds of waste per 1,000 troops and that is what some service command figures show they have done an excellent Job, almost super- excellent jot of conserving foods. Perhaps to find out what is con- sumed, it is going to he necessary to rim a few surveys, I think every- body is cognizant of that. Getting hack to the hospital wards, recently this directive came out' and we saw it. It deals with food conservation of hospital wards and has that as its entire objective, to reduce waste in hospi val wards, nothing else. There is nothing devised in the directive ox. one of the service commands to improve food service on the ward. It is primarily on cutting down waste. I think there that the Medical Department has a definite responsi bility to see whether or not the recovery of those patients is affected by such rations, and if they are and it does affect their recovery and nothing is done about it, then perhaps some responsibility is being shirked. COLONEL TUET1ER; Colonel Lee, would you care to discuss a little bit as to how the Air Surgeon's office comes into the nutrition field? COLONEL LEE; Sir, it is a matter I know very little about, I am sorry. We have not any very active nutrition department in '' the Air Surgeon's office. COLONEL NORTON: I have nothing to say. COLONEL TURNER: Colonel Youmans Is extremely ’busy. He has a lot of problems- coming up to the Surgeon General's Office, deal- ling with the Quartermaster, and I think we would all he interested to what 'extent that same relationship exists in the Service command, in the service command headquarters. COLONEL YOUMANS : I would put the shoe on the other foot and that is that in the past we have not heen careful about our messing practices in hospitals. The food waste does tend to he high in hospitals. I am quoting largely from my experience in civilian life and that is perhaps the basis for some of this attempt to improve on our functions and responsibilities because we have fallen down to some ex- tent. At the present time there is in preparation in the Surgeon's office in a new hospital administrative manual, a section on messes, which when published should be a very useful guide to giving proper messing practices and at the same time not leading to a possible over- emphasis upon food waste and consequent reduction in food consumption. C1 ) Colonel Marsh, won't you comment a little on the use of the nutri- tion officer, and work in your command? COLONEL MARSH: We have had a very happy experience with our nutrition officer. I think he is a star on the subject. One of the things that we have been particularly interested in lately is the nutrition on hospital trains. We have had oar nutrition officers riding hospital trains for some time. For the past few months, every once in a while; they take a trip on a hospital train and they have made some very vast improvements in the nutrition of the feeding and messing of patients on hospital trains. On this food wastage business, I agree with the gentleman from Fort Knox. We have one hospital which shows a remarkable record and on close examination we found that they were only counting the food that was taken from the plates; they were not counting any food wastage in the kitchen. Offcourse, they had the "best record in the Service Command. COLONEL TURNER; Colonel Franklin, do you care to talk about nutrition from the standpoint of an Army? COLONEL 3TRANKLIN : Well, sir, there is a lot of wasted food for reasons •that have not teen found here, overseas. They issue, say, ham. or sausage five days in succesion. The men would get sick of it, they couldn't eat it. Then that was wastage. I would like to say this: In the Army Ground Force, General Lear has been very insistent about conservation of food and not wasting it and every line officer or medical officer that inspected Army troops has been watching to see how much wastage there is. COLONEL TURNER: Colonel Long COLONEL LONG: I would like to interject one thought about food wast- age as far as it may he concerned with prevention of infections. I think there is a real danger that medical Inspectors must, he on their toes to catch with respect to certain over- zealous efforts to prevent food wastage. Colonel Youmans, of course, is interested, as we all are, in the maintenance of adequate nutrition. Consequently, he does not want this over-zealous thought on food wastage, to be overdone. I have known of instances where the C.O. has been so careful not to throw away any good food that he has insisted upon the serving of food three or four times. In other words, the use of left-over foods. That certainly is an extremely important thing from the point of view of the medical inspector. I won’t say "it doesn't matter” tut I know of a chart depicting food poisoning out-breaks, that is, bacterial food poisoning out-breaka that I dubbed by a certain name as being "so and so’s peaks,” and those peaks I thought were largely due to the fact that this over-zealous officer insisted on the re-use or re- serving of food. Many times you can not properly re-cook food, as you know, so that is one more factor with respect to the food wastage program that we must keep in mind at all times. COLONEL ■BANTON; One question that bothers me a little hit: these reports go through a number of hands and in situations like this, the Fourth Service Command states; "we have just gone over the food as issued for January. It is very adequate, except short on riboflavin." Then they say, "Wo have taken up the master menu for April. It is very good except it is short on reboflavin." And month after month that report of the shortage of riboflavin goes in. I wonder if it is actual or if we could not readjust and get this apparent failure of ours brought out? COLONEL YOUMANS: I am glad you spoke admit that because yesterday I signed an endorsement about the adequacy of a ration or a menu, with regard to riboflavin. Those requirements are set up on standards which have been established by the Food and Nutrition Board. You can see the reason for it, because the feeding of the sol- dier, like the feeding of anybody, is going to be under attack from the point of waste and also the point of adequacy. More people outside the Army are concerned with the nutrition of the soldier than you can shake a stick at, so that the Quartermaster and The Surgeon General's Office in order to do the best thing possible, have tried to hold up the nutrients of the diet to the level estab lished by the Food and Nutrition Board. The Food and Nutrition Board like most other people can make mis- takes. They are not all-knowing, and they have set the riboflavin re- quirement too high. It will be reduced in the course of the next few weeks at the next meeting of the Board, probably. We have known that, so when the analysis has come through, we have not been disturbed by the fact that it is less than the required amount. However, we think that in those cases a statement should be made with regard to that analysis saying that this discrepancy is not significant because of new standards of requirements. That is what I did yesterday, made such a statement on a requested analysis. I think from the viewpoint of the Surgeon when he runs across such statements from his nutritional officer or from other people, from the food service supervisor, or the Food Service Director, if he wishes reinforcement, with regard to his opinion about it, if he will let us know, we will be very glad to give you opinions supporting that point of view. COLONEL TURNER: The Board will get you out of the red, I gather. Any further comments? Col. Lacock, what about the Fifth Service Command? COLONEL IACOCK: ¥e are having a Quartermaster meeting this week or next week, I forgot which, in which the nutrition officers are invited from the large posts, and one of those offi- cers will then come in to the service command headquarters. ¥e have none at the present time. COLONEL TURNER: Colonel Carroll. COLONEL • CARROLL: I think that Colonel Allen mentioned the fact that German prisoners tended to eat uncooked meats. We found that in the First Service Command, also, I think that one of the reasons for that is this: It is pretty well known that in Germany that the hogs are pretty well free of trichina; • about 95 per cent of them are free of them, whereas in this country the ' rate of trichina infection among hogs is very high, so it is extremely Important that the pork products be- cooked before ingestion. The next thing is about the nutrition officer. The First Service Command at the present'time does not have a nutrition officer. We had one and he was our loss and The Surgeon General's Office gain. Capt. Dyer formerly in the First Service Command. He did a splendid job while he was there and I learned a great deal about the nutrition program from Captain Dyer. As far as the food wastage is concerned, one of the places where there is a good hit of wastage at any post is the officers* ness;. In most instances in an officers’ mess they tend to place a lot of food right on the table so that individuals can take what they want, whereas ii you have them changed to cafeteria style where individual servings are placed on plates, and if they want more they can go hack for se- conds, that is one way of cutting down on.the food wastage. It is a very good way. I think that another thing that Capt. Dyer used to stress and that is that you go around into mess kitchens and many times we would go together - he would find that Immediately after the noon meal they would start cooking vegetables to he used at the evening meal. In other words, they cook all the life out of them and there would he a great loss in vitamin content in that way. I found in going with Capt, Dyer -• I will just mention those few things -- I learned many practical things about nutrition. I think a lot of directives are perfectly all right, hut most of us do not have time to read all of them hut do have the opportunity to go around with a good nutrition officer, you can learn a great deal about it. It is my feeling that in each service command there should he at least one nutri- tion officer, at least at Service Command Headquarters. ¥e have none now, where we had to cut down the total number of officers in our office. They are looking around for a place to lop off an officer and they sometimes tend to drop a nutrition officer. I wonder if there is any way, even if we can’t within the ordinary T.O. in the Service Command surgeon's office, is there any way that we can get the service of a nutrition officer? VOICE:. Assign him to a camp. COLONEL CARROLL: t Even if you assign Mm to a camp, still in some of the .service commands they have a T.O. for the entire service command. That is no 'out. At least in our service com- mand it is not. There is no way of getting around it. GOMEL YOUMAHS: I don't think there is any complete answer to that ques tion. It is a difficult one, there is no doubt about that. There are certain things which are used. They do assign them to camps. In India they assign them to hospitals and then put them out on detached service from time to time at different places in order to cover the territory. In the Ninth Service Command a system of areas is being worked out which I think is a very useful thing under many circumstances and in the Southwest Pacific, General Denit has recently insisted on and gotten an over- all theater allotment which he considers best so he can send the nutrition officer where he wants, for instance with task forces, where he thinks they serve a very useful function. I think you have to use different systems depending on the circumstances. I would like in closing, perhaps to comment on that phase of it. The matter of nutrition is quite a complicated special affair. Unless one has made a special effort, he is not alert or has not full knowledge about all the different phases of nutrition. Nevertheless the medical service has a definite responsibility for'these things which, to some extent, we have tended to neglect because of the press of other matters. Now, the nutrition officer has the knowledge, the ability and the train- ing, the technical specialization, to take care of these matters. ¥e think that they can be very useful and should be used whenever possible. GOMEL TURNER: The next item on the program is entitled "Health Program in Occupied Countries." HEALTH PROGRAM IN OCCUPIED COUNTRIES COLONEL T. B. TURNER, MC, DIRECTOR, CIVIL PUBLIC HEALTH DIVISION. COLONEL TURNER: I just wish to make a few informal remarks because this program is in operation only overseas and does not direct- ly concern the group here. You may he interested in hearing a brief outline of problems in organization. The military government program has gone by a number of names. The first was "AMGOT" which somehow got an unpopular connotation. There were many jokes made about it, the most common perhaps being that "AMGOT ain’t got," because they didn’t seem to have any supplies to do anything with. Gradually the whole program directed to the civilian population of occupied or enemy countries has come to be known as The Civil Affairs program. If you are dealing with an enemy country such as Germany or Japan it is called Military Government but in the occu- pied and liberated countries the relationship is not that of command. ¥e function in an advisory capacity and that is generally spoken of as Civil Affairs. The function is not new but the organization is new to this extent: Early in the course of the war a Division was set up on the War Department Special Staff level, under General Hilldring, known as the Civil Affairs Division. That has its counterpart in most of the major headquarters, where it is ordinarily known as the G-5 Division. There is one at General Eisenhower's headquarters; the North Afri- can theater or the Mediterranean Theater now. Admiral Nimitz' head- quarters, and General MacArthur's headquarters. On the staff of this headquarters is a Chief Public Health Officer who is responsible for the public health aspects of the overall Civil Affairs program. As you know, in the European Theater this is headed by General Draper, on leave as Deputy Surgeon Genera,! of the U. S. Public Health Service; in the Mediterranean Theater it is headed up by Brigadier , General Parkinson of the British Army; in General MacArthur's head- quarters by Col. Smith, also a former U.S. Public Health Service officer; and the chief medical officer in Admiral Nimitz' theater has not yet been designated. The main purpose of this program, of course, is: 1. To aid the fighting forces by prevention of epidemics in the civilian population. You can easily see how such epidemic might disrupt military operation. We have had small pox outbreaks in various cities and of course the constant threat of explosive epi- demics of plague, cholera and so forth might very easily disrupt an important theater. 2. When an occupying army assumes responsibility for the government of a chaotic country, one of the functions of that government is public health. 3. There is the common, humanitarian aspect of the problem. In Europe our problems have not been particularly numerous. Many things -we wanted to do could not be done because of lack of transport. Out in the Pacific a very different type of operation is developing, particularly in these smaller Islands. The fire power directed toward those islands has been devastating; the civilian casual- ties have been extremely high, and on one operation, particulary, that of Saipan, the invading forces were quite unprepared to deal with the tremendous civilian casualties and the load that was placed thereby on the occupying forces. From that time on therefore there has been a tendency to build up the Civil Affairs group, so that the Army could be relieved of that responsibility. The main functions of the Civil Public Health Section might be divided into: 1. Communicable disease control; 2. Problems of medical care - providing medical care and hospitalization for wounded and injured civilians; 3. Nutritional problems; h. The problems of medical supply, which is extremely important and was largely neglected in the early stages; 5. Sanitary engineering problems - purification of water supply, sewage disposal, etc. We have no procurement objective for civil public health officers, at the present time, although it is expected that more will be needed for operations in the Pacific. I will be glad to answer any questions. Are there any questions about this, before we go on to the next item? COLONEL ALLEN: What is the need for personnel for this servic^? COLONEL TURNER: At the moment we have about two hundred Medical Depart- ment officers in the various theaters. You understand that we can only hope to provide an administrative fo- cus for the public health services in the civilian population. We can’t hope to supply enough personnel,* actually to run hospitals or treat patients. We expect that more officers will be needed in the future. COLONEL ALLEN: ' The reason I ask that question directly, Colonel, is that a few of our officers, who are occupying key posi- tions, have made applicatidn for this service and we hate very much to give them up, unless the need is sufficient. COLONEL TURNER: It ‘is anticipated that more will he needed in the Far East. It depends on the tactical plans. We do need peo- ple with administrative ability, preferably with public health experience, but not necessarily so. It is xorimarily an adminis- trative job and, in addition, of course, we do need or we will need sanitary engineers and supply officers. Are there any other questions about this? I might say that the need has grown as time has gone on. Tacti- cal commanders, Army commanders, did not want these men in the "begin . fling and now they are asking for more than, can he supplied. ' A VOICE: Do these men operate in the theater directly under your office. .. ..COLONEL TURNER: No, they don't work directly under us at all. It is a straight military organization. They work directly under the Chief Civil Affairs Officer, who is on the staff of the Commanding General of the Army, Corps, or Division. That has teen one of the difficult organizational problems hut is the only organiza- tion possible. It won't function unless there is the closest possible liaison between the two medical officers i.e., the Surgeon and the Civil Public Health Officer. Actually; the surgeon is not only sur- geon of the Army or Corps; as the case may he; hut as the chief advisor of the Commanding General; he is technically over the public health officer althoughtthe latter operates directly under his chief civil affairs officer. \ Are there any questions? If not; I would like to ask Major Horack to discuss Medical Intelligence. MEDICAL INTELLIGENCE •• - ITS PURPOSE AND FUNCTION MAJOR HAROLD M. HORACE; MC, ACTING DIRECTOR; MEDICAL INTELLIGENCE DIVISION. MAJOR HORACE:' Colonel Turner, gentlemen, the general subject of medi- cal intelligence is of only limited concern to this group. On the other hand, it is very directly to be associated with the overall problems of preventive medicine. In that I am going to attemp to outline for you a good bit of our background and the scope of our forces and activities. The,collection of information regarding medical health and sani- tary conditions in foreign areas was begun in July; and comes under G-2. The program was Initiated and supervised by Brigadier General James S. Simmons who was then the Chief of the Subdivision of Preventive Medicine of the Professional Services Division. The ini- tial studies were prepared by members of General Simmons’ staff; the first of which was entitled; "A Plan for the Military Administration of public. Health in Occupied Territories.” Subsequently; General FoX; Colonel W. A, Hardenbergh; Colonel A. W. Sweet and Colonel V. H. Cornell participated in the preparation of medical and sanitary surveys of the Caribbean.areasand of North; Central and South America. In April; 15Al; the Preventive Medicine Division was created and in June of that year; a Subdivision of Medical Intelligence; was- orga- nized. This Subdivision was organized in response to a growing demand for readily available information concerning health and sanitary condi- tions in foreign areas. The declararation of war in December; llAl; gave great Impetus to this activity and in a committee appointed to investigate the Medical Department took special notice of.medical intelligence with the comment that it should be developed with full appreciation of its, importance and recommended an increase in person- nel and activities. These recommendations. were• adopted and there fal- lowed a period of expansion and development of the Yield of techni- cal medical intelligence. This expansion embraced not only the inter- ests of the Preventive Medicine Service but also the interests of the entire Medical Department.. . • V Interest in this newly developed field of intelligenee was evi- denced by the fact that some information concerning a few' of the acti- vities of the Medical Intelligence Division soon extended beyond the bound of the War Department; even to the gentlemen of the press. Early in the fall of T k-2, a feature writer for one of the popular magazines wa.S bucked up to our office by the Public Relations Division. The writer was a fascinating fellow who had all the self-assurance of Oscar Levant and a journalistic style that was something of a cross be- tween that of Bill Lawrence of the New York Times and a reporter for the Police Gazette. He was not what could be called a bashful fellow for; after a summary introduction; he informed us that he had discovered that the Medical Corps had an Intelligence Division and that he would like us to supply him with a few pertinent details with regard to our organization, our sources of information, and how this information was utilized. In addition to this, he wanted a few gory stories and one or two specific examples of how the Army’s Medical Intelligence Division had decisively altered the course of the war. This was all he needed to complete his story, the text of which was in draft form and the title selected. in his effort to persuade us to give him the facts, he pointed out that the story would have a real hews value not only because it was an entirely new angle on a popular subject, but because it was a new field of intelligence -- the like of which did not exist- in any-; other army.' • ■ - . As the conversation progressed he demonstrated that he was in reality a man well informed in the various aspects of military history, even the medical side, and that he had at his command a rather ama- zing assortment of facts, figures, rates and ratios. He knew, for example, that up until the present war more soldiers had died from disea.se than were killed by the enemy or died of wounds. But this was not the type of information he was after. What he wanted was a vivid, spectacular story which conformed with the popu- lar concept of what medical intelligence was or should,be, and one that was full of Intrigue and accounts of the activities of medical spies. Like all good reporters, he got his story but it was not quite the one he had expected.; and after the Public Relations Division had finished with it there were parts of it that none of us recognized. Nevertheless, it was a good story, a story that set forth quite clearly the aim and functions of our particular types of intelligence. I would like to read to you just a little bit from that, because it sets forth what I want to present to you, I believe, rather clearly. It is entitled ’’The Army's Health Spies," a good title; "Wherever our soldiers.go, throughout the world, they are protected against disease, fever and parasites by the careful advance research work of the Army's Medi- cal Intelligence Division. It is a splendid job." yourself and drop a pencil point on a map of the world. Maybe it will land on a country in the tsetse-fly belt of Africa or on one of the unwashed states of India. Wo matter where it lands, the chances are that the United States Army has more medical information about that place than local physicians practicing there. "Its Medical Intelligence Division - a part of the Preventive Medicine Service of The Surgeon General's Office ■ collects information about every country on earth. It spies out health facts the way other intelligence organizations gather information about enemy combat planes and deck armor. No matter where troops move, it must be ready with a complete file of facts. "The reanon for this activity is apparent. We face a situation radically different from the one faced in IS-l?. At that time our Army was fighting in countries with problems parallel 175 to our own. In France, doctors found the same measles they had known at hone in Iowa, the same pneumonia they had seen in Penn- sylvania. This time we are headed for some of the backwoods regions of the earth and we are encountering some very special miseries. ‘’Medical Intelligence has a spectacular mass of facts. It knows about poison snakes along the Gold Coast and about lice, ticks, and disease-spreading insects of other countries. It has surveys of buildings all over the world which might serve as emer- gency hospitals and it has word about the type of electricity generated by utility plants; if the Army decides to go to a cer- tain country it doesn’t want to take 60-cycle X-rays when only 25-cycle current is available. Medical Intelligence has full information about breeding habits of mosquitoes that infest any country; it has charts that show disease rates. Reports have to te complete.” It is fair to admit that for the sake of Journalistic style L.he author stretched a. few points, but in general his account was a good sketch of what Medical Intelligence is and does. It d’id not, of course, include a number of activities which are strictly of an intelligence character nor did it adequately emphasize the relation- shin of this activity to the over-all program of the.Preventive Medi- cine Service. For the latter reason I would like to simply outline to you some- thing of ovr organization and actually what we are now doing, parti- cularly iin so far as there is an Interest in this. Organization; Like most intelligence groups we are organized along conventional lines and our Division consists of a Collection Branch, an Analysis Branch, and a Dissemination Branch. Collection; Although there is a special unit assigned to the collection of information, this responsibility is shared by all person nel assigned to the Division. During the past four years, sources of information have been developed extensively with a view to obtaining pertinent facts concerning the organization, administration, operation and experiences of the medical services in co-belligerent and enemy forces, the collection of captured enemy equipment and documents; and research and development in the fields of military medicine, public health and the medical sciences in all foreign countries. It also includes the collection of epidemiological data as well as information on medical and research institutions, hospitalization facilities, medical practitioners, public health administration and regulations, water supplies, sewage disposal, nutrition and the fauna and flora of medical importance. The sources of this information are manifold and it will suffice to say that it has been derived from a systematic exploitation of all official intelligence channels, a thoroughgoing review of the litera- ture, contacts established with commercial concerns and innumerable interviews with personnel, both military and civilian, who are in pos- session of information of importance to medical intelligence. These sources are supplemented by information obtained from medical intelli- gence officers assigned to the various theaters. All of this informa- tion is catalogued and is cross- indexed according to subject and geo- graph!*c location. Analysis: The data collected is used "by the Analysis Branch in the preparation of special medical surveys for incorporation in the Joint Army Navy Intelligence Studies. I might mention that these are classified confidential, which contain a perfectly amazing amount of information, I think they are the "best over-all studies of any area that are available today. The material is also used in the preparation of the War Depart- ment technical bulletins, medical, and our particular series are all entitled, "Medical and Sanitary Data on "(blank)”whatever it might be. These reports are organized under the following headings: Public health organization; Water supplies and sewage disposal; Food supplies; Insects and flora of medical importance; Medical institutions and personnel; and Information concerning the prevalence of disease. More than 200 surveys have been prepared and all of them are being kept up to date. In addition to these surveys special reports are pre- pared for use in connection with the planning for future military opera- tions and for numerous other special purposes. Pissemination; The Dissemination Branch is charged with the respon- sibility for the dissemination of medical intelligence to appropriate commands, agencies and individuals, both in the Zone of the Interior and in the Theaters of Operations. It is of interest to note that during l£l(4 approximately 370,000 copies of the medical and sanitary surveys were published and distributed throughout the Service Commands, to the POE’s, AGE, ASF Training Center, the AAF and numerous special units, both in this country and abroad. In addition, this branch pre- pares and distributes to especially designated headquarters, a limited number of copies of carefully selected and timely abstracted reports of medical importance. It is also charged with the responsibility for the exploitation of all captured enemy equipment and the dissemination of information concerning the same. To this end special enemy equipment intelligence teams were organized and dispatched to the various theaters for the specific purpose of obtaining information and equipment which would be of value to the Medical Department from the standpoint of intelligence, research and development and training. This sketchy and admittedly incomplete outline of the development, organization and function of Medical Intelligence does little more than to Indicate that within the Preventive Medicine Service there is a unit which is actively engaged in the compilation of data which is of interest and importance to those who are concerned with public health, preventive Medicine and related problems as they occur in foreign areas. The material which is available for Informational as well as training piirposes include those' which I have Just mentioned. I have some copies here if you are interested in reviewing them. 1. TB MEDs - Medical and Sanitary Surveys, which, as previously mentioned, contain information concerning public health organization and administration, water supplies, sewage disposal, nutrition, food supplies, veterinary problems, fauna, flora, medical care and practic© and disease information. 2. Current foreign epidemiological data. 3. Information on tile organization, administration, operation and. experiences of the medical forces of co-"belligerent and enemy forces. k-.r Information concerning captured enemy equipment and supplies, including those items which are used in the prevention and control of disease,'and - 5. Several thousand intelligence documents and reports covering a wide variety of topics pertaining to preventive medicine and public health in foreign areas. All of this information or parts of it can "be made available. In the case of intelligence documents, it is very difficult and hard for us to disseminate those, but in the case of technical bulle- tins which represent summaries of available information, they can be obtained. As we obtain more equipment, that, too, can be made avail- able to certain selective training centers for instructional purposes. I thought it might, perhaps, be of interest for me to show you just one or two things that we have picked up and which we consider to be of a very real interest. As you know, in some of our* kits and chests we have a standard microscope' that weighs about 35 pounds. It is cumbersome, it is bulky. It is not well suited for the purpose, simply because of its bulk and size. The teems which we have operating in the Pacific area were fortunate enough to pick up this particular microscope which is of very real Interest to us at the present time and I believe is being pursued by the Laboratory Division who are promoting studies of it for incorporation, if possible, in one of the field chests or at least a modification of it. It is a Japanese ’scope and comes in one of these cases. It is much like a toy but it folds up very neatly and exactly. It has two objectives, and standard lenses. This particu.lar scope has been a matter of very considerable in- terest to .men in the field and is also one of the hardest items to get back here for study. It seems that it is quite a collector'1 s item among Medical Officer. I should mention that the Germans also, have some very fine items of equipment that we are interested in. These two things I brought up because they are of very current use at this time and acre actually being considered from the standpoint of research and development . This rather unattractive bottle contains a large number of pills, an anti- malarial of a now type. It is related to plasmochin. Prelimi- nary studies indicate that it may be of some value. The National Re search Council is at the present time is pursuing this possibility. I shov these two things simply to point out the fact that something ac- tually is being done with this captured enemy equipment. Thank you. COLONEL TURNER: Are there any questions of Major Horack? It is extra- ordinary material that this Division turns out, of course Any of you who have "been abroad have certainly studied carefully the TB MEDS on the areas to which you are going. Are there any questions? COLONEL TURNER: We are going to proceed to the last topic we are dis- cussing this morning and that is the question of foreign quarantine. It, of course, has "been of increasing im- portance to the country as a whole and to the Amy, because the Army, with its vast transportation system in and out of this country, must assume a measure of responsibility in preventing entrance of any foreign or exotic diseases into this country. Lt. Col. Khies is in charge of the Quarantine Branch of the Epi- demiology Division and served as a member of. the Departmental Quaran- tine Commission, on which there was also a Navy and a Public Health Service representative. Captain Shaffer, whom you all know hy this time, as the promoter of this conference, is his principal assistant and will speak on this subject today. FOREIGN QUARANTINE IN MILITARY TRAFFIC -■ RECENT DIRECTIVES - CAPT. THOMAS E. SHAFFER, ACTING ARMY QUARANTINE LIAISON OFFICER. CAPTAIN SHAPFER; Col. Turner and fellow officers and friends: This is a relatively new venture, this subject of foreign qua- rantine as related to the Army and I would like to say that before the plan that is being put into effect by The Surgeon General was formulated, we realized that some changes probably will be necessary, as in all new programs. We have presented a plan and it is hoped it will work. We realize that if changes are necessary, they must be made. The entrance of the Army into foreign quarantine is relatively new. The Foreign Qiiarantine Branch in the Epidemiology Division of the Preventive Medicine Service was established in the fall of 1944. I will give you a little of the background as to how the Army became involved in enforcement of foreign quarantine. Many of you may know that by law the matter of foreign quarantine has been delegated to the U. S. Public Health Service, which has respon- sibility for the enforcement of foreign quarantine as it relates to the diseases of man or diseases of animals that are communicable to man. The Department of Agriculture is responsible for foreign quaran- tine as it relates to domestic animals and certain wild animals. There is a third service, the Fish and Wildlife Service, located in the Department of the Interior, which is interested in preventing the introduction of diseases of wild animals, except those of ruminants and swine, which are a responsibility of the Department of Agriculture. A peculiar thing has happened in foreign quarantine, in that com- mercial traffic in the last few years has been reduced almost to the zero point, but traffic as a whole has been up, because military traf- fic has increased, so the problem of quarantine is a very real one, although it is different than before. I might say a word or two as to what quarantine embraces. By foreign quarantine is meant those measures designed to keep out of one country the diseases that might be imported from another country. Not only diseases of man but those of plants and animals are implied and it has been further extended to include pests and vectors. When I speak of foreign quarantine, I am not speaking of communi- cable diseases in the sense of those referred to in AR-40-210, which is concerned with all communicable diseases. Foreign quarantine in- cludes only the diseases that have been internationally agreed upon as serious threats if transported across international boundaries. There are five diseases of man upon -which everyone agrees as of extreme importance in this regard; cholera, plague, yellow fever, epidemic typhus and smallpox. Countries have agreed that "because of the historical role of these diseases in producing epidemics, those diseases should he internationally quarantinahle, to prevent their dis- semination. It is only logical that some countries would go further and set up their own rules on other diseases hy saying, "We are not going to let you in if you have a particular disease." An example of that is in this country, where we have added to this list of five diseases, lepro- sy, a sixth, and we have added psitticosis and anthrax so we have really eight quarantinahle diseases. We are not worried about rabies in this country but England is, so they add on rabies and so does Hawaii; but the five basic ones previously mentioned are internationally agreed upon. We have to add on to that, then, diseases of plants and animals. These are too numerous to even mention because there is a long list of them. Then pests both plants and animal. Measures designed to pre- vent their importation may be the most important role that the Army has to play in the whole quarantine picture; that is, preventing entrance of insect plant pests that might be brought back from other countries. As to whether we exaggerate or whether the question has "been exaggerated is a matter for question. With all the measures that are put forth to prevent the entrance of the seven or eight quarantinahle diseases into this country and the numerous stations that the Public Health Service has maintained and the very large hospital facilities for maintaing people with quarantinahle diseases, in the past twenty years, there have "been intercepted only 128 cases of quarantinahle disease at the border. In the past ten years they have only inter- cepted 13. Of those 13, nine were smallpox, of which we already have plenty and there would he no real crime in bringing it across the border. . * ' ... One case of bubonic plague was intercepted and one case of leprosy, which we already have, and two cases of epidemic typhus. In the last four years there has been one case of quarantinahle disease intercepted, a case of leprosy. As I say, it is a matter for question as to how much the. danger may be exaggerated. Medically, I think everyone agrees it is not a great problem but the public views it as of the greatest importance and the Public Health Service has to maintain a defense if Only because of that. - - The civil authorities, the Department of Agriculture, the Depart- ment of the Interior and the U.S. Public Health Service have had the responsibility until the war came along. With the increased military traffic they gradually have had to make assignments of certain small duties to the Army. In the Public Health Service decided th-at something should be done in a formal fashion instead of these temporary measures, so that the Public Health Service wrote to the Secretary of War and Secretary of the Navy requesting that a Commission be set up, with representatives of the Army, Navy and Public Health Service, to study the whole problem of foreign quarantine, particularly as referred to military traffic and to aerial traffic. Aeria.1 traffic would have had to be studied anyway because most of our regulations are based on a marine traffic. The problem of aerial traffic has been growing gradually and the quarantine measures ■ that have "been applied to It have heen largely on the marine basis, without taking into account the differences in aerial travel. The whole problem needed to be studied, and the Interdepartmental Quarantine Com- mission was appointed in The members of this Commission may be known to some of you: Captain T, B. Magath of the Navy, who used to be at the Mayo Clinic; Lt. Col. Philip T. Khies, MC of the Army Air Forces and Dr. G-. L. Dunnahoo of the Public Health Service. They travelled together,-and later separately, all over the world, to every place they could reach to study quarantine methods. They talked with Health Officers, studied methods in force and in the summer of , made their recommendations. I think one of the outstanding points in their report was the conclusion that the present methods of quarantine are antiquated. When the war is over, foreign quarantine has to be established on a modern basis. Under the accepted system, in order to stop the entry of a disease at the country's border, you must know what diseases are present in other parts of the world. If a person comes from a part of the world where a disease is epidemic, he is subject to questioning, and perhaps observation, at the border. One way in which information has been gathered was through the consular Bill of Health, which is extremely unreliable because very often those reports are filled out abroad and never reach the area for which they are Intended until six weeks later. Originally intended for dissemination of information in the days before modern methods of communication were developed, the Bill of Health has outlived its use- fulness. Since system of quarantine enforcement was set up, immunizations have become so widespread and so reliable that it is felt that they can be taken as a basis of exclusion of disease., as safely as knowing what diseases are present where a man came from. You note that among our five quarantinable diseases there is reliable immunization against smallpox, yellow fever, and epidemic typhus. As for cholera there would be some question but for practical purposes it is reliable. As far as plague is concerned, the immunization is probably a reliable one. If a person is immunized against those five diseases, it really makes no difference where he comes from, as it is unlikely that he will come in siiffering from a quarantinable disease and spread it jin this country. I think it is safe to say that in the future a traveler can go from country to country as long as he is immunized against all of these diseases without being stopped at the border for examination. That, however, is not a general policy as yet. It is most readily adaptable to the Army and Navy traffic since military personnel are well immunized against the quarantinable diseases. If everyone agrees that satisfactory evidence of immunization is as acceptable as proof that you once have had the disease, then immunization should allow free traffic. The U.S. Public Health Service has agreed to accept evidence of immunization against quarantinable diseases and the constant medical surveillance possible in the Army as equivalent to border inspection and detention or observation. A man who is immunized in accordance with War Department requirements does not have to be inspected provid- ing he is free of lice and is under the surveillance of medical officers In order for the Army to cooperate in this program of foreign quarantine, it was necessary to set up some mechanism for supervising it The Secretary of War made The Surgeon General responsible for all matters of foreign quarantine. He is responsible for foreign quaran- tine, as it applies to Army personnel; whether it be Ground Forces; Ser- vice Forces or Air Forces. The Surgeon General is assisted by The Army Quarantine Liaison Officer; Lt. Col. Philip KhieS; who has his ofiice in the Preventive Medical Service. The purpose of this office -ls to maintain liaison with all interested civil agencies and with all Army; Navy and public Health Service representatives concerned in order to keep the enforcement of foreign quarantine correlated and as uniform as possible. A tremendous number of agencies are directly concerned in foreign quarantine. The Army had very few directives on the subject of foreign quaran- tine so that one of the first steps necessarily; was to get out some regulations calling the attention of the Army to its obligations in foreign quarantine. There have been two recent directives that define the Army's part .in foreign quarantine. One of them is AR 40-225; which outlines responsibilities in foreign quarantine enforcement and the other is a War Department Circular; No. 453; 1>44; which implements and explains in detail the policies set forth in the A.H. Briefly-; I will, very quickly summarize how we believe the Army can handle foreign quarantine. When a man returns to this country or loaves this country he is required by the provisions of AR 615'-250 to have a physical- Inspection within 48 hours of his departure.for the detection of communicable diseases. It is also required that his immunization records be checked to assure that he is properly Immunized and it is further required that the physical inspection be particularly directed bo see that the individual is free of vermin. It has been felt that this processing; which is- required before embarkation; is perfectly reliable in lieu of a foreign quarantine procedure after debarkation. Any man who is returning to this country or leaving this country could embark and by virtue of that physical inspection performed within 48 hours before leaving he could fulfill the requirements for entry' into another country. If he has been properly immunized for the area which he is leaving; if he is free of vermin and if he; at that time; has no quarantinablo •- disease — those five quarantinable diseases.■ We feel that if a person; at the time of his exit from a country; meets the requirements of freedom from quarantinable disease and vermin - and is immunized against the diseases present in the area he is leaving; he should be allowed free entry into- another country providing he re- mains under jurisdiction of the Army. That is fundament all:/ the plan that has been sanctioned by the U.S. Public Health Service.- There should be no inspection and no processing necessary at the port of arrival if proper procedure was followed abroad before embarkation. All the processing shouLd be done at the point of departure. No new procedure is added; sinc-e the inspections are called for already in AR 615-250. ' v The only additional work will be the preparation of-a certificate for the group to be given to the master of-the vessel or the aircraft pilot; stating that evoryon.o on that vessel or that airplane has met Immunization requirements of the area he is-leaving and that he is free of vermin and that he has no quarantinable disease. Exceptions have ■ to be noted separately; and it is perfectly possible that there will be exceptions. A transport may' bring back a man who has not been immuniz ed properly; because at the last minute he could not got immunization. We might bring back a man who has leprosy. We might bring back any of the other quarantinable diseases under unusual circumstances. They can be brought back but they must then be processed at the port of entry. They won’t bo allowed in the free flow of traffic through the port of entry that we foresee under this plan I have just outlined. Pneumonic plague will not be transported under any conditions. There has been some objection from the Transportation. Corps and the A.T.C. in that they think that a new procedure is being added on. Except for the additional clerical work, we don't foresee that any additional procedure being added. Physical inspection has to be made anyway; a man has to bo immunized and have a certificate that he is free from vermin. It saves a lot of procedure at the time of debarka- tion. There are two types of traffic in which the Army is involved: marine traffic and air traffic. By agreement the Public Health Service is going to take the responsibility for all marine traffic including that under Army jurisdiction. The Army has no responsibility except in assisting the Public Health Service for marine traffic. The Public Health Service will handle that, except for plants and plant products which will bo the responsibility of the Department of Agriculture. . In the air-borne traffic, the Army is assuming the responsibility for personnel in air-borne traffic coming into this country at Army air- ports. Our personnel will have to do the processing and must satisfy the Public Health Service at all times that they are not allowing qua- rantinablc diseases to come into the country. The Department of Agri- culture will conduct its own inspections. It comes down to the fact that A.T.C. is bearing the brunt. Their personnel is going to have to do the processing at the beginning of travel. Their personnel is going to be involved in it on this end. As we see it, the processing in the United States is not going to in- volve medical personnel at all. It is a clerical procedure and it has been recommended that it be handed over to Priorities and Traffic and that the Medical Department stay out except for special problems.. Men arrive with a certificate from the other side; if all the men aboard meet the requirements, this Is, they are free of vermin, they have been immunized and they have no quarantinable disease, they can by easily taken care of by a civilian. He looks at the list, sees that there are ten men on the plane, and that ten men are certified; they go through and no medical inspection is necessary. In marine traffic, and I am not going to spend too much time on that, one factor that is problem of concern is rats aboard the vessel. We have to worry about rats on vessels, while on airplanes we have to worry, not about rats, but about insects. There have been set up regu- lations as to how airplanes should be disinsectized, and AAF Regulation 6l- 3 may be consulted for details. Usually any plane that is coming to this country from warm climates, where mosquitoes might breed - - there are a few excepted places where there is no vegetation on the island -• has to be disinsectized two minutes before it takes off. Many of you may have been through that and many more may sometime be in a plane and find that just before the take-off they come in and close all the compartments, close all the doors after which the pilot goes through and uses an aerosol spray. The com- partments are kept closed for two minutes and then he takes off. The purpose behind that is to prevent entrance of living stow-away insects into this country. The problem of insects coming in is a matter of some little concern to us and to Brazil, because of their Gambiae experience a a few years ago. Might I mention just one more thing. Our present directives call for a notation concerning foreign quarantine in the monthly sanitary report from all stations, such as ports of embarkation where the Army personnel are engaged in foreign quarantine procedures. There was a recent War Department Memorandum sent out on that subject. Those monthly sanitary reports will be the basis of a monthly report that Col. Khies has to render to the U,S. Public Health Service, to keep them in touch with our work. It must not be forgotten that if the Army violates foreign quaran- tine requirements in any respect, the Government is going to hold the Public Health Service responsible, not the Army. We have a working agreement with them but we have a tremendous responsibility to them. I would like to mention several regulations that have a direct bearing on quarantine. One of the bibles is AAE Regulation 6l-3, which deals with foreign quarantine as it is applied to air travel. It will interest the men from the ports to know that there is in the making in the Transportation Corps a circular that will deal with quarantine in- spection of Army vessels, personnel and cargo arriving at ports of em- barkation. That circular will describe when Army vessels should fly the ”Q" flag and when they will be given exemption. It is a subject that needs to be broadcast. Many of the transport surgeons don't know when they have a right to come directly in to port or when they have to anchor and be inspected. COLOHEL TURNER: I think there will be some questions. Are there any questions about this? Major Riedel, what about the Air Transport Command? MAJOR RIEDEL: Our policy as to quarantine has not been definitely for- mulated and unfortunately it has been handled by another officer. I think Capt. Shaffer knows about that. I am not prepared to make a statement. COLORED TURNER: What about the Transportation Corps? MAJOR. RBWMAN: There is nothing on my mind. I thought a brief explana- tion of how it is functioning in some ports would he interesting and if some ports have arrangements with Public Health officers we might be able to institute a plan. Capt. Shaffer has gone over the physical aspects, of the troops. In returning personnel it becomes very important to have these, troops inspected very thoroughly prior to coming into ports, so the surgeon can give them a certificate for their clearance., because they are not further inspected prior to furlough, providing they get out on a furlough within 72 hours. It becomes not only a problem of clearing quarantine but also a problem of the health of the community to which they may go on furlough shortly after arrival. Among the things that we run into with regard to clearance of qua- rantine there are one or two instances that I might cite to show you what happens. A transport surgeon will come in and give a certificate for free clearance. They come into port, the patients and personnel will be debarked and then the transport surgeon reports the voyage, at which tiem he will request fumigation of the ship for rats. It just does not add up because if there are enough rats aboard to require fumigation of the ship, then the quarantine service is at least slightly in question. The second thing is that transport surgeons must keep themselves thoroughly informed at all times regarding contact in foreign countries with regards to conditions of that port, so that they can render a true statement on return to the United States. Otherwise, the Public Health officials will get wind of it, either through the Captain of the ship, who makes the report, or in some other way, and question the transport surgeon's veracity. That becomes very conflicting and a lot of-explana- tion is necessary and a lot of things have to he cleared up when such a thing occurs so that the very important parts of it are that the trans- port surgeon - I am dealing now only with Army responsibility --- must make his report of the voyage tie in with the clearing certificate. He must have in that clearing certificate a true statement of facts with regards to the ports he has been in and ascertain the diseases prevalent in those areas. COLONEL TURNER; Anybody else from the Transportation Corps? CAPTAIN WARP: I would like to ask a technical question. What channels must he followed in forwarding that certificate from the Transport Surgeon to the U.S. Public Health Service quarantine officer? Must they he delivered hy mail or hy person? There was some discussion on that. CAPTAIN SHAFFER: I don’t think that the channels are indicated. It must reach the Public Health Service official within 2k hours after docking. I think that that is a matter of local arrangment hut it is important that he get it within 2k hours. They have given us quite a concession and we must cooperate to maintain this relationship. MAJOR BUZ.2ERD; This Circular 453 > Section 3; paragraph 6; ve would like an interpretation of it. It says: "When a vessel under the jurisdiction of the Army departs from any port for oversea travel; the transport commander will furnish a statement to the Master certifying that all military and civilian personnel aboard (l) satisfy current War Department immunization requirements; (2) are free from vermin and (3) are free from quarantinahle disease. Exceptions should he noted specifically so that if necessary they may he brought to the attention of the quarantine authority at the port of entry." Row this is our interpretation, and if I am wrong, I would like to be corrected. This is an additional report. Obviously the Transport Commander can not certify to this unless he gets it from the Transport Surgeon. As soon as the ship departs from the ports the Transport Ser- vice must sit down and write out this report and transmit it to the transport commander so that he can pass it on to the.master. We require all personnel on board ship to be examined 2k hours prior to debarkation, whether it is a foreign port or an American port, at which time the transport surgeon makes out a medical clearance certi- ficate which has bqen prepared by our office. It sets forth the same statement, practically, with some additions, that are contained in the Quarantine Certificate. We wonder why one copy of this clearance certificate can'o oe paased on to the Master for quarantine purposes, for the use of civil quarantine officials, whether it is England, France, Italy or the United States. The clearance certificate that we have is used purely for Army purposes. The certificate is passed on to the staging area. However, it contains all the necessary information that any quarantine official needs. is made out 2k hours prior to debarkation which eliminates the necessity for us making extra reports. COLONEL TURNER: Can you answer that, Captain Shaffer? CAPTAIN SHAFFER; Briefly, the physical inspection has to he made on the other side before these men can get on the vessel. Is that not correct? Within l|-8 hours of embarkation a phy- sical examination must be performed. MAJOR BUZZEKD: And 2h hours before they get off. CAPTAIN SHAFFER; First of all they have to have an examination "before they get on the vessel, not "because of quarantine regulations "but "by the provisions of AR 615 250, par. 5* We don’t expect to have an individual certificate for each man. We want.a group certificate saying that all the men, with the exceptions of those noted, have met the requirements, "based on that inspection. It is felt that if you wait for that examination shortly before arrival, that you are going to reach port with men who do not meet the requirements and you will have more administrative difficulty at the port of arrival. This screening will keep them off the vessel on the other side until they can meet these requirements. That is essentially the reason for it. MAJOR BUZZES!): I don't think you are ever going to have an ideal situa- tion "because when the men get off the ship they are not going to he immunized. It is necessary to give immuni- zation during the voyage. We receive , before the troops embark, a clearance certificate which states the diseases that have been prevalent in the camp, which units are affected with the diseases, those in which there are contacts to certain communicable diseases, and which states how many typhus, tetanus and other innoculations are required. Sometimes they are finished up. before they get here and sometimes they are not. It is necessary to paas the information on to a port surgeon at the port of debarkation so that the immunization can be completed. CAPTAIN SEVPFER: If there is an easier way to do this than the way pres- cribed, that is what we want to find out. No doubt Col. Knies will be up to New York and he would like to hear about it. It is possible that there is an easier way to do it. MAJOR NEWMAN: The Information as presented by the staging area to the port is Mainly information utilized hy the transport- surgeon -while with the troops aboard the vessel, to enable him to carry out any treatments on vaccinations as necessary enroute. Then he makes a certificate up for the port surgeon of the receiving port as to the number of treatments that are still due on arrival. That, to me, is to some extent a separate thing from that required by the Public Health Service with regards to quarantinable diseases and clearance on the quarantine certificate. It will have to be stated that certain immunizations were given to troops going into that country and on leaving the country. It would have to be so stated. CAPTAIN COOPER; I might ask one question that is not entirely academic. It actually occurred in the San Francisco rejoort. We received two Japanese prisoner of war patients with leprosy. Who gets them? Who takes care of them? CAPTAIN SHAFFER; The enforcement of foreign quarantine is further compli- cated hy military security. A lot of things happen in that connection and the Public Health Service Just has to say, "Well, there is a war to win.” Those lepers are going to he taken under the guidance of the Provost Marshal General and confinement is assured. They don’t come under our regulations as such. Although alien lepers are not allowed to come into this country, we can't keep a Japanese prisoner of war out once he has reached a port. COLONEL TURNER: I wonder if the representatives from Canada might like to comment on quarantine problems? MAJOR NEUEELD; We have nothing to say. COLONEL YOUMANS: What about the return value of these examinations and all this paraphernalia of the Public. Health 'Service? What diseases would we have gotten, if we had not imown they were going to have it when they came across the border? COLONEL TURNER: That is my thought. However, the value of the policeman, even if he doesn't arrest anybody, is that he is there. COLONEL YOUMANS: If we had let them come we would probably have had more than 13 cases in ten years. CAPTAIN SHAFFER: Yes. typhus, plague, and yellow fever are the ones we don't have here and they are the ones we want to keep out particularly. Leprosy and samiIpox we have already in this country. COLONEL NORTON: I would like to present Capt. Allen who has charge of the Industrial Hygiene Laboratory, located in this building. He mentioned earlier today that some of us might want to go through there. He has some things out on display and he expressed the thought that perhaps it might be better, instead of just drifting in from time to time, that if we could set aside just ten or fifteen minutes sometime, all of us could go over there, or at least those of us who are interested in seeing it. It is right here in the building and he would be glad to be of any service that he can. COLONEL TURNER: That is fine. I don’t know where those ten or fifteen minutes are coming from during this lunch hour. We get lunch and there are photographs to he taken at 1:10. If anyone wants to go hadly enough to finish lunch hy one o'clock and go up there I think that would he find. We meet hack here at one thirty, and I dare say that something after the meeting might he arranged for those who are particularly interested. Afternoon session not recorded. 18? 25-39706-250