One of the most remarkable things about the 1918 pandemic was the great
rapidity with which it spread to all parts of the world. From the report
of the first cases which landed in Boston until the epidemic arrived in
San Francisco the time consumed was less than two months, and the peaks
of the two epidemics were just about one month apart. Apparently no part
of the world escaped. Asia, Europe, Africa, North and South America, and
some of the remote islands of the Pacific, all reported large epidemics,
with high mortality and great suffering. The deplorable failure of
precautionary measures in controlling the spread, or at least in
limiting the disease, may be offset in a measure by the unusual
conditions under which almost everybody had been living. Vast numbers
from all over the world were gathered together because of the war.
Thousands of men were housed together in army camps or in training
cantonments. Other thousands were doing relief work or engaged in the
manufacture of munitions. Most of those at home were doing double duty,
and were on a severe nervous strain. Everyone everywhere was working to
the limit and was consequently fatigued. The necessities of war had cut
down the amounts of food generally, and sugar and fat rations
particularly. Traffic, both between nations and at home, had never been
so great nor accommodations so insufficient. So that it is likely that
all of these and many more changes in the daily routine of individuals
led to a condition of lowered resistance, and at the same time increased
their chances of exposure. One point, at least, stands out prominently,
and that is that “influenza as it occurred clinically during the first
great wave was different from those cases which appeared later.” This
was seen in the acuteness of the onset, in the severity of symptoms, and
in the high mortality rate. Therefore, any measure which afforded
protection, if only for the time being, is worthy of retrial.
In view of the fact that recurrences have followed closely in the wake
of all former influenza epidemics, and with the hope of stimulating
concerted investigation of preventive measures, the American Public
Health Association (57), at its meeting in Chicago in December, 1918,
appointed a committee to outline “a provisional working formula, based
on the facts and opinions brought out at the meeting.” A summary of the
opinions as taken from the report of the committee is given here. They
reported that the disease was probably due to some micro-organism or
virus as not yet identified; that while it was known as “influenza,” it
was not known to be identical with the disease generally known under
that name; that there was no known laboratory method of differentiating
it from ordinary colds, bronchitis, etc.; that there was no known
laboratory method of determining when a patient ceased to be infective;
and that the deaths from influenza were due to secondary pneumonia
resulting from an invasion by one or more forms of streptococci, or by
one or more forms of pneumococci, or by the so-called influenza bacillus
or bacillus of Pfeiffer. Because of the clear and concise manner in
which this report brings out the opinions held, at the time, by a
majority of the medical profession a portion of the report is given here
_verbatim_.
“Evidence seems conclusive that the infective micro-organisms or virus
of influenza is given off from the noses and mouths of infected persons.
It seems equally conclusive that it is taken in through the mouth or
nose of the person who contracts the disease, and in no other way except
as a bare possibility through the eyes by way of the conjunctivæ or tear
ducts.
“If it be admitted that influenza is spread solely through discharges
from the nose and throats of infected persons, finding their way into
the noses and throats of other persons susceptible to the disease, then,
no matter what the causative organism or virus may ultimately be
determined to be, preventive action logically follows the principles
named below, and, therefore, it is not necessary to wait for the
discovery of the specific micro-organism or virus before taking such
action.
“1. Break the channels of communication by which the infective agent
passes from one person to another.
“2. Render persons exposed to infection immune, or at least more
resistant, by the use of vaccines.
“3. Increase the natural resistance of persons exposed to the disease by
augmented healthfulness.”
The ways and means of carrying out these principles are many and varied,
and it is merely the intention of this paper to put together a sort of
digest of some of the more important arguments for and against some of
the seemingly more important measures proposed.
_Methods Proposed for Breaking the Channels of Communication_
(a) Rigid quarantine for all persons suffering from the disease and all
contacts. During the epidemic quarantine was advocated by many people.
It was pointed out that the disease spread most rapidly in camps, in
ships, and in quarters generally where large numbers of persons were
closely associated; that it was quite as contagious and more rapidly
fatal than most diseases which are regularly quarantined; that while it
was admitted that there is no laboratory method to make certain the
diagnosis, and no method of telling how long convalescents are capable
of transmitting the disease, as there is, for instance, in diphtheria,
still there is no question of the value of the arbitrary quarantine used
in measles, scarlet fever and smallpox, all of which are diseases in
which the parasitic causes are not known. Further, the opinion was
expressed that complete isolation and quarantine would not only protect
the community from influenza, but that it would also in a measure
protect the patient from contact with numerous outside strains of
pneumococci and streptococci, and so lessen secondary infection and
reduce the general mortality.
There are many reasons why quarantine is not applicable in epidemic
influenza. Most important of all is probably the inability to make
certain the diagnosis, especially during the early stages in light
cases. This would work detrimentally in several ways. Really ill
patients would delay calling a physician until late, for fear of
unnecessary quarantine. Many needless and unjust quarantines would
result when the diagnosis was uncertain and the physician anxious to
carry out quarantine measures efficiently. Many patients would have
contacts running about and infecting their neighborhoods while a delayed
diagnosis was being made. Influenza was so contagious during the
epidemic that it would have necessitated general quarantine not only of
all infected persons but also of all contacts to have obtained any
favorable results, and since nearly everyone was either a patient or a
contact, all lines of business would literally have been paralyzed by
the procedure. If it is true that the infected person is most dangerous
to others before he has developed symptoms himself, he is a carrier
impossible of detection and control. Points in favor of the hypothesis
that infected persons spread the disease before they develop symptoms
are found in the following facts. As the disease passed from community
to community officials became alert for the appearance of the first
case. In army barracks and in large institutions it was often possible
to determine the first case at its development. The case was, in many
instances, removed at once and isolated, but I have seen no instance in
which such a measure was successful in curbing the disease. As
subsequent cases appeared they were likewise immediately removed, but
the cases continued to spread just the same. Bloomfield (38) cited the
incident of a student who spent a few hours visiting his sister in a
part of the country where there had been no influenza. He appeared well
at the time, but six hours after his return to school he developed
influenza. Two days after the contact the sister came down with the
disease. On the other hand, he told of a student who did not contract
the disease, though he slept for two nights in the same bed with his
roommate, who had returned to school with a well-developed case of
influenza. The unsuccessful attempts to transmit influenza in the
experiments of Rosenau (37), McCoy (37a) and others already cited would
indicate that the cases from whom the material was taken were no longer
infectious, although some of them had been showing symptoms for only
about 12 hours. Bloomfield observed that the general use of face masks
in the wards did not alter the course of the epidemic, and stated that
if face masks are protective, infection from early unisolated cases must
be assumed.
Provided influenza is generally transmitted during the period of
incubation, a theory which seems consistent with the facts, rigid
quarantine for epidemic influenza is impracticable and probably useless.
_Partial Isolation by Means of the Cubicle System_
The so-called cubicle system consists in the dividing of rooms, or more
particularly of wards, into small compartments by means of suspending
sheets from wires so that each bed is separated from its neighbor. Capps
(39) reported favorably on the method as used at Camp Grant, where
sheets or halves of tents were suspended from wires or from the mosquito
netting frames which were a part of the standard beds. Doctors, nurses
and attendants were forced to wear masks in the wards, and patients were
not allowed out of the cubicles without them. In discussing this paper
Thayer emphasized the value of screening, masking and the wearing of
gowns, and also recommended thorough washing of the hands between the
examination of each two patients; and Emerson called attention to the
fact that the first demonstration of the cubicle system as an adequate
means of preventing acute respiratory diseases was made at the Pasteur
Institute of Paris, where it had been in operation for 10 years. The
latter stated that the system had been used in various hospitals in
America and was essential for the care of diphtheria, measles and
scarlet fever. He further indicated that if the technique of personal
cleanliness of nurses, doctors and attendants could be perfected, it was
probable that the height of the cubicle partition could be reduced to
that of a “red string.” The method certainly seems worthy of
consideration and trial, particularly in large general hospitals and
public institutions.
_The Use of the Face Mask_
The question of the value of wearing a gauze mask over the mouth and
nostrils during an influenza epidemic is still an open one. Masks,
however, have been found useful in protecting against some other
diseases of respiratory origin. In December, 1917, Weaver (40) reported
favorably on the use of gauze masks in the Durand Hospital of Infectious
Diseases. The masks were used by nurses in attendance upon patients with
contagious diseases, and also by patients who were convalescing from
diphtheria, meningitis or pneumonia and who were in the same wards with
those having other respiratory diseases. In a later article Weaver (41)
stated that by the use of masks they had been able to reduce the
percentage of diphtheria carriers among their nurses in the diphtheria
wards to 5.2 per cent., as compared to the average of 23.25 per cent.
during the 20 months immediately preceding their adoption of their use.
He recommended the general use of masks for physicians when in contact
with all types of respiratory diseases. In March, 1918, Capps (39a)
reported encouraging results in the control of infections through the
masking of all patients at Camp Grant. During the epidemic the wearing
of masks became quite general, and was very popular in many sections.
Several sets of laboratory experiments have been carried out recently to
determine whether the masks are of practical value or not. The
experiments have generally consisted in spraying cultures of living
bacteria over sterile bacterial plates which were protected by one or
more layers of gauze. A number of variations were made in the manner in
which this was done: (a) the distance between the nozzle of the spray
and the mask was 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.