The most outstanding feature of the war from the medical standpoint has been the really remarkable results obtained in the prevention of disease. War on an unparalleled scale has been going on for more than four years, waged under conditions in themselves calculated to initiate and spread contagious diseases; yet with the exception of typhus fever in Serbia and the recent epidemic of respiratory disease there have been no extensive epidemics such as have occurred in previous wars. Typhoid fever, which, up to the time of the Russo-Japanese War, had been the scourge of armies in the field, has been almost a negligible quantity. In the Boer and SpanishAmerican Wars, typhoid killed and incapacitated thousands. In the Russo-Japanese War the real beginning was made and typhoid checked. In the war just over, it has been entirely robbed of its sting. As with typhoid, so with the other war pestilences. Trench

fever after a short time was brought under control through scientific investigation. It has been not only by preventive measures in warding off epidemics but also by close attention to personal hygiene that health in the armies. on the western front has been maintained at a high standard. Preventive medicine during the past twenty years has progressed apace, and its value has been greatly emphasized by its strong showing in the war. The experience thus gained should now be put to good use in civilian communities.

If masses of men enduring the stress and strain of modern warfare can be kept healthy by the enforcement of sanitary and hygienic measures, it will certainly be reasonable to suppose that the general health of a civilian population cannot fail to be greatly benefited by the adoption of similar methods. Journal of the American Medical Association, LXXI, 24, (December 14, 1918), p. 1999.

Something is known concerning the nature of influenza. Much remains to be determined. Administrative health agencies, however, must act in the light of present knowledge. They cannot wait until the last word has been said in respect to the identity and nature of the micro-organism or virus that causes the disease, or in respect to the channels through which it may be spread, or for the discovery of specific vaccines or sera for prevention or cure.

T

HE above statements preface the report of the committee of the American Public Health Association which, at the December meeting of the Association, was charged with the duty of preparing a provisional working formula for the control of influenza, based upon the facts and opinions elicited at the meeting.

Carrying out the plan of summarizing present knowledge and basing a working program upon it, the committee presents in its introductory statement these points which summarize much of what we now know about influenza:

The present epidemic is the result of a disease of extreme communicability, limited, so far as the committee's information shows, to human beings.

The micro-organism or virus primarily responsible for the disease has not been identified, but there is no reason whatsoever for doubting that such an agency is responsible for it.

It has not yet been satisfactorily established that the present epidemic is due to the disease heretofore known as influenza, nor has it been established that all preceding outbreaks of disease styled at the time "influenza" have been outbreaks of one and the same malady.

There is no known laboratory method by which influenza (in the lack of definite information as to the identity of the disease now prevalent the committee refers to it by this name) can be distinguished from an ordinary cold, bronchitis or other inflammation of the membranes of the nose, pharynx and throat, or by which it can be determined when a person who has had influenza ceases to be a carrier.

Research and clinical laboratories are necessary agencies for the supervision and ultimate control of the disease the former for the identification of the causative organism or virus and for the propagation of a vaccine and a serum, and the latter for the supervision and control of vaccines and sera which may be used and for the information they can give as to variations in the types of infective organisms which may occur.

Influenza deaths commonly result from pneumonias, due to apparently secondary invasions of the lungs by streptococci, pneumococci or the bacillus of Pfeiffer.

Evidence seems conclusive that the infective organism or virus is given off from the nose and mouth of infected persons and is taken in through the mouth or nose (or perhaps the eye) of the person who contracts the disease.

Prevention.

The principles of preventive action, which can be stated despite the fact that the causative organism or virus is still unknown, are the following, according to the committee:

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

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

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

The committee proposes to break the channels of communication by preventing droplet infection, by sputum control and by supervision. of food and drink. The first of these is declared to be of prime importance. The sputum danger is said to rest chiefly in contamination of the hands and common drinking and eating utensils. Evidence is considered to indicate little danger through food and drink.

Taking up the second of its preventive principles, the committee says that evidence as to the success or lack of success of vaccine practice is contradictory and irreconcilable. "In view of the fact that the causative organism is unknown, there is no scientific basis for the use of any particular vaccine against the primary disease. If used, any vaccine must be employed on the chance that it bears. a relation to the unknown organism causing the disease. The use of vaccines for the complicating infections rests on more logical grounds, and yet the committee has not sufficient evidence to indicate that they can be used with any con

fident assurance of success. In the use of these vaccines the patient should realize that the practice is still in a developmental stage." The committee prescribes conditions which it believes should be complied with in experimental use of vaccines to determine their preventive or curative value.

In regard to increased natural resistance of persons exposed to the disease, the committee recommends that physical and nervous exhaustion be avoided by paying due regard to rest, exercise, physical and mental labor and hours of sleep, but says the evidence is conclusive that youth and bodily vigor do not guarantee immunity to the disease.

Pointing out that preventive measures practicable and necessary in any given situation depend to a great extent upon local conditions and upon the stage and type of the epidemic curve, the committee declares it impossible to lay down rules for the guidance. of all health officials alike. It states general principles that should underlie administrative measures for the prevention of influenza and advises that the application of these principles to the needs of any particular community must be left for determination by local health officials. The preventive measures recommended by the committee are as follows:

1. Efficient organization to meet the emergency, providing for centralized co-ordination and control of all resources.

2. Machinery for ascertaining all facts regarding the epidemic (compulsory reporting, a lay or professional canvass for cases, etc.)

3. Widespread publicity and education with respect to respira

tory hygiene and the danger of the common cold.

4. Administrative procedures. taken up in detail under the following heads:

Laws, properly enforced, forbidding the use of common cups, requiring proper washing of glasses at public drinking places and requiring proper ventilating facilities.

Closing: "The limitation of gatherings with respect to size and frequency, and the regulation of the conditions under which they may be held, must be regarded as an essential administrative procedure. Nonessential gatherings should be prohibited. Necessary gatherings should be held under such conditions as will insure the greatest possible amount of floor space to each individual present, and a maximum of fresh air, and precautions should be taken to prevent unguarded sneezing, coughing, cheering, etc. Where the necessary activities of the population, such as the performance of daily work and the earning of a living, compel considerable crowding and contact, but little is gained by closing certain types of meeting places. If, on the other hand, the community can function without much of contact between individual members thereof, relatively much is gained by closing or preventing assemblages."

Schools: The committee discusses the following points which must be considered in regard to the closing of schools: (a) Probability of increasing or decreasing number and degree of contacts between children by closing; (b) weather and transportation conditions affecting children enroute to school; (c) nursing and inspection system in the schools; (d) possibility of diagnosing and segregating case in school before child has made a number of contacts; (e) release of personnel and facilities for fighting epidemic by closing schools; (f) possible lowering of educational standards by absence of teachers if schools remain open; (g) possible drag on classes, constituted by children who remain at home because of illness or fear; (h) possibility of outbreak occurring, despite closing, when schools reopen.

Churches: If churches remain open, services should be as few as

possible and intimacy and frequency of personal contacts should be reduced to a minimum.

Theaters: Reliance upon ejection of careless coughers, with theaters remaining open, is discouraged. "The closing of theaters may have as much educational value as their use for direct educational purposes. Discrimination as to closing among theaters, movies, etc., on the basis of efficiency of ventilation and general sanitation, may be feasible."

Saloons and Other Drinking Places: Closing should depend upon the probability of the spread of the disease through drinking utensils and crowding.

Dance Halls, Billiard Rooms, etc.: Such places should be closed where their operation causes considerable personal contact and crowding.

Street Cars, etc.: "Ventilation and cleanliness should be insisted upon in all transportation facilities. Overcrowding should be discouraged. A staggering of opening and closing hours in stores and factories to prevent overcrowding of transportation facilities may be cautiously experimented with. In small communities where it is feasible for persons to walk to their work it is better to discontinue the service of local transportation facilities."

Funerals: Public funerals should be prohibited.

Masks: Wearing of masks should be compulsory in hospitals and for all who are directly exposed to infection. It should be compulsory for barbers, dentists, etc. Compulsory wearing of masks by the entire population is of doubtful value, according to evidence before the committee, which says it was not encouraged by the evidence to suggest the general adoption of the practice. Voluntary wearing of masks should be encouraged.

Isolation of influenza patients should be practiced. In cases of unreasonable carelessness it should be legally enforced.

Placarding should be practiced in cases of unreasonable carelessness.

Hospitalization cannot be depended upon to eliminate influenza unless every infective person can be detected as such