Part 14

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

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

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

_General Closing Orders_

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

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

_The Closing of Schools_

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

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

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

_The Closing of Public Dance Halls_

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

_Regulation of Public Eating and Drinking Places_

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

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

_Regulation of Traffic_

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

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

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

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

_Enforcement of Anti-Spitting Ordinances_

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

_Increasing Natural Resistance by Augmented Healthfulness_

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

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

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

GENERAL MEASURES

_Public Health Administration_

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

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