COMPENDIUM FOR MEDICAL OFFICERS By GILBERT E. SEAMAN, M.D., F. A.C.S. Major and Chief Surgeon Wisconsin National Guard Compendium For Medical Officers By GILBERT E. SEAMAN. M. D.. F. A. C. S. Major and Chief Surgeon Wisconsin National Guard 19 17 CANTWELL PRINTING CO., MADISON, WIS. State of Wisconsin, The Adjutant General's Office, Madison, May 12, 1917. General Orders, No. 4. The following compilation of the laws of the United States and regulations of the War Department, relative to the Med- ical Department of the United States army and the Wisconsin National Guard, together with other facts concerning military surgery and hygiene, prepared by Major Gilbert E. Seaman, Chief Surgeon, Wisconsin National Guard, is published for the information of all concerned. By Command of the Governor: ORLANDO HOLWAY, The Adjutant General, Official: Chief of Staff. Adjutant General. FOREWORD This compendium is intended to set forth what I believe surgeons in field service will generally agree upon as fairly representing the essentials of information required by Medical Officers serving with troops, particularly in the zone of the advance. The information herein contained represents to a great extent the lectures and lessons in the course for Medical Officers of the Wisconsin National Guard, conducted during April and May, 1917. It is composed principally of quota- tions of laws and orders directly related to the work of the Medical Department, of compilations of information, and of comment based on personal experience. This handbook is published with the hope that it may serve the useful purpose of saving time and labor for Medical Officers and that it will also direct their attention to the study of such indispensable publications as Army Regulations, Manual of the Medical Department, Field Service Regula- tions, Medical Service in Campaign (Straub), Elements of Military Hygiene (Ashburn), Preventive Medicine (Rosenau), Gunshot Wounds (Legarde), The Oxford War Primers, War Surgery (Delorme), Wound Infections (Wright), Drill Regulations Sanitary Troops, Mason's Handbook for Hos- pital Corps, Military Hygiene (Havard) Military Hygiene (Munson), and to current medical literature setting forth the latest experiences of surgeons now active in the Great War and many other available publications written by men of judgment and experience. Many of the above named publications are furnished Medical Officers of the Army and of the National Guard on requisition to the Surgeon General of the Army or to the Chief Surgeon of their state. While prepared specifically for Medical Officers, it is hoped that the handbook will also be of service to Line Officers and others in the service. Attention is called to the fact that changes in the organization of the army are constantly being made and that there is constant progress in military medicine and surgery. While the information contained in the following pages is as accurate as it is possible to make it at the time of its writing, it will therefore be subject to such modification as future developments make necessary. It should also be 3 borne in mind that if some of the statements on the treat- ment of wounds seem dogmatic, they are for the most part culled from the teachings of the highest authorities in military surgery at the present time. I am greatly indebted for valuable assistance in the pre- paration of this manual to Major J. W. Frew, Major Charles II. Stoddard, Major G. W. Neilsen, Capt. Clarence Kenney, Lieut. R. W. Blumenthal,Lieut.HerbertGraebner, Lieut. W. F. Lorenz, Lieut. A. A. Mitten, Medical Officers of the Wisconsin National Guard, Major J. R. McDill, First Lieut. W. S. Middleton, M. R. C., Dr. H. V. Ogden and Dr. A. S. Loevenhart. GILBERT E. SEAMAN. Milwaukee, Wis., June 1, 1917. 4 Page FOREWORD 3 ORGANIZATION OF THE UNITED STATES ARMY 9 Composition of the Regular Army-The Medical Depart- ment-Composition of the National Guard-Other Laws Governing the National Guard. APPOINTMENTS AS MEDICAL OFFICERS 21 Appointments in the Medical Corps of the Regular Army -In the Medical Officers' Reserve Corps of the Regular Army-In the Medical Corps of the National Guard. MOBILIZATION OF THE NATIONAL GUARD 23 How and When Drafted Into Federal Service-Company Rendezvous, Mobilization and Concentration Camps- Training-Organization and Equipment-Medical Sup- plies-Detail of Officers-Duties of Medical Examiner- Records and Reports. CAMPS AND HOSPITALS 28 Mobilization Camps-Concentration Camps-Camp Hos- pitals-Hospital Trains and Trains for Patients. ORGANIZATION OF THE MEDICAL DEPARTMENT IN WAR 32 Table Giving Outline of Organization-Maximum Statu- tory Strength of Units-Objects of Medical Department Administration--Duties of Medical Department--The Sanitary Service in War. SANITARY TROOPS ON DUTY WITH LINE ORGANIZATIONS 37 Equipment Available-Duties of Surgeon of Line Organ- ization as Commander of Sanitary Troops on Duty-- Duties of Sanitary Personnel. EQUIPMENT OF MEDICAL DEPARTMENT 40 Individual Equipment of Medical Officers--Equipment of Enlisted Men. REQUISITIONS 42 Proper Forms-How and By Whom Made. REPORTS 45 Need of Accuracy--Various Important Reports Required of Medical Officers. PHYSICAL EXAMINATION OF RECRUITS 50 Rigid Examination the Foundation of Military Efficiency -Obligation of Medical Examiners-Importance of Age Limits-Of Relative Weight and Height--Routine of Medical Examination in Detail. CAMP SANITATION 59 Selection of Camp Site-Daily Inspection-Cleanliness of Kitchen Essential-Ice Box-Incinerator-Waste Water -Latrines-Disposal of Waste. TABLE OF CONTENTS 5 Page WATER FOR TROOPS IN THE FIELD 65 Methods of Making Water Supply Safe-Improvised Filter -Forbes Portable Sterilizer-Carnal Filter-Lyster Bag. THE RATION 67 Garrison Ration-Field Ration-Travel Ration-Food Supplies for Hospitals and Ambulances-Individual Cook- ing by Soldiers-Preparation of a Menu. PERSONAL HYGIENE 72 Importance of Personal Hygiene-Difficulties Under War Conditions-Cleanliness-Alcohol-Water and Food Suitable Clothing-Care of the Feet-Disease Dangers of Uncleanliness-Preventing Venereal Disease-Golden Rules of Personal Hygiene. DUTIES OF MEDICAL OFFICERS AT THE FRONT 79 Duties of Medical Officers-Division Surgeon in Com- mand-Battalion Sections of Regimental Detachments-■ Regimental Aid Stations-Diagnosis Tags-Dressing Stations-Field Hospitals-Importance of Maps. LINES OF ASSISTANCE (Diagram) 84 THE AMBULANCE COMPANY IN THE FIELD 85 A Vital Link-Mule Driven and Motor Driven Ambu- lances-Personnel and Material of Ambulance Companies -Units for Field Work-Establishing the Dressing Sta- tion-Methods of Handling the Wounded. THE FIELD HOSPITAL 90 Personnel of a Field Hospital-Function-Operation- Location-Establishing a Field Hospital-Field Hospital Departments-Evacuation of Patients. MILITARY MEDICINE 94 Importance of Military Medicine-Supervision of New Recruits in Training-Safeguarding Food Supplies- Anti-Typhoid and Small Pox Vaccinations-Venereal Prophylaxis- Malaria - Semi-Monthly Inspection--Ty- phus-Cerebro-Spinal Meningitis-Paratyphoid Infec- tions-Infectious Diseases. SICK CALI 104 Purpose of Sick Call-Best Hours for Sick Call. TUBERCULOSIS IN WAR 106 A Big War Problem-Development of Disease in Warring Countries Proves Value of Anti-Tuberculosis Campaigns -150,000 French Soldiers Rendered Non-Effective by Disease-England's Preparedness-Dr. Hermann M. Biggs on Foreign Situation-National Committee Out- lines Program for United States-Lessons from Canada's Experience-Measures for Control of Disease and Care of the Tuberculous Soldiers Recommended by Dr. Jabez H. Elliott, Captain, Canadian Army Medical Corps. MILITARY DENTISTRY 112 Importance and Need of Dental Service in Army-Char- acter of Treatment-Extent of Dental Work Allowed. 6 Page BALLISTICS AND TOPOGRAPHY 115 Nature of Wounds Made by Various Missiles-Weapons and Missils-Importance of Knowledge of Topography by Medical Officers. ILLUSTRATION OF MISSILS (From Photographs) 116-119 MILITARY SURGERY 124 General Considerations-Need of Military Training for Civilian Physician-Bacterial Infection of Wounds--New War Problems-Classification of Wounded-What First Aid Comprises-Treatment of Shock-Control of Hem- orrhage, Immobilization of Fractures, Relief of Pain-■ Problem of Infection-Hemorrhage-Locke's Solution-- Ringer's Solution-Treatment of Wounds-Treatment of Wound Infections-Methods of Treatment--Vaccine Therapy-The Dakin-Carrel Method; Discovered Early in Present War; General Use; Extracts from Address by Dr. Carrel; Proper Technique Imperative; Economic Value; Preparation of Solution Described by Dr. Dakin; Reactions to Test Solution; Routine of Treat- ment; Precautions Necessary-Hyclorite-Use of Kalk Solution. REGULATIONS GOVERNING THE EMPLOYMENT OF THE RED CROSS IN TIME OF WAR 150 Red Cross Units as Part of Sanitary Service-Subject to Military Law in Time of War-Service Which May be Required by War Department-Standing of the Per- sonnel-Classification of Personnel-Red Cross Units for Army Service: Ambulance Companies; Base Hospitals; Organization of Base Hospitals; Hospital Units and Sur- gical Sections; Emergency and Training Detachments; Other Units and Detachments; General Hospitals and Convalescent Homes-Registry of Units-Uniforms- Equipment-Transportation. THE GENEVA CONVENTION 160 Extracts from the Agreement Between Nations With Respect to the Care and Protection of the Sick and Wounded. 7 CHAPTER I. ORGANIZATION OF THE UNITED STATES ARMY The following extracts are from the Law of June 3rd, 1916, as published in Bulletin No. 16, War Department, June 22nd, 1916, for the information and guidance of the Army. Be it enacted by the Senate and House of Representa- tives of the United States of America in Congress assembled, That the Army of the United States shall con- sist of the Regular Army, the Volunteer Army, the Officers' Reserve Corps, the Enlisted Reserve Corps, the National Guard while in the service of the United States, and such other land forces as are now or may hereafter be authorized by law. Sec. 2. Composition of the Regular Army.* The Regular Army of the United States, including the existing organizations, shall consist of sixty-four regiments of Infantry, twenty-five regiments of Cavalry, twenty-one regiments of Field Artillery, a Coast Artillery Corps, the brigade, division, army corps, and army headquarters, with their detachments and troops, a General Staff Corps, an Adjutant General's Department, an Inspector General's Department, a Judge Advocate General's Department, a Quartermaster Corps, a Medical Department, a Corps of Engineers, an Ordnance Department, a Signal Corps, the officers of the Bureau of Insular Affairs, the Militia Bureau, the detached officers, the detached noncommissioned officers, the chaplains, the Regular Army Reserve, all organized as hereinafter provided, and the following as now authorized by law: the officers and enlisted men on the retired list; the additional officers; the professors, the Corps of Cadets, the general Army service detachment, and detachments of Cavalry, Field Artillery, and Engineers, and the band of the United States Military Academy; the post noncommissioned staff officers; the recruiting parties, the recruit depot de- tachments, and unassigned recruits; the service school de- tachments; the disciplinary guards; the disciplinary organ- ♦Subject to pending proposed changes. 9 izations; the Indian Scouts; and such other officers and en- listed men as are now or may be hereafter provided for: Provided, That hereafter the enlisted personnel of all organ- izations of the Regular Army shall at all times be maintained at a strength not below the minimum strength fixed by law: Provided further, That the total enlisted force of the line of the Regular Army, excluding the Philippine Scouts and the enlisted men of the Quartermaster Corps, of the Medical Department, and of the Signal Corps, and the unassigned recruits, shall not at any one time, except in the event of actual or threatened war or similar emergency in which the public safety demands it, exceed one hundred and seventy- five thousand men: Provided further, That the unassigned recruits at depots or elsewhere shall at no time, except in time of war, exceed by more than seven per centum the total authorized enlisted strength. Sec. 3. Composition of Brigades, Divisions, ami so forth. The mobile troops of the Regular Army of the United States shall be organized, as far as practicable, into brigades and divisions. The President is authorized, in time of actual or threatened hostilities, or when in his opinion the interests of the public service demand it, to organize the brigades and divisions into such army corps or armies as may be necessary. The typical Infantry brigade shall consist of a head- quarters and three regiments of Infantry. The typical Cavalry brigade shall consist of a headquarters and three regiments of Cavalry. The typical Field Artillery brigade shall consist of a headquarters and three regiments of Field Artillery. The typical Infantry division shall consist of a head- quarters, three Infantry brigades, one regiment of Cavalry, one Field Artillery brigade, one regiment of Engineers, one field signal battalion, one aero squadron, one ammunition train, one supply train, one engineer train, and one sanitary train. The typical Cavalry division shall consist of a head- quarters, three Cavalry brigades, one regiment of Field Artillery (horse), one battalion of mounted Engineers, one field signal battalion (mounted), one aero squadron, one ammunition train, one supply train, one engineer train, and one sanitary train. The typical army corps shall consist of a headquarters, two or more Infantry divisions, one or more Cavalry brigades or a Cavalry division, one Field Artillery brigade, one telegraph battalion, and one field signal battalion, and such ammunition, supply, engineer, and 10 sanitary trains as the President may deem necessary. A brigade, a division, an army corps, and an army headquarters shall consist of such officers, enlisted men, and civilians as the President may prescribe. Each supply train, ammunition train, sanitary train, and engineer train shall consist of such officers and enlisted men and shall be organized as the Presi- dent may prescribe, the line of officers necessary therewith to be detailed under the provisions of sections twenty-six and twenty-seven, Act of Congress approved February second, nineteen hundred and one. Nothing herein contained, however, shall prevent the President from increasing or decreasing the number of organizations prescribed for the typical brigades, divisions, and army corps, or from pre- scribing new and different organizations and personnel as the efficiency of the service may require. Sec. 10. The Medical Department. The Medical Department shall consist of one Surgeon General, with the rank of major general during the active service of the present incumbent of that office, and there- after with the rank of brigadier general, who shall be chief of said department, a Medical Corps, a Medical Reserve Corps within the limit of time fixed by this Act, a Dental Corps, a Veterinary Corps, an enlisted force, the Nurse Corps and contract surgeons as now authorized by law, the com- missioned officers of which shall be citizens of the United States. The Medical Corps shall consist of commissioned officers below the grade of brigadier general, proportionately dis- tributed among the several grades as in the Medical Corps now established by law. The total number of such officers shall approximately be equal to, but not exceed, except as hereinafter provided, seven for every one thousand of the total enlisted strength of the Regular Army authorized from time to time by law: Provided, That if by reason of a re- duction by law in the authorized enlisted strength of the Army aforesaid the total number of officers in the Medical Corps commissioned previously to such reduction shall for the time being exceed the equivalent of seven to one thousand of such reduced enlisted strength no original appointment to commissioned rank in said corps shall be made until the total number of commissioned officers thereof shall have been reduced below the equivalent of seven to the thousand of the said reduced enlisted strength, nor thereafter so as to make the total number of commissioned officers thereof in excess of 11 the equivalent of seven to the thousand of said reduced enlisted strength, and no promotion shall be made above the grade of captain in said corps until the number of officers in the grade above that of captain to which the promotion is due shall have been reduced below the proportional number authorized for such grade on the basis of the reduced enlisted strength, nor thereafter so as to make the number of officers in such grade in excess of the proportional number authorized on the basis of said reduced enlisted strength: Provided further, That when in time of war the Regular Army shall have been in- creased by virtue of the provisions of this or any other Act, the medical officers appointed to meet such increase shall be honorably discharged from the service of the United States when the reduction of the enlisted strength of the Army shall take place: Provided further, That persons hereafter com- missioned in the Medical Corps shall be citizens of the United States between the ages of twenty-two and thirty years and shall be promoted to the grade of captain upon the com- pletion of five years' service in the Medical Corps and upon passing the examinations prescribed by the President for promotion to the grade of captain in the Medical Corps: Provided further, That relative rank among captains in the Medical Corps, who have or shall have attained that rank by operation of law after a period of service fixed thereby, shall be determined by counting all the service rendered by them as officers in said corps and as assistant surgeons in the Regular Army, subject, however, to loss of files by reason of sentence of courtmartial or by reason of failure to pass examination for promotion: Provided further, That hereafter the Presi- dent shall be authorized to detail not to exceed five officers of the Medical Department of the Army for duty with the military relief division of the American National Red Cross. The Enlisted Force of the Medical Department shall consist of the following personnel, who shall not be included in the effective strength of the Army nor counted as a part of the enlisted force provided by law: Master hospital ser- geants, hospital sergeants, sergeants (fust class), sergeants, corporals, cooks, horseshoers, saddlers, farriers, mechanics, privates (first class), and privates: Provided, That master hospital sergeants shall be appointed by the Secretary of War, but no person shall be appointed master hospital ser- geant until he shall have passed a satisfactory examination under such regulations as the Secretary of War may prescribe before a board of one or more medical officers as to his quali- 12 fications for the position, including knowledge of pharmacy, and demonstrated his fitness therefor by service of not less than twelve months as hospital sergeant or sergeant, first class, Medical Department, or as sergeant, first class, in the Hospital Corps now established by law; and no person shall be designated for such examination except by written authority of the Surgeon General: Provided further, That original enlistments for the Medical Department shall be made in the grade of private, and reenlistments and promotions of enlisted men therein, except as hereinbefore prescribed, and transfer thereto from the enlisted force of the line or other staff departments and corps of the Army shall be governed by such regulations as the Secretary of War may prescribe: Pro- vided further, That the enlisted men of the Hospital Corps who are in active service at the time of the approval of this Act are hereby transferred to the corresponding grades of the Medical Department established by this Act: Provided further, That the total number of enlisted men in the Medical Department shall be approximately equal to, but not exceed, except as hereinafter provided, the equivalent of five per centum of the total enlisted strength of the Army authorized from time to time by law: Provided further, That in time of actual or threatened hostilities, the Secretary of War is hereby authorized to enlist or cause to be enlisted in the Medical Department such additional number of men as the service may require: Provided further, That the number of enlisted men in each of the several grades designated below shall not exceed, except as hereinafter provided, the following per- centages of the total authorized enlisted strength of the Medical Department, to wit: Master hospital sergeants, one-half of one per centum; hospital sergeants, one-half of one per centum; sergeants, first class, seven per centum; sergeants, eleven per centum; corporals, five per centum; and cooks, six per centum: Provided further, That the number of horseshoers, saddlers, farriers, and mechanics in the Medical Department shall not exceed one each to each author- ized ambulance company or like organization: Provided further, That in said department the number of privates, first class, shall not exceed twenty-five per centum of the number of privates: Provided further, That if by reason of a reduction by operation of law in the authorized enlisted strength of the Army aforesaid the number of noncommis- sioned officers of any grade in the Medical Department whose warrants were issued previously to such reduction shall for 13 the time being exceed the percentage hereinbefore specified for such grade, no promotion to such grade shall be made until the percentage of noncommissioned officers therein shall have been reduced below that authorized for such grade on the basis of the said reduced enlisted strength, nor thereafter so as to make the percentage of noncommissioned officers therein in excess of the percentage authorized on the basis of the said reduced enlisted strength: but noncom- missioned officers may be reenlisted in the grades held by them previously to such reduction legardless of the percentages aforesaid; and when under this provision the number of non- commissioned officers of any grade exceeds the percentage specified, any noncommissioned officer thereof, not under charges, may be discharged on his own application: Pro- vided further, That privates, first class, of the Medical De- partment shall be eligible for ratings for additional pay as follows: As dispensary assistant, $2 a month; as nurse, $3 a month; as surgical assistant, $5 a month: Provided further, That no enlisted man shall receive more than one rating for additional pay under the provisions of this section, nor shall any enlisted man receive any additional pay under such rating unless he shall have actually performed the duties for which he shall be rated. The President is hereby authorized to appoint and com- mission, by and with the advice and consent of the Senate, Dental Surgeons, who are citizens of the United States between the ages of twenty-one and twenty-seven years, at the rate of one for each one thousand enlisted men of the line of the Army. Dental surgeons shall have the rank, pay, and allowances of first lieutenants until they have completed eight years' service. Dental Surgeons of more than eight but less than twenty-four years' service shall, subject to such examination as the President may prescribe, have the rank, pay, and allowances of captains. Dental Surgeons of more than twenty-four years' service shall, subject to such exam- ination as the President may prescribe, have the rank, pay, and allowances of major: Provided, That the total number of dental surgeons with rank, pay, and allowances of major shall not at any time exceed fifteen: And provided further, That all laws relating to the examination of officers of the Medical Corps for promotion shall be applicable to dental surgeons. Sec. 16. Veterinarians. The President is hereby authorized, by and with the ad- vice and consent of the Senate, to appoint Veterinarians 14 and Assistant Veterinarians in the Army, not to exceed, including veterinarians now in service, two such officers for each5 regiment of Cavalry, one for every three batteries of Field Artillery, one for each mounted battalion of Engineers, seventeen as inspectors of horses and mules and as veter- inarians in the Quartermaster Corps, and seven as inspectors of meats for the Quartermaster Corps; and said veterin- arians and assistant veterinarians shall be citizens of the United States and shall constitute the Veterinary Corps and shall be a part of the Medical Department of the Army. Hereafter a candidate for appointment as assistant veter- inarian must be a citizen of the United States, between the ages of twenty-one and twenty-seven years, a graduate of a recognized veterinary college or university, and shall not be appointed until he shall have passed a satisfactory exam- ination as to character, physical condition, general education, and professional qualifications. An assistant veterinarian appointed under this Act shall, for the first five years' of service as such, have the rank, pay, and allowances of second lieutenant; that after five years of service he shall have the rank, pay, and allowances of first lieutenant; that after fifteen years of service he shall be pro- moted to be a veterinarian with the rank, pay and allowances of captain, and that after twenty years' service he shall have the rank, pay, and allowances of a major: Provided, That any assistant veterinarian, in order to be promoted as here- inbefore provided, must first pass a satisfactory examination, under such rules as the President may prescribe, as to pro- fessional qualifications and adaptability for the military service; and if such assistant veterinarian shall be found de- ficient at such examination he shall be discharged from the Army with one year's pay. The Secretary of War, upon recommendation of the Sur- geon General of the Army, may appoint in the Veterinary Corps, for such time as their services may be required, such number of reserve veterinarians as may be necessary to attend public animals pertaining to the Quartermaster Corps. Reserve veterinarians so employed shall have the pay and allowances of second lieutenant during such employment and no longer: Provided, That such reserve veterinarians shall be graduates of a recognized veterinary college or university and shall pass a satisfactory examination as to character, physical condition, general education, and professional 15 qualifications in like manner as hereinbefore required of assistant veterinarians; such reserve veterinarians shall con- stitute a list of eligibles for appointment as assistant veter- inarians, subject to all the conditions hereinbefore prescribed for the appointment of assistant veterinarians. Within a limit of time to be fixed by the Secretary of War, candidates for appointment as assistant veterinarians who shall have passed satisfactorily the examinations prescribed for that grade by this Act shall be appointed, in the order of merit in which they shall have passed such examination, to vacancies as they occur, such appointments to be for a pro- bationary period of two years, after which time, if the serv- ices of the probationers shall have been satisfactory, they shall be permanently appointed with rank to date from the dates of rank of their probationary appointments. Pro- bationary veterinarians whose services are found unsatis- factory shall be discharged at any time during the proba- tionary period, or at the end thereof, and shall have no fur- ther claims against the Government on account of their probationary service. The Secretary of War shall from time to time appoint boards of examiners to conduct the veterinary examinations hereinbefore prescribed, each of said boards to consist of three medical officers and two veterinarians. Sec. 57. Composition of the Militia. The militia of the United States shall consist of all able- bodied male citizens of the United States and all other able-bodied males who have or shall have declared their intention to become citizens of the United States, who shall be more than eighteen years of age and, except as hereinafter provided, not more than forty-five years of age, and said militia shall be divided into three classes, the National Guard, the Naval Militia, and the Unorganized Militia. Sec. 58. Composition of the National Guard. The National Guard shall consist of the regularly enlisted militia between the ages of eighteen and forty-five years organized, armed, and equipped as hereinafter provided, and of commissioned officers between the ages of twenty-one and sixty-four years. Sec. 60. Organization of National Guard Units. Except as otherwise specifically provided herein, the organization of the National Guard, including the composi- 16 tion of all units thereof, shall be the same as that which is or may hereafter be prescribed for the Regular Army, subject in time of peace to such general exceptions as may be author- ized by the Secretary of War. And the President may pre- scribe the particular unit or units, as to branch or arm of service, to be maintained in each State, Territory, or the District of Columbia in order to secure a force which, when combined, shall form complete higher tactical units. Sec. 62. Number of the National Guard. The number of enlisted men of the National Guard to be organized under this Act within one year from its passage shall be for each State in the proportion of two hundred such men for each Senator and Representative in Congress from each State, and a number to be determined by the President for each Territory and the District of Columbia, and shall be increased each year thereafter in the proportion of not less than fifty per centum until a total peace strength of not less than eight hundred enlisted men for each Senator and Rep- resentative in Congress shall have been reached: Provided, That in states which have but one Representative in Congress such increase shall be in the discretion of the President: Provided further, That this shall not be construed to prevent any State, Territory, or the District of Columbia from organ- izing the full number of troops required under this section in less time than is specified in this section, or from maintain- ing existing organizations if they shall conform to such rules and regulations regarding organization, strength, and arma- ment as the President may prescribe: And provided further, That nothing in this Act shall be construed to prevent any State with but one Representative in Congress from organiz- ing one or more regiments of troops, with such auxiliary tioops as the President may prescribe; such organizations and me- bers of such organizations to receive all the benefits accruing under this Act under the conditions set forth herein. Sec. 64. Assignment of National Guard to Brigades and Divisions. For the purpose of maintaining appropriate organization and to assist in instruction and training, the President may assign the National Guard of the several States and Terri- tories and the District of Columbia to divisions, brigades, and other tactical units, and may detail officers either from the National Guard or the Regular Army to command such 17 units: Provided, That where complete units are organized within a State, Territory, or the District of Columbia the commanding officers thereof shall not be displaced under the provisions of this section. Sec. 73. Federal Oath for National Guard Officers. Commissioned officers of the National Guard of the several States, Territories, and the District of Columbia now serving under commissions regularly issued shall continue in office, as officers of the National Guard, without the issuance of new commissions: Provided, That said Officers have taken, or shall take and subscribe to the following oath of office: "I , do solemnly swear that I will support and defend the Constitution of the United States and the constitution of the State of , against all enemies, foreign and do- mestic; that I will bear true faith and allegiance to the same; that I will obey the orders of the President of the United States and of the governor of the State of ; that I make this obligation freely, without any mental reservation or purpose of evasion, and that I will well and faithfully dis- charge the duties of the office of in the National Guard of the Unites States and of the State of , upon which I am about to enter, so help me God." Sec. 74. Qualifications for National Guard Officers, Including Medical Officers. Persons hereafter commissioned as officers of the National Guard shall not be recognized as such under any of the provisions of this Act unless they shall have been selected from the following classes and shall have taken and subscribed to the oath of office prescribed in the preceding section of this Act. Officers or enlisted men of the National Guard; officers on the reserve or unassigned list of the National Guard; officers, active or retired, and former officers of the United States Army, Navy, and Marine Corps; grad- uates of the United States Military and Naval Academies and graduates of schools, colleges, and universities where military science is taught under the supervision of an officer of the Regular Army, and, for the technical branches and staff corps or departments, such other civilians as may be especially qualified for duty therein. Sec. 75. The provisions of this Act shall not apply to any person hereafter appointed an officer of the National Guard 18 unless he first shall have successfully passed such tests as to his physical, moral, and professional fitness as the President shall prescribe. The examination to determine such quali- fications for commission shall be conducted by a board of three commissioned officers appointed by the Secretary of War, from the Regular Army or the National Guard, or both. Sec. 76. Filling of Vacancies when Drafted into Federal Service. All vacancies occurring in any grade of commissioned officers in any organization in the military service of the United States and composed of persons drafted from the National Guard under the provision of this Act shall be filled by the President, as far as practicable, by the appoint- ment of persons similarly taken from said guard, and in the manner prescribed by law for filling similar vacancies occur- ring in the volunteer forces. Sec. 82. Armament, Equipment, and Uniform of the National Guard. The National Guard of the United States shall, as far as practicable, be uniformed, armed, and equipped with the same type of uniforms, arms, and equipment as are or shall be provided for the Regular Army. Sec. 101. National Guard, When Subject to Laws Governing Regular Army. The National Guard when called as such into the service of the United States shall, from the time they are required by the terms of the call to respond thereto, be subject to the laws and regulations governing the Regular Army, so far as such laws and regulations are applicable to officers and enlisted men whose permanent retention in the military service, either on the active list or on the retired list, is not contemplated by existing law. Sec. 111. National Guard When Drafted into Federal Service. When Congress shall have authorized the use of the armed land forces of the United States, for any purpose requiring the use of troops in excess of those of the Regular Army, the President, may, under such regulations, including such physi- cal examination, as he may prescribe, draft into the military service of the United States, to serve therein for the period of the war unless sooner discharged, any or all members of 19 the National Guard and of the National Guard Reserve. All persons so drafted shall, from the date of their draft, stand discharged from the militia, and shall from said date be subject to such laws and regulations for the government of the Army of the United States as may be applicable to mem- bers of the Volunteer Army, and shall be embodied in organ- izations corresponding as far as practicable to those of the Regular Army or shall be otherwise assigned as the President may direct. The commissioned officers of said organizations shall be appointed from among the members thereof, officers with rank not above that of colonel to be appointed by the President alone, and all other officers to be appointed by the President by and with the advice and consent of the Senate. Officers and enlisted men in the service of the United States under the terms of this section shall have the same pay and allowances as officers and enlisted men of the Regular Army of the same grades and the same prior service. Sec. 115. Physical Examination. Every officer and enlisted man of the National Guard who shall be called into the service of the United States as such shall be examined as to his physical fitness under such regula- tions as the President may prescribe without further com- mission or enlistment: Provided, That immediately preceding the muster out of an officer or enlisted man called into the active service of the United States he shall be physically examined under rules prescribed by the President of the United States and the record thereof shall be filed and kept in the War Department. 20 CHAPTER II. APPOINTMENTS AS MEDICAL OFFICERS Appointments in the Medical Corps in the Regular Army. Applicants must be between 22 and 32 years of age, a citizen of the United States, have a satisfactory general education, graduate of a reputable Medical School, at least one year's hospital training. Examinations will consist of two parts, a preliminary examination and a final or qualify- ing examination, with a course of instruction at the Army Medical School intervening. Commissions are issued in the grade of First Lieutenant with promotion to Captain after five years' service and to higher grades as vacancies occur, in examination. Permission to appear for examination may be applied for by letter to the Adjutant General of the Army. (See para- graphs 3 to 9, M. M. D., 1916). Appointments in the Medical Officers' Reserve Corps of the Regular Army. Under the new regulations for the examination of candi- dates for appointment in the Medical Officers' Reserve Corps of the Army, the candidate is required: First, to submit his application in writing to the Surgeon General of the Ar my; second, the application should he accompanied by two testimonials; find third, the personal history blank, properly filled in as directed thereon, after having the same certified to before a Notary Public. (These blanks may be obtained from the Surgeon General, U. S. Army, Washington, D. C.) The requirements for appointment are that the applicant must be a citizen of the United States, between 22 and 55 years of age, a graduate of a reputable medical school legally authorized to confer the degree of doctor of medicine, he must have qualified to practice medicine in the State in which he resides, and be in the active practice of his pro- fession. 21 The examination is physical and professional; the profes- sional examination to be oral, except in case of failure, when it will be written. Such written examination will be in the following subjects: 1. Practice of medicine, including etiology, clinical de- scription, pathology, and treatment of diseases. 2. Surgery--principles and practice. 4. Hygiene-personal and general, especially as to the prophylaxis of the more prevalent epidemic diseases. Specialists will be examined in their specialty. Commissions are issued for a period of five years, at the end of which lime officers may be recommissioned in the same or higher grades, that is, first lieutenant, captain, and major. The Act of June 3, 1916, creating the Medical Officers' Reserve Corps provides that in time of peace only those of the grade of first lieutenant maybe ordered to active duty, and this with their own consent, but in time of war the services of officers of all grades are at the disposal of the Government. Appointments in the Medical Corps of the National Guard. Under the present law and existing regulations, the candi- date is required, First to submit his application in writing to the Chief Surgeon; Second, the application must be ac- companied by two testimonials; Third, the personal history blank, properly filled in as directed thereon, and the same certified to by a notary public. (Blanks may be obtained from the Chief Surgeon or the Adjutant General of the State.) The requirements for appointment are that the applicant must be a citizen of the United States, not more than thirty five years of age, a graduate of a reputable Medical School, licensed to practice medicine in the State in which he resides, in active practice. The examination is physical and professional, and is con- ducted by a Board of Medical Officers appointed for that pur- pose and approved by the War Department. Commissions are issued in the grade of First Lieutenant, and after five years' service and upon passing a satisfactory examination, Medical Officers are promoted to the grade of Captain and subsequently to that of Major and higher grades as vacancies occur. 22 CHAPTER III. MOBILIZATION OF THE NATIONAL GUARD The following extracted paragraphs are taken from Special Regulations No. 55, War Department, April 2nd, 1917, and are of special interest to Medical Officers. Every Medical Officer should be supplied, if possible, with a copy of Special Regulations No. 55. 1. Transmission of Call or Draft. The Proclamation of the President, calling or drafting the National Guard, or any part thereof, into the service of the United States will be transmitted by the Secretary of War to the governor of each State and Territory and to the command- ing general of the National Guard of the District of Columbia. The adjutant general of each State and Territory and the District of Columbia will transmit to all commanders of organizations and individuals concerned the terms of the call or draft and the date on which they are required to respond thereto. 2. Induction into Federal Service. No official act, other than the President's call or draft, is required by law to mark the change of status of the Na- tional Guard to Federal control. The call or draft itself inducts all organizations and individuals concerned into the service of the United States on the date they are required to respond to the call, or in case of a draft on the date thereof. "The National Guard when called as such into the serv- ice of the United States shall, from the time they are required by the terms of the call to respond thereto, be subject to the laws and regulations governing the Regular Army." (Sec. 101, act of June 3, 1916.) All members of the National Guard and of the National Guard Reserve drafted into the service of the United States shall, from the date of their draft, stand discharged from the militia, and shall, from said date, be subject to such laws and regulations for government of the Army of the United States as may be applicable to members of the Volunteer Army. (See Sec. Ill, Act of June 3, 1916.) 23 9. Company Rendezvous, Mobilization and Concen- tration Camps. The home station of a company or other National Guard organization will be known as its company rendezvous. The place of assembly for the National Guard from a State, Territory, or the District of Columbia, when called or drafted into the service of the United States, is known as the mobiliza- tion camp. (See par. 253 F. S. R.) A mobilization camp need not necessarily be under canvas. "A concentration camp is a place near the scene of intended operations or near an embarkation point, where troops are assembled for immediate use against the enemy or for trans- port to an over sea theater of operations." (Par. 254 F. S. R.) (See pars. 254 to 256 F. S. R.) 11. Training at Mobilization Camps. Programs of instruction and training for National Guard Troops assembled at mobilization camps will be prepared under the direction of department commanders and furnished camp commanders. Division inspector-instructors are avail- able under the direction of department commanders to prepare these programs prior to mobilization. They will conform in general to the provisions of General Orders No. 36, War Department, 1916. Programs of instruction for sanitary troops will be based on Drill Regulations and Serv- ice Manual for Sanitary Troops, United States Army, 1914, and Mason's Handbook for Sanitary Troops. Senior inspector- instructors of sanitary troops of National Guard divisions are available under the direction of department commanders to prepare these programs. 16. Minor Physical Defects of Applicants for Enlist- ment. Department commanders are authorized to waive minor defects or deficiencies of an applicant for enlistment which are not sufficient to disqualify the applicant for field service. On the recommendation of the medical examiner, the mustering officer is authorized to waive such defects, and if he is unable to decide whether or not to authorize waiver he will forward his recommendations to the department com- mander, whose decision thereon will be final. In cases where no mustering officer is present the recom- mendation of the medical officer examining the applicant will 24 be submitted by the commanding officer of the post, station, or camp directly to the department commander. In all cases the action of the department commander or mustering officer will be noted on the report of physical examination. (See 12 to 15. Special Regulations No. 55.) 19. Discharge on Account of Disability. Officers and enlisted men of the National Guard found physically disqualified for service will be discharged by the department commander on the recommendation of the mustering officer. In case of an officer, the department commander will state in the order that the officer is discharged "By order of the President." (2431538 A. G. O.) In either case a certificate of disability will be made out by the medical examiner on Form No. 17, A. G. 0., on which will be shown whether or not the disability existed or origin- ated prior to the date the officer or enlisted man responded to the call, or in case of draft the date thereof. 21. Organization and Equipment of the National Guard. Pending the publication of Tables of Organization and equipment manuals, the Act of June 3, 1916, as published in Bulletin No. 16, War Department, 1916, and General Orders No. 50, War Department, 1916, should be consulted to ascer- tain the strength and composition of regiments and smaller units; and the Unit Accountability Equipment Manuals and General Orders No. 39, War Department, 1915, should be consulted to ascertain the equipment of headquarters, com- panies, and detachments. Medical Supplies. All medical supplies furnished without requisitions, in- cluding material for camp hospitals, will be invoiced to the camp surgeon. Shortage in arms, equipment, clothing, and medical sup- plies of organizations, exclusive of those incident to increase of personnel to maximum war strength, found to exist at mobilization camps, will be corrected by requisitions sub- mitted through military channels. Equipment found to be in excess of that required for the troops will be reported by the camp quartermaster and camp surgeon to the depart- ment commander. 25 48. Method of Accounting for United States Property for the National Guard. When the National Guard is not in Federal service the property and disbursing officer for the United States is accountable to the Militia Bureau for all United States property issued to the National Guard within his State. Supply officers of regiments or separate units less than a regiment are accountable to him for all quartermaster, ordnance, engineer, and signal property issued by him to regiments or separate units less than a regiment. A medical officer of the regiment or separate unit less than a regiment is accountable to him for all the medical supplies. Company commanders and individual officers are responsible, but not accountable, for the property or supplies issued to them on memorandum receipt by supply or medical officers. When an organization of the National Guard is in Federal service the method of accounting for United States property is the same as given above, except that supply and medical officers are accountable directly to the proper bureaus of the War Department. 51. Detail of Officers. When all or any part of the National Guard is called or drafted into the service of the United States, the commanding general of each territorial department will at once detail a mustering officer and the necessary assisting mustering officers for each State and Territory, and the District of Columbia, within the limits of his department, from line officers of the regular Army. He will also detail for each State and Terri- tory, and the District of Columbia, a medical examiner and the necessary assistant medical examiners from officers of the Medical Corps of the Regular Army The medical examiner may also be detailed as camp surgeon. (See par. 25.) Officers so de- tailed will be ordered to proceed without delay to the State mobilization camps, assistant mustering officers and the medical examiner being ordered to report upon arrival to the mustering officer for duty. In cases where troops are not sent to mobilization camps, these officers will be ordered by department commanders to company rendezvous or new sta- tions of organizations. (See pars. 4, 27 and 28.) 53. Duties of Medical Examiner. The medical examiner will direct, supervise, and when practicable make the examinations of officers and enlisted 26 men as to physical fitness, required by section 115 of the Act of June 3, 1916. He will be responsible that the reports of physical examination and identification record cards are made, authenticated, and completed, in accordance with instructions of the War Department. He will assist the mustering officer in the inspection of records, equipment, and property returns of sanitary troops (see pars. 63, 65 and 66.) If not practicable for the Regular Army medical examiners to make all examinations, medical officers of the National Guard will be detailed to assist in the work. (See par. 13.) When the initial muster of troops is made at company rendezvous or at points other than mobilization camps (see pars. 27, 28 and 51) the medical examiner will direct and supervise the prompt administration of the vaccination against typhoid fever and small pox. 54. Records and Reports of Mustering Officers and Medical Examiners. Mustering officers and medical examiners will preserve complete records of orders, correspondence, and all matters receiving their action and relating to individuals or organ- izations of the National Guard. Upon being relieved they will submit detailed reports of their duties to the department commander, turning over all instructions and records to their successors, and whenever a mustering office is finally closed the mustering officer will forward the official records referred to above directly to the Adjutant General of the Army. Before a command leaves its station or camp in home terri- tory en route to a camp of concentration, or to the theater of operations, all members thereof and all civilians who are to accompany it should be examined to ascertain their freedom from contagious disease and their physical fitness for the contemplated movement. In movements of troops by rail the senior medical officer of the command will inspect the accommodations provided, giving special attention to the water supply, and will make proper recommendations for the correction of any defects observed, (par. 589-590, Page 196, M. M. D., 1916.) 27 CHAPTER IV. CAMPS AND HOSPITALS Mobilization Camps. The places of assembly for Volunteers and for the Organ- ized Militia of the State, Territory, or the District of Colum- bia, when called into the service of the United States, are known as mobilization camps. The sanitary service of the mobilization camp is under the direction of the senior medical oflicer on the staff of the camp commander, who will be designated as camp surgeon. So far as practicable, officers of the Medical Corps only will be detailed as surgeons of mobilization camps. The chief objects to be obtained by the Medical Depart- ment at camps of mobilization are: (a) To make the physical examinations prescribed by Army Regulations and to secure accurate records of the condition of officers and men upon their ad- mission to the Federal service. This will be effected in accordance with instructions from the War De- partment; (b) To make physical examinations of civilians attached to troops and to exclude those who are unfit for the contemplated service; (c) To administer prophylactic vaccinations. A record of these examinations will be kept as prescribed in paragraphs 187, 188 and 193; M. M. D. 1916. (d) To equip all individuals and organizations with such articles of Medical Department property as are re- quired by existing orders, and to completely equip all individuals and organizations pertaining to the Medical Department; (e) To instruct all individuals and organizations so far as practicable in personal and camp hygiene, and in addition to instruct the Medical Department per- sonnel, commissioned and enlisted, in the routine work of the Medical Department in the field. An important factor in the instruction will be the object lesson afforded by the administration of the camp and 28 the measures inaugurated for the maintenance of sanitary conditions therein. This instruction will be carried out under the immediate supervision of the camp surgeon, acting under the direction of the de- partment surgeon. It will be systematically arranged and will follow a definite program furnished by the department surgeon. All letters and reports to the department surgeon, the division surgeon (unless he is in camp), or the Surgeon Gen- eral will be forwarded through the camp surgeon in order that they may be returned to the writer for correction, if necessary. The equipment for a camp hospital, varying according to the anticipated strength of the camp, will be supplied to mobilization camps by direction of the War Department without requisition. Supplies and equipment pertaining to the Medical De- partment in the hands of organizations temporarily at camps of mobilization will be maintained intact, being used only for purposes of drill and inspection. The camp surgeon will provide a suitable place in which the medical personnel attached to the organizations may hold sick calls and will furnish the necessary supplies for the treatment of the sick. (M. M. D., 1916, Pages 196-197.) Concentration Camps. The places which are selected by the War Department, when war is imminent or has been declared, for the assembly of troops for joint operations or for embarkation, are known as concentration camps. The sanitary service of a concentration camp is under the direction of the senior medical officer from the staff of the camp surgeon. In addition to his routine duties as camp surgeon, it will be the duty of this officer: (a) To continue the instruction of the personnel begun at the home stations of the troop or at the mobiliza- tion camps; (b) To ascertain by inspection of descriptive lists, vaccination registers, and other records available whether the prescribed vaccinations and physical examinations of all the personnel of the camp have been made and to complete such inoculations or vaccinations as may be necessary; 29 (c) To make sure, by proper measures, that all troops are equipped as contemplated in the War Regulations. (See paragraph 594). A camp hospital will be provided for the camp upon re- quisition by the camp surgeon, unless other hospital facili- ties are available in the immediate vicinity. The supplies and equipment pertaining to the Medical Department in the hands of the organizations temporarily at the camp will be maintained intact, being used only for purposes of drill and instruction. The camp surgeon will provide a suitable place in which the personnel attached to the organizations may hold sick calls and will furnish the necessary supplies for the treatment of the sick. (M. M. D., 1916, Page 197). Camp Hospitals. A camp hospital is an immobile unit, organized and equipped for use in camps where the care of the sick would otherwise result in immobilization of field hospitals or other sanitary formations pertaining to organizations. Department and division surgeons and other adminis- trative officers charged with providing for the sick and wounded under field service conditions will prevent the im- mobilization of sanitary formations pertaining to organ- izations by providing for the establishment of camp hos- pitals where necessary. The equipment and personnel of a camp hospital will vary with the requirements of the situation. A suitable camp hospital for one or two regiments may be formed with a regimental hospital equipment, less transportation (pars 869 and 872, M. M. D.) as a nucleus. A camp hospital for a brigade or larger organization may utilize the equipment of a field hospital (par. 879 only) as a nucleus. In Paragraph 886 will be found a list of supplemental supplies for the equipment of camp hospitals, more or less of which will be necessary according to the conditions which are to be met. (See also Par. 859 M. M. D.) A camp hospital is under the control of the senior medical officer on the staff of the camp commander and is admin- istered by him or by one of his subordinates. (M. M. D., 1916, Page 198). Hospital Trains and Trains for Patients. Hospital trains are Medical Department organizations and will be provided by the War Department when required 30 for the transportation of the sick and wounded. In cases of emergency, when hospital trains are not available, ordinary trains for patients will be provided for the temporary use of the Medical Department. A hospital train made up of ten cars, of which eight are for patients (capacity 200), is allowed-in accordance with Tables of Organization-a personnel of three medical officers (captains or lieutenants); three noncommissioned officers (one sergeant, first class, and two sergeants); two acting cooks; twenty-two privates, first class, and privates (twenty nurses and two orderlies). The equipment of the hospital train and the personnel and equipment of trains for patients will be determined according to the needs of each case. Hospital trains and trains for patients in the service of the interior will operate under the direction of the Surgeon General. Each train will be under the command of the senior medical officer on duty therewith. The commanding officer of a train will, some hours before it is due at the hospital which is to receive its patients, notify the commanding officer of the latter by telegram of the time of its arrival and the number of patients to be provided for. (M. M. D., 1916, Page 200). 31 CHAPTER V. ORGANIZATION OF THE MEDICAL DEPARTMENT IN WAR The details of organization of the Medical Department, the amounts and kinds of transportation allowed, and the factors on which the allowance of transportation is based, are given in Tables of Organization. The following table gives an outline of the organization of the Medical Department in War: (Manual Medical Depart- ment, 1916, Page 195.) Department surgeons. Medical service, mobilization camps. Medical service, concentration camps. Camp hospitals. General hospitals. Convalescent camps. Hospitals, ports of embarkation. Surgeons, ports of embarkation. Hospitals for prisoners of war. Medical supply depots. Hospital trains and trains for patients. Rest stations. Hospital ships and ships for patients. Sanitary inspectors. Service of the Interior Zone of the Advance (Division Surgeons. Medical department personnel on duty with line organizations. Directors of am- bulance companies 'Camp in- firmaries. I Ambulance. | companies. Sanitary- Trains. Directors of field hospitals. Field hospitals. Surgeon General Base section (surgeon, base group): Base medical supply depot. Base hospitals. Convalescent camps. Contagious disease hospitals. Trains, boats and ships. Casual camps for sanitary troops. I Sanitary squads. | Field Laboratories. American National Red Cross units. Sanitary inspectors. Intermediate section (surgeon, inter- mediate group): Rest stations. American National Red Cross units. Advance section (surgeon, advance group): Advance medical supply depot. Theater of Opera- tions. Chief Surgeon, Field Army. Zone of the) Line of Com- munica- tions (Sur- geon base group.) Sanitary Coin mn Evacuation hospitals. Evacuation ambulance companies. 32 MAXIMUM STATUTORY STRENGTH* Sanitary Units, (Militia Bureau, March 16, 1917) The proportions of privates, 1st class, to privates, will be 5 to 1 (privates, 1st class, 5, privates 1) in all sanitary de- tachments and units. (a) Regiment of Infantry. Sanitary troops attached, 1 major 3 captains or 1st lieutenants 1 sergeant, 1st class 3 sergeants or corporals 29 privates, 1st class, and privates. (b) Battalion of Infantry. Sanitary troops attached, 1 captain or 1st lieutenant 1 sergeant or corporal 7 privates, 1st class, and privates. (c) Regiment of Cavalry. Sanitary troops attached, 1 major 3 captains or 1st lieutenants 2 veterinarians 1 sergeant, 1st class 3 sergeants or corporals 29 privates, 1st class, and privates. (d) Squadron of Cavalry. Sanitary troops attached, 1 captain or 1st lieutenant 1 sergeant or corporal 7 privates, 1st class, and privates. (e) Regiment of Field Artillery. Sanitary troops attached, 1 major 2 captains or 1st lieutenants 2 veterinarians 1 sergeant, 1st class 2 sergeants or corporals 20 privates, 1st class, and privates. ♦Subject to changes. 33 (f) Battalion, Field Artillery. Sanitary troops attached, 1 captain or 1st lieutenant 1 sergeant or corporal 7 privates, 1st class, and privates. (g) Battalion of Engineers. Sanitary troops attached, 1 captain or 1st lieutenant 1 sergeant or corporal 7 privates, 1st class, and privates. (h) Regiment of Engineers. Sanitary troops attached, 1 major 2 captains or 1st lieutenants 1 sergeant, 1st class 2 sergeants or corporals 20 privates, 1st class and privates (i) Field Battalion, Signal Troops. Sanitary troops attached, 1 captain or 1st lieutenant 1 sergeant or corporal 5 privates, 1st class, and privates. (j) Ambulance Company. 5 captains or 1st lieutenants 2 sergeants, 1st class 7 sergeants 11 corporals 1 horseshoer 1 saddler 1 farrier 1 mechanic 3 cooks 123 privates, 1st class, and privates (k) Field Hospital Company. 1 major 5 captains or 1st lieutenants 3 sergeants, 1st class 6 sergeants or corporals 1 horseshoer 1 saddler 1 farrier 1 mechanic 2 cooks 58 privates, 1st class, and privates. 34 Objects of the Medical Department Administration The objects of the Medical Department administration in war are: (a) The preservation of the strength of the army in the field by: 1. The necessary sanitary measures; 2. The retention of effectives at the front and the movement of non-effectives to the rear without obstructing military operations; and 3. The prompt succor of the wounded on the battle- field and their removal to the rear, thus preventing the unnecessary withdrawal of combatants from the, firing line to accompany the wounded and thereby promoting the general morale of the troops; (b) The care and treatment of the sick and injured in the zone of the advance, on the line of communications, and in the home territory. Duties of the Medical Department. The Medical Department is charged with the adminis- tration of the sanitary service. Specifically, its duties are: (a) The initiation of sanitary measures to insure the health of the troops; (b) The direction and execution of all measures of public health among the inhabitants of occupied territory; (c) The care of the sick and wounded on the march, in camp, on the battlefield, and after removal there- from; (d) The methodical disposition of the sick and wounded; (e) The transportation of the sick and wounded; (f) The establishment of hospitals and other formations necessary for the care of the sick and wounded; (g) The supply of sanitary material necessary for the health of the troops and for the care of the sick and wounded; (h) The preparation and preservation of individual records of sickness and injury, in order that claims may be adjudicated with justice to the Government and to the individual. M. M. D. Pages 179-180. The Sanitary Service in War. In time of war, the activities of the military establishment embrace: (1) The service of the interior; (2) The service of the theater of operations. Administrative Zones. 35 The service of the interior functions both in peace and in war; that of the theater of operations in war only. (Page 179, M. M. D.) The service of the interior is carried on by: (1) Department commanders; (2) Bureau chiefs, having for this, purpose general depots of supply, general hospitals, arsenals, etc. The service of the theater of operations is carried on by the commander of the field forces. The theater of operations is divided into two zones: (1) The zone of the line of communications. (2) The zone of the advance. Personnel of the Sanitary Service. In time of war, the Sanitary Service includes: (1) All persons serving in or employed by the Medical Department, including officers and men temporarily or permanently detailed therein; (2) Members of the American National Red Cross assigned to duty with the Medical Department by competent authority; (3) Individuals whose voluntary service with the Med- ical Department is duly authorized. The personnel of the Medical Department and all other persons assigned to duty with that department are collec- tively called Sanitary Troops. The following persons serve in or are employed by the Medical Department; (1) Medical officers of the Regular Army (including officers of the Medical Reserve Corps), of the Organ- ized Militia called into the service of the United States, and of the Volunteer Army; (2) Physicians under contract; (3) Members of the Dental Corps; (4) Members of the Hospital Corps; (5) Members of the Nurse Corps; (6) Officers and soldiers of the line or staff detailed for duty with the Medical Department; (7) Civilians employed by the Medical Department. 36 CHAPTER VI. SANITARY TROOPS ON DUTY WITH LINE ORGANIZATIONS Sanitary troops with line organizations, including detach- ments with regiments, battalions, trains, etc., vary in per- sonnel with the strength of the organization served and the nature of the duties they are required to perform. (See Tables of Organization: War, Regimental Organizations.) When a regiment is operating independently the Medical Department equipment available for its use consists of the first-aid packet, carried by each officer and enlisted man of the Army as a part of his individual equipment; the articles carried as individual equipment by each medical officer, (par. 864, M. M. D., 1916) and by each member of the Hos- pital Corps (par. 865, M. M. D., 1916); the combat equipment (par. 866 and 867); the camp infirmary equipment (par. 869 and 870); and the additional articles necessary for the establishment of a regimental hospital (par. 872, M. M. D., 1916.) (a) The additional articles for the regimental hospital will be taken to the field only under circumstances requiring the organization to provide hospital care for its own sick and wounded. (Par. 631-632, M. M. D., 1916, Page 203.) When a regiment or other line organization is operating as a part of a division the Medical Department equipment provided for its exclusive use consists of the first aid packets and individual equipments mentioned in the preceding paragraph, and the combat equipment (Par 886-867). A small box of surgical dressings (par. 954) and one or more litters are carried on each ammunition wagon. The requisite articles for the establishment of the aid station are carried on the pack mule allotted the sanitary service, which marches with the combat train of the organization. The medical officer responsible for this equipment will see that it is complete and that it is maintained intact for service in com- bat. 37 (a) On the march and in camp, with the exceptions noted in paragraph 601, the medical supplies and dispensary service required by regimental organization are provided through the medium of the camp infirmary. (b) In combat it is contemplated that the expenditures of dressings, etc., from the equipment of regimental organiza- tions will be replenished from reserve supplies of the nearest ambulance company or camp infirmary. (See par. 551.) The surgeon of a line organization is both an advisory and an administrative officer. (a) He commands the sanitary troops on duty with the organization. (b) He is the advisor of the organization commander in medical and sanitary matters and, to the extent of his au- thority, is responsible for the execution of sanitary measures in connection with the organization. (c) He provides care and treatment for the sick and wounded and is responsible for the efficient performance of the sanitary service of the organization. (d) He makes such sanitary inspections as may be neces- sary. In connection therewith he supervises the water supply and its purification, the sanitation of kitchens, the disposal of garbage and waste water, the police of latrines and urinals and the filling in and marking of the same when discontinued, the police of bathing places and picket lines, the measures taken for the destruction of flies and mosquitoes, and all other sanitary procedure necessary to preserve the health of the command. (e) He instructs at suitable times designated by the com- manding officer, the entire personnel of the organization in personal hygiene and first aid. (f) He trains his subordinates in all departments of field sanitary work. (g) He makes timely requisition for necessary supplies and equipment. On the march the duties of the sanitary personnel are to render first aid where required, to transport the sick and wounded, and to make suitable disposition of them on arrival in camp. Ordinarily the surgeon marches with the regimental commands, and one medical officer marches in the rear of 38 each battalion. Each officer is mounted and accompanied by a mounted orderly. The remaining regimental sanitary personnel usually march with the battalion units. When out of the presence of the enemy, ambulances are ordinarily ordered distributed by the division commander throughout the column, in the rear of regiments, battalions, etc. Unless otherwise ordered these ambulances join their companies at the end of the day's march or at the beginning of an engagement. When a regiment operates independently it may be assigned its full quota of four ambulances. (See par. 673 and 721, M. M. D., 1916.) (Pages 203, 204, 205). 39 CHAPTER VIL EQU1PMENT OF MEDICAL DEPARTMENT All Medical Officers supply their own personal equip- ment such as uniform, etc. Many states including Wisconsin will issue through the Chief Quartermaster on requisition such field equipment as the following; saddle, bridle and all neces- sary horse equipment, field trunk, field furniture, bedding roll, blankets etc. Many articles of quartermaster's and ordnance supplies and clothing may be purchased, if the necessary stock is available, through the Chief Quarter- master. All Officers should be equipped for the field as above indicated. Individual Equipment for Medical Officers. 1 Medical officer's web belt. 1 Instrument Case. 1 Medicine Case. 1 Book Diagnosis Tags. 1 Empty Flask for Hypodermic Solution. 1 Hypodermic Syringe. 12 Extra Needles for Hypodermic Syringe. 1 Clinical Thermometer. NOTE. The articles included in the above list constitute special equipment carried only by medical officers below the grade of Lieutenant Colonel. Equipment for Inlisted Men. The following property constitutes the essentials of the individual equipment of the enlisted men of the Med- ical Department. (A) Quartermaster property, 1 belt, waist, web. 1 bed sack. 2 blankets, woolen. 2 breeches, olive drab, woolen. Chevrons, olive drab, (for non-com- missioned officers). 1 coat, olive drab, woolen. 1 cord, hat, service. 1 cord, tying, hat, service. 1 hat service. 1 leg- gings, canvass, pair. 1 overcoat, olive drab, woolen. 1 poncho. 2 shirts, olive drab, woolen. 1 shoes, russet, pair. 1 slicker, for mounted men instead of poncho. 1 tag, identi- 40 fication. 1 tent, shelter half complete. 1 first aid packet. (B) Ordnance property. 1 blanket roll straps, set. 1 canteen. 1 canteen strap. 1 cup, 1 fork, 1 knife, 1 spoon, mess. 1 haversack, or new pack. 1 axe, Hospital Corps, 1 meat can, 1 scabbard. 1 waist belt, hospital corps, russet leather. For mounted men. 1 horse equipment complete. (C) Medical Property. 1 emergency case for each Sergeant. 1 emergency case strap. 1 first aid packet. 1 pouch hospital corps for each private, excepting those acting as orderlies, or new belt. 1 pouch orderly for each private first class or private acting as orderlies. Each medical officer on duty with line troops is entitled to an orderly. All property is issued on requisition by Organization Commanders or on memorandum receipt to individual officers, and must in every instance be accounted for. All losses of public property must be accounted for by respon- sible and accountable officers in accordance with the re- quirements of Army Regulations. All property is (1) Quartermaster property, (2) Ordnance property, (3) Medical Property. 41 CHAPTER VIII. REQUISITIONS FOR PROPERTY 1. In making requisitions the following points are so fre- quently neglected, that special attention is called to them: (A) Requisitions should be made in quadruplicate, one copy being retained, and three forwarded direct to the sup- ply department. They should be prepared on the proper Medical Department blank form No. 35, if it is available. If blanks are not available, use plain paper. (b) The headings at the top of the form should all be properly and completely fdled in. The "Station" should include not only the town or camp, but also the name of the hospital or infirmary; as, for instance, "Regimental Infirmary, 1st Wisconsin Infantry, Camp Douglas, Wisconsin, or Wis- consin Field Hospital No. 1, Milwaukee." In case of a regimental infirmary, "command" means the entire regi- mental strength. "Annual", "quarterly," "emergency," "post", "field," or "dental" should be stricken as directed in note. (c) The requisition should be signed by the senior surgeon of a regiment or the commanding officer of a field hospital or ambulance company, and his rank should be placed below the signature. Approval of medical requisitions by the regi- mental commander is not necessary. The date space should be filled in and the requisition briefed. (d) 'I he surgeon of an organization is responsible for providing medical supplies on his own initiative. He should, therefore, frequently check over his property and make timely requisition before medicines, dressings, etc. are approaching exhaustion. As far as possible, a reserve should be kept on hand to draw from for daily use, so that chests and cases may be kept intact and ready for emergency use in the field. Ordinarily, requisitions should cover antici- pated needs for at least one month. (e) Organizations under canvas are usually furnished field supplies only, except at isolated stations where no hospital facilities are available. The medicines, dressings, etc. available are shown in Paragraphs 864, 865, 866, 869, 871, 872, 874, 879, 907, 913, 923, 932, 933, 940, 947, 948, 42 953, 954, 955, 956, 958, Manual of the Medical Department, 1916. Only those field supplies pertaining to a camp in- firmary should be asked for by the surgeon of a regiment. Articles shown on Post Supply Table, Paragraphs 843, 844 and 845, Manual of the Medical Department, 1916, are approved only for Posts or isolated stations above and the reason for asking for them must be shown in the "Remarks Column" in each instance. (f) In the first column of the requisition blank form, there should be entered the official names of the articles desired, written just as they appear in the supply table in the Manual of the Medical Department. The articles should be arranged in the order they appear in the supply table. Two or more lines may be taken for each entry if necessary. In the first column, after the name of the article should be entered the appropriate "unit of issue"; viz. number, bottle, tin, roll, lb., oz., doz., gross, quart, etc. The unit entered on the requi- sition should conform to that shown in the supply table. (g) The "Expended," "On hand," and "Wanted" columns should contain numbers only. Requisitions should not be submitted with units, such as "pills," "bottles," "rolls," "doz.," etc. entered in these columns. If none of the articles in question are on hand, an "0" should be placed in the proper location in the "On hand" column. (h) In the "Remarks" column the reason for asking for the articles, should be stated. This may be general for the whole column, if only expendable articles on the supply table are asked for. In case of non-expendable supplies, a special remark should be made in this column to show whether the articles are needed to complete the authorized equipment or to re- place unserviceable articles. Unserviceable articles should be carried as "On Hand" in the "On Hand" column and a notation made in the "Remarks" column that such and such numbers are unserviceable. (i) There should be no greater amount of serviceable non-expendable material on hand with a regiment, field hospital or ambulance company, than is sufficient to make it conform with the prescribed allowances for such an organi- zation. Authorized articles not on hand should be required for at once. (j) Gare should be taken that only medical property is asked for on medical requisitions. Ordnance property is obtained by ordnance requisition sent to the Department 43 Ordnance Officer; Quartermaster property should be ob- tained from regimental quartermaster. Hypochlorite of lime for water sterilizing bags (Lyster Bags) is Quarter- master's property. The same is true of quicklime for gen- eral disinfecting purposes. (k) Medical Department blank forms should be obtained by requisition on Form 37, Medical Department. This requi- sition should be for blank forms only, no other medical supplies being asked for on it. If no Form 37 is available, ask for blanks by letter addressed to proper officer or depart- ment. (1) Blank forms for Ordnance Department, Adjutant General's Department, Quartermaster's Department, and Inspector General's Department should be obtained for the medical officer by the regimental commander. (m) Medical supplies are frequently shipped by freight and several weeks are apt to elapse between sending in of requisitions and receipt of the articles. This shows the importance of exercising forethought and preparing requi- sitions in plenty of time. In war or emergency, supplies, except very bulky ones, are shipped by express or mail, but even with this procedure at least a week is likely to elapse before supplies can be delivered. 44 CHAPTER IX. REPORTS Nothing causes a young medical officer, first entering the military service, more unrest and worry than the rendering of the various reports required by regulations. It is not the in- tent here to explain all the reports that are called for but merely to describe the very essential ones which must be made out correctly to keep up the work. On arrival at camp or post, the first duty of a medical officer is to report to the Commanding Officer and the Chief Surgeon. The Chief Surgeon will usually have some special reports to be made direct to him. Daily Reports. Reports to be made daily are: Surgeon's morning report of sick, Form 71 M. D. Morning report, San. Det., Form 332 A. G. 0. Daily sick report, San. Det., Form 339 A. G. 0. When in the field, in addition to these reports there will be made: Daily field reports of sanitary personnel and transporta- tion, Form 82. Daily field report of patients, Form 83. The first three forms require no explanation as full in- structions are given on the forms except that in marking the disposition of a patient in any sick book, the term "Light Duty" should never be used. The entry must be "Duty," "Quarters," or "Hospital." In filling out Form 82, a usual error is to class men and officers who have been transferred or temporarily assigned elsewhere as non-effectives. In the non-effective column there should be entered only bonafide members of the com- mand who are temporarily non-effective from sickness. Per- sonnel permanently assigned elsewhere or transferred should be listed under the column "Lost" and appropriate remarks describing the transaction entered on the reverse side of the blank. Entries in the column "From Last Report" of each 45 day's form should tally with the column "Total Effective" on the previous day's report. In form 83, the entry in the column, "Remaining Sick from Last Report," should tally with the final total of the preceding day and the other columns should be filled out as described. On the reverse side of the blank, the classification of cases remaining under treatment must total the same as the number entered under a similar heading on the face of the blank. These two reports are made in duplicate, one of each to be retained with the command and the other to be sent to the chief surgeon each morning. A report of the physical examination of the whole command is made to the Chief Surgeon twice each month. Monthly Report. Personal Report. A Personal Report is made monthly by letter in duplicate to the Surgeon General, through the Department Surgeon. This letter should be in the usual accepted form of official correspondence, the entry under the heading "Subject" being "Personal Report for " naming the month. In the body of the report, the medical officer should state what duty he has been on during the month, adding any marches, camps, or maneuvers. This same report will be made on any change of status or station, the entry under the heading, "Subject," showing the char- acter of the report. Other Reports. Return of the Medical Department. For this report, Form 47 a. M. D. is used. The first return executed must contain, according to rank, all the names of the soldiers belonging to or present with the formation during the period of the return, indicating where they came from and the date of joining. In subsequent returns, only gains and losses will be reported, the soldier's rank and the character of the gain or loss with the date being given in each case. A final return or muster-out or the breaking up of the command will con- tain the names, according to their rank, of all soldiers be- longing to the formation since the date of the preceding re- turn, including the list of gains and losses and showing the distribution of the men upon the breaking up of formation. If a loss is by discharge, the character and soldier's physical condition will be noted. Under "Remarks," record will be 46 made after an engagement or campaign of any participation therein by the formation or by its individual members, naming them, and also of any commendation of the formation as a whole or of individual members. Payrolls. Form 366 a, and 366 W. D. Full instructions are printed thereon. Statement of Hospital Funds. Form 49 M. D. is used and is to be filled out where a unit has a hospital fund. If there is no such fund, a statement of this fact will be made on the blank. Report of Sick and Wounded. This report consists of three forms; the Report Sheet form 51; the Nominal Check list form 51a; and the Report Cards form 52 M. D. This report is one of the most important and great care should be exercised to have it exactly in accordance with the instruc- tions. The report cards are merely duplicates of the register cards, made out at the infirmary for every man or officer who is taken up as sick. The detail of these entries will be taken up more fully under register cards. The report sheet, form 51, will be made out according to the directions thereon, care being taken in the following entries: On line one, the location on the last day covered by the report, must be given. Under "Command" every company or detachment that is served by the infirmary should be entered and in the next space beneath every variation of the composition of this command, such as arrival or departure of companies, giving dates and names of accompanying medical officers, should be given. Location of all camps occupied during the month, with dates of arrival and departure, must be given. Under "Numerical Reports for the Month," cases that are carded for "Record Only" and "Transfer Only," will be entered above the usual entries in these columns; those "for Record Only' in the column "Returned to Duty." The cards for these two classes will show no days lost. The total of com- pleted cases, plus those remaining, should equal the number entered in the space, "Total Accounted For." Great care must be taken that the entries under this heading agree accurately with the notations on the report cards. The nominal check list, form 51 M. D., is a list of the names in numerical sequence as shown on the report cards, and care must be taken that the names, initials, etc., agree accurately with those entered on the cards. These reports are made in duplicate, one set being retained and one forwarded to the Surgeon General through the Department Surgeon. 47 Register Cards. The register cards, form 52 M. D., from which the report cards are made, are the histories of the sickness or wounds of every officer and man who is treated by the medical department, who is taken up as sick in quarters or hospital or who is carded for record or transfer only. The various headings are plain but some explanation is necessary in order to fill them out as desired by the Surgeon General. In space 9 service must be entered in years and a fraction as 2^2 years; also this is for federal service only. In space 10, the cards will be numbered consecutively beginning with number one and carried indefinitely until the close of the station, irrespective of any changes of location. In space 12 is usually entered "From Command," or it may be "From Desertion." If a member of some other command is treated the entry will be "Casual from command: proper station-," giving the name of the Company. Cases taken up for immediate transfer will have added in the same space "Carded for trans- fer only," with an asterisk, referring to back of card where entry will be made, "Doing full duty while with Command." Cases taken up for "record only", will have entered here "Carded for record only," with accompanying remarks on the back of the card as outlined in the M. M. D. Par. 445. In space 13 will be entered cause of admission and the word- ing of this entry must agree with that in paragraph 455 M. M. D. All diseases or injuries will be entered as "in line of duty" unless the surgeon knows, first, that the disease or injury existed before entering the service; second, that it was con- tracted while absent from duty without permission; or third, that it occurred in consequence of wilful neglect or immoral conduct of the man himself. When a man is admitted for an operation to correct some defect that existed prior to his entering the service the operation is the cause of admission not the original disease, and his sickness is therefore in line of duty. Where two causes of admission are given, each should be numbered and two answers under the same num- bers are required in space 14. No complications will be entered in space 15 unless they occurred after the date of admission. In space 16 will be entered the disposition as "Duty," "Death," or "Transferred to-", naming the place to which transferred. The word "Duty" infers a cure, so if the case is not wholly cured, the entry should be "Duty Improved." In space 18 is entered the name of the Hospital or Infirmary 48 giving the treatment. In space 20 will be entered the location of the unit on the last day of the report. On the back of the card will be entered the days lost in quarters, or in hospital, bearing in mind that the day of admission is a day lost and the day of discharge is not. Muster Roll. Form 21, A. G. O., contains full instruc- tions. A new form for the use of the National Guard known as the Service Record Form 29, A. G. 0., takes the place of old forms 29, A. G. 0., Descriptive List, No. 25, A. G. 0. Re- servists Discriptive Card, also Form No. 46, A. G. 0., De- scriptive and Assignment Card and No. 443, A. G. 0., This is an important form, which follows the soldier through his entire service. Full instructions are printed thereon. This roll has full directions attached. Commanding officers of sanitary formations, who are accountable for property, must keep a record of all transac- tions regarding same, so as to make a complete return at the close of their service or at such other time as the authorities may direct. Articles lost or destroyed should be acted on by a survey- ing officer, before they are replaced by requisition. A regimental surgeon is responsible to the regimental quartermaster for quartermaster supplies, but he must make the returns of ordnance and medical property to the chiefs of these bureaus in Washington. The ordnance return is made in duplicate on Form 18, 0. D. semi-annually, one sent forward and one retained. The medical return is made on Forms, 17, 17a, 17b. The first is merely the cover; the second is the form that is to be sent forward, and the third is the one to retain. The best way to keep this work in control is to enter on these blanks all property on hand at the beginning of service, and then add each new transaction as it occurs. At the end of the period all that will be necessary to complete the return, will be to balance the sheets and sign. While the above is by no means a complete list of the neces- sary reports it contains the most important ones and a knowl- edge of their use and execution will be of great value to any officer. Most of the other reports called for are self ex- planatory and the officer who has mastered the above will have little or no trouble with the others. 49 CHAPTER X. PHYSICAL EXAMINATION OF RECRUITS The efficiency of a military force depends upon its "man power," upon the physical and mental make-up of the indi- vidual soldier. The physical examination of recruits, therefore, is a serious duty to be performed intelligently and conscientiously. This duty the people, the President, the Congress and the Military Commanders have placed upon the medical profession and specifically upon Military Med- ical Officers. The Medical Officer who slurs the examination of a re- cruit and who, from want of care or want of conscience, passes a man who is unfit to bear the strain of military service and who, by the application of the rules dictated by medical science, military experience, and common sense should be excluded from military service, commits a crime against the individual recruit, against the military organiza- tion, and against his country. He fails in his duty as a medical officer and he violates his oath of office. It does not follow that a man who supports himself and his family by manual labor will necessarily make an efficient soldier. Such a man may have physical defects which in no degree impair his usefulness at labor but which, when he is called upon to meet the strain of military campaign, may quickly render him not only useless as a soldier but a serious burden to his command. Army's Strength Depends on Individual Soldier. Despite all the wonderful advances which science has made in the mechanics of destroying human lives, all the ingenious inventions of modern warfare such as highpower explosives, shrapnel, grenade liquid fire, poison gas, Big Berthas, giant howitzers, aeroplanes, Zeppelins, and caterpillar tanks, the final determining factor in battle is still the human body directed by the thinking mind. The individual soldier is the greatest asset of all, the foot soldier, or infantryman, the supreme agent of all attacking engagements. Aeroplanes and advance cavalry may locate the enemy, the artillery may sweep their trenches or batter down their embank- ments, but it is the infantryman who finally storms the de- 50 fenses and takes the desired position, oftentimes in hand- to-hand conflict. On march, maneuver, or battle-ground, the infantryman carries with him his house, his water and food supply, and also his weapon of defense. With this load, which may vary anywhere between fifty and sixty-four pounds depend- ing on the type of equipment adopted by the War Depart- ment, he must be able to march twenty miles a day in the hot sun on hard roads; he must know how to conserve his quart of water; how to care for his feet; how to cleanse his body under field conditions; how to be hygienic;how to balance his diet; and above all, under the stress of hardship, privation and most trying conditions, he must be able to maintain an even temperament and to be absolute master of himself, with his mind so well under control that when the time for action comes, he will not become panic stricken. Other and greater demands are made on the physical endurance and the mental poise of the soldier but this brief outline serves to demonstrate in a general way that only the fit can meet the everyday requirements of war. It serves to demonstrate, also, the need for the greatest and most conscientious care on the part of the examining officer. Where serious doubt exists as to the physical efficiency of a recruit, the safe rule is to reject. Where men are accepted with physical defects not causes for rejection, such defects must be noted on the physical examination blanks. Military Commanders and Military Surgeons from the earliest times have found, through campaign experience, that where an army has been raised without proper regard to the physique of the recruits it has always proven inefficient for continued or difficult service. Age of Recruits is Important. Recruits must be selected with reference to the rules as to maximum and minimum age. Men above the age of 35 years are not readily amenable to the requirements of military life and men below the age of 19 or 20 are apt to be unde- veloped in physique and physically incapable of standing the strain of active field service. Nothwithstanding all unauthoritative statements to the contrary, made by men who have not carried the responsibilities of military com- manders in the field, the testimony of all military experience for more than one hundred years is opposed to the enlist- ment of undeveloped youths for military service. 51 Boys between the ages of 18 and 21 sometimes show good physical development and when they conform to the normal physical standards which have been dictated and formulated by experience, they make acceptable soldiers. They have initiative, are active, receptive, apt to be brave, and often regardless of consequences. These qualifications are desirable under most conditions of military life and necessary under some conditions. Nevertheless, it must not be forgotten that military experience has demonstrated that young and undeveloped men break down under the strain of exposure and the hardships of active campaign in the field; that they are more susceptible to contagious disease than their older comrades; and that, where an army has large numbers of them, they fill the ambulances and hospitals and constitute a serious menace to the fighting force. After the battle of Leipzig, Napoleon said: "We must have grown men. Boys serve only to fill the hospitals and encumber the roadside." Neither military experience nor the physical facts have changed in this respect since the time of Napoleon. On the other hand, it must not be forgotten that men well along in middle life, even though technically able to meet the physical requirements laid down for recruits, are apt to be somewhat stiffened and rigid physically, perhaps mentally obtuse, and may not be desirable recruits. Such men are frequently no better able to endure the strain of active campaigning than immature youths. Grown Men Needed. Relative Weight and Height Important. The matter of weight and height and of relative weight and height is of prime importance. Very tall men frequently gain their height at the expense of bulk and consistent de- velopment of the internal organs. When called upon to carry the load of a private soldier in the field, such men soon play out from lack of proportional vital force.. The nearer men come in their physical make-up to the generally accepted normal standards, the more likely they are to endure the strain of march and battle and the more valuable they are as soldiers. It has been truly said that "an army consists of the bayo- nets in the field and not the names on the muster roll." 52 For the present purposes, the rules for the examinations of recruits laid down in Circular No. 5, War Department, April 6, 1916, govern and should be adhered to. These in- structions are to be modified only by subsequent instruc- tions from competent authority. Medical Officers should not advise a request for waiver of defects listed as causes for rejection, except in the few individual cases where the Medical Officer, considering all the circumstances, is convinced that the recruit will be able to do his full duty under the most trying military conditions and where his advice could be fully justified, both from a medical and from a military standpoint. It is, of course, expected that in the examination of recruits Medical Officers shall exercise their medical judgment and skill but under no circumstances should military requirements be placed second- ary to any other consideration. Adhere to Regulations. MEDICAL EXAMINATION OF RECRUITS. The routine of examination is so arranged as to facilitate elimination of recruits manifestly disqualified for service without completion of the entire examination. Discovery of defective vision or hearing or of deficient measurements, for instance, obviates the need of further tests or inspection. On the other hand, the medical examiner will use every possible diagnostic procedure at his disposal, including the use of the microscope, the X-ray, and other laboratory methods if necessary for the determination of occasional doubtful cases and he may, if practicable, admit such cases to hospital for study and observation for a reasonable period in order that a definite conclusion may be reached in regard to them. A copy of Circular No. 5, containing detailed instructions for the examining of recruits and organized militia, should be in the possession of all medical officers and should be carefully studied. The following is a condensed summary of the routine of examination and of important causes for rejection, arranged for ready reference, and while it con- tains the leading essentials, it should be supplemented by the more detailed information contained in Circular 5. Routine of Examination. Vision.-Test each eye separately, carefully covering 53 the other eye and making sure that the vision in the covered eye is completely occluded. For the Line and Signal Corps, the visual acuity demanded is 20/40 for the right eye and 20/100 for the left, provided no organic disease exists in either eye. For the Ordnance Department and Hospital Corps, 20/70 in each eye, correctible to 20/40 with glasses, provided no organic disease exists in either eye. Cause for Rejection-Defective vision, organic disease. Hearing. Test the hearing with the whispered voice, the examiner using his residual air to produce the whisper. The applicant should stand with his back to the examiner, while an assistant closes each of the applicant's ears in suc- cession by pressing a finger firmly on the tragus. If the whisper is inaudible, the voice may be raised gradually. Cause for Rejection-Defective hearing, organic disease. General Inspection. The applicant, stripped of all his clothing, is then subjected to a general inspection, followed by the taking of measurements and weight and the giving of exercises. (Pars. 11-19, inclusive, Pages 15-17, Circ. 5). The applicant must be entirely nude during the whole of the examination after he has been subjected to the tests of vision and hearing. A superficial examination of many applicants determines their rejection. They are undersized, undeveloped, or poorly nourished, manifestly lacking in stamina and resistance to disease. Obesity is a cause for rejection when so marked as to interfere with marching or other military duties. Among general diseases which are causes for rejection are chronic malarial poisoning resulting in marked cachexia, grave anaemia, or splenic enlargement; tuberculosis; recur- rent attacks of rheumatism and chronic articular rheuma- tism; malignant tumors of all kinds; constitutional syphilis. Mental and nervous diseases which are causes for re- jection include insanity, general paralysis, epilepsy, chorea, somnambulism, defective mentality, degeneracy, chronic alcoholism, drug habit. Heart. The heart will be examined by auscultation (by percussion and palpation if necessary) and the apex beat located; doubtful cases will be further examined in the dorsal position. The heart should also be examined after moderate exercise such as hopping a short distance 54 on one foot. The condition of the arteries will be investi- gated with reference to aneurism and arteriosclerosis. Causes for Rejection-Hypertrophy and dilation of the heart, valvular diseases, pronounced tachycardia and marked arrhythmia, aneurism. Careful distinction should be made between organic murmurs and those of functional origin. Lungs. The lungs will be examined both anteriorly and posteriorly by inspection, palpation, percussion and aus- cultation. Causes for Rejection--Pulmonary tuberculosis, chronic bronchitis, chronic pneumonia, pulmonary emphysema, asthma, chronic pleurisy. Rectal. The applicant having been directed to bend for ward and to separate the buttocks, the anal region will be inspected for hemorrhoids, fistula, mucous patches and other defects. Causes for Rejection-Fistula in ano, stricture and pro- lapse of rectum, hemorrhoids if large. Legs and Back. The applicant, standing erect, the legs will be examined for varicose veins. The back will be ex- amined for spinal curvature and other abnormalities. Causes for Rejection-Old varicose ulcers, marked curvature (postural kyphosis and scoliosis), fractures, dis- locations, Pott's disease. Feet. The applicant will then raise each foot behind him for inspection for corns and flat foot. He is then directed to face the examiner and the feet are again examined for flat foot, corns, ingrown toenails, bunions, deformed or missing toes, hyperidrosis, and bromidrosis; the knees for genu varum and valgum. Cases showing flat foot should be particularly examined to determine the strength of the foot. Causes for Rejection-Perceptible lameness or limping, excessive bow-legs, club foot, flat foot if accompanied by weakness, marked eversion of the foot and marked bulging of the inner border, loss of the great toe or of any two toes on the same foot, ingrown toenails of the great toe unless remedial, overriding of the toes, webbing of the toes, hallux vulgus if marked, bunions when marked, supernumerary toes when they interfere, hammer toes if marked, corns on the sole of the foot if painful, hyperidrosis and bromidrosis if marked, sodden feet, all anomolies in the number, form and proportion of the extremities producing deformity or interfering with function. 55 Genital Organs. Both sides of the scrotum will be palpated for changes in the testicles, epididymis, and con- tents of the tunica vaginalis, and for varicocele. The genitals will be inspected for any evidence of venereal diseases and for malformations, the glans penis and corona being exposed and the penis stripped; the pubic region is to be examined for pediculi. Examination is to be made by inspection and palpation for femoral, inguinal, ventral and umbilical hernia. Inguinal glands will be palpated, also the epitrochlear and cervical glands, and the applicant will be questioned as to syphilis. Causes for Rejection-Hermaphroditism, absence or loss of penis, phimosis if complete, varicocele if painful or marked, pronounced atrophy or loss of both testicles, chronic orchitis or epididymitis, syphilis, gonorrhea, chanroids. For Nervous Instability. The applicant, being directed to stand with the inner borders of the feet together, arms horizontal, fingers apart, and eyes closed, he will be examined for tremors and nervous instability. Hands and Arms. The hands and arms are to be in- spected for deformities, old fractures and dislocations, amputation of fingers, partially flexed or ankylosed joints, and for impaired functions. Causes for Rejection-All anomalies in the number, form or proportion of the extremities producing deformity or interfering with function, deviation of the normal axis of the forearm, atrophy of muscles, old ununited fractures, ankylosis, amputation of an essential portion, resection of a joint, excessive curvature of a long bone, severe sprains, chronic oedema, chronic synovitis, floating cartilage in a joint. Neck. The neck is to be inspected for goitre and other defects. Causes for Rejection-Cervical adenitis if tubercular, extensive goitre. Mouth. The applicant being directed to open his mouth, his teeth will be examined, the palate will be inspected for fissures and perforation, and the mucous membrane for mucous patches and for scars of former ulcerations. Causes for Rejection-Pronounced alveolar pyorrhea, excessive loss of teeth, malformation of the tongue, malignant tumors, abnormal conditions of palate. There should be at least four opposing molars. 56 Face. The face will be examined for harelip or other re- pulsive deformities or stigmata, for facial paralysis, and for other evidences of disease. Causes for Rejection-Harelip, extreme ugliness, un- sightly deformities, ununited fractures and deformities of the maxillary bones, and dislocations. Nose. The nose will be inspected for disease and de- formities and for dilated vessels indicative of alcoholism. Causes for Rejection-Loss of nose, deformities, nasal obstruction if irremedial, chronic suppurative conditions. Ears. Each external ear and mastoid region will be in- spected. Causes for Rejection-Loss of an ear, marked hyper- trophy or atrophy, atresia or tumors of the ear canal, chronic suppuration of the middle ear, mastoiditis. Eyes. Each eye will be inspected for evidence of muscular or other defect and for disease, the lids being everted and examined for trachoma. Causes for Rejection-Loss or disorganization of eye, organic disease, inflammation. Scalp. The scalp will be inspected for pediculi and disease and the cranium palpated for evidence of former injury, depression from fracture or trephining, and for stigmata of degeneracy. Causes for Rejection-Tinea, malignant tumors, per- manent and extensive alopecia, imperfect ossification, persistence of the anterior fontanelles, extensive cicatrices, depressed fractures, monstrosity in size of head. Skin. The skin will be inspected for anaemia, jaundice, eruptions, and other symptoms of disease, for hypodermic and other scars, and for pediculi; also for evidence of success- ful vaccination. Causes for Rejection-Eczema of long standing or rebellious to treatment, chronic impetigo, extensive psoriasis and ichthyosis, pemphigus, lupus, and sycosis; elephantiasis, ulcerations of the skin not amenable to treatment or of malignant origin, extensive, deep or adherent scars that interfere with military requirements or that show a tendency to break down, obscene or offensive tattooing, scabies, and pediculosis unless the applicant, otherwise desirable, manifests a willingness to rid himself of the parasites at once. 57 Abdomen. The condition of the abdominal organs will be investigated. Causes for Rejection-Wounds, injuries, muscular ruptures, fistulae, hernia, chronic dyspepsia, gastric ulcer, dysentery, complicated undinariasis, chronic appendicitis, chronic enlargement of liver or spleen, marked protrusion of abdomen due to excessive fat. Nose, Ear and Throat. The applicant will be taken into the dark room, where examination will be made of the anterior and posterior nares, the pharynx, and the tym- panic membranes. Causes for Rejection-Chronic laryngitis, syphilis and tuberculosis of the larynx, stricture and aphonia; mal- formations and deformities of the pharynx, post-nasal adenoids; chronic enlargement of tonsils, stricture or pro- nounced dilation of oesophagus. Other Causes for Rejection. The Chest-Marked deviation in form, abnormal development, congenital mal- formations, acquired deformities, adhesions following pleu- risy, deformities of the scapulae or clavicle interfering with the carrying of military equipment, suppurative periostitis, caries or necrosis, old fractures with faulty union. The Pelvis-Malformations and deformities sufficient to interfere with function, perineal urinary fistula. The Kidneys and Bladder-Nephritis, floating kidney, hydronephrosis, pyonephrosia, renal calculi, chronic cystitis, vesical calculi, incontinence of urine, retention of urine. The Urethea-Epispadias, urethral fistulae and urethral strictures, chronic prostitis, prostatic calculi. History. As each region or organ is examined, appropriate questions should be asked to elicit the history of any injury or disease of that part. The applicant should be questioned as to his family and personal history, particularly in regard to tuberculosis, typhoid fever, epilepsy, and enuresis; with reference to injury and surgical operations; also in regard to his use of alcohol and tobacco. Applicants giving a history of typhoid fever may be examined afterward, if deemed advisable, to determine whether they are bacillus carriers. Minor cases of disability that are not causes for rejection must be noted on the blank. 58 CHAPTER XI. CAMP SANITATION Military authorities generally realize the vital importance of scientific sanitation, and are now fully awake to the fact that stringent sanitary measures result in the saving of many lives, compared to which in number the loss from wounds in battle seems small. In war the utilitarian view of our service takes precedence of the sentimental. Armies are made for the purpose of fighting and winning battles, and if there is any medical factor operat- ing to diminish the efficiency of an army, it is the duty of the medical officers to see that it is eliminated as soon as possible. Sick men immediately become a burden and a menace to an army and diminish the fighting strength. Therefore sick- ness must be prevented or reduced to the minimum. This result is accomplished first by the selection of men who are physically sound; second by the institution of the various prophylactic measures against typhoid, small pox and other transmissible disease; and third, but by no means least in importance, carrying out the well recognized rules of sanita- tion in camps and in the field. "Officers and men of all arms must have a knowledge of sanitation and its importance, to the end that no depletion of the fighting force occurs through avoidable causes. "The importance of adopting and carrying out proper sani- tary measures cannot be over-estimated." (F. S. R. 1914). The Chief Surgeon is responsible for supervision of the sanitary condition of his command, through the Sanitary Inspectors, who in turn hold responsible the senior medical officers on duty with a regiment or smaller unit. The first duty which devolves upon the Surgeon, particu- larly of a newly raised regiment, will be to instruct and drill the entire command in the elements of personal and camp sanitation, and particularly to see to it that his assistants and the sanitary detachment are thoroughly instructed, so that they in turn may give the best possible service in the instruction of the men of the command. Authority Rests with Chief Surgeon. 59 The Commanding Officer of a Regiment will usually dele- gate every detail of sanitation to his surgeon, and it is neces- sary for the best results that cordial relations exist between the Commanding Officer and the Medical Officer; that the Commanding Officer have a full understanding of the reasons which control the Surgeon and the methods by which he seeks to put into effect sanitary measures. Selection of Camp Site. The most important considera- tions are, elevation and dryness, avoiding, if possible, areas previously occupied by troops, since the soil in these places is almost surely polluted and may give rise to disease. The latrines, to be constructed immediately upon making a new camp, should be ditched and banked, so as to avoid flooding of the camp site with the excreta, in times of storms, etc. The tents of the men are to be immediately ditched or trenched. The kitchen should be as far as possible from the latrines on opposite side of camp. The Regimental Surgeon inspects his camp area daily, noting any defects found, and reporting the same to the proper commanders, who should correct the same immed- iately. If possible, it is advisable to have the organization commander accompany the Regimetital Surgeon on his daily rounds, since the line officer will have more intimate knowledge of actual conditions existing in his territory, by so doing. The condition of the ground, as regards the proper policing is very important,-special attention being paid to food particles and fruit and vegetable peelings, which are apt to attract flies in warm weather. The interior of the men's tents, post-exchange, kitchens, latrines and bath houses should be investigated frequently, and unsanitary conditions promptly corrected. The bedding, clothing and blankets should be exposed to the sunlight daily, if possible, and the tent sides kept up for ventilating purposes. The tents should be furled at least once a week, and the floor surfaces thoroughly raked over. No food should be permitted in the men's tents, for obvious reasons. Kitchens. The Company Kitchen is one of the most im- portant places in a camp, and here the utmost cleanliness must be observed, since a little carelessness in this depart- ment might result in a large number of sick. The Cook should be selected on account of his ability to prepare food for the men in an attractive, satisfying'and digestible form; he must be Daily Inspection of Camp Area. 60 economical and be able to use the ration in a variety of ways, so that the men will not tire of certain foods prepared in the same manner day after day. He must be a man who is clean in person,-bathing frequently, washing his hands often and wearing clean clothing at all times. His hair should be cut short and he should wear some sort of head covering, while on duty in the kitchen. Whenever a cook is found to have unsanitary and careless habits, which cannot be corrected, he should be supplanted. This also applies to cooks who are diseased in any manner which might be dangerous to the company. The kitchen should be as free from flies as it is possible to make it, and excepting the slight disorder neces- sary at meal time, should be prepared for the closest in- spection at any and all times. Absolute Cleanliness Esential. The cloths used in cleaning dishes and kitchen uten- scils, as well as the towels used in wiping the same, must be washed and boiled daily, before being hung up to dry. The bread board and meat block must be kept scrupulously clean to prevent food contamination. The kitchen and mess tables should be so constructed as to permit the most thorough cleaning. A standard equip- ment as outlined below, might be adopted in camps of permanent or semi-permanent nature. For kitchen table tops five 2 by 6- inch pieces of lumber, of a length dependent upon space avail- able, are recommended. These boards are laid close together, and the second and fourth boards are not nailed, so that they may be lifted out and the entire top thoroughly scrubbed before replacing the loose boards. This must be done daily. The mess table tops are to be constructed of two by 12-inch boards, of proper length, and nailed about an inch apart, so as to permit of proper cleaning between the edges. It should be a rule never to construct table tops for kitchen or mess hall of matched or tongued lumber, on account of the difficulties encountered in keeping the same sanitary. Unless an ice box is furnished to the company by the camp quartermaster, the ingenuity of the company artificer must be drawn upon to construct one which will be acceptable. The insulation of the ice box is important, since quanti- ties of perishable foods must be kept at the proper temperature for several days at a time. The box should be lined with some metal, as galvanized iron, so that the inside of the box may be scrubbed and scalded, and kept clean at all times. Food must not come in direct contact with the ice at any time, 61 since contamination might result from such carelessness. The ice box should be elevated sufficiently above the ground to permit its draining into a pail, pan or other container, which may be emptied when necessary. The waste water should not be allowed to drain into ditches or pits, because these places quickly become foul, and are breeding places for flies and mosquitoes. Pans, food grinders and other kitchen utensils should receive daily attention, and be ex- amined carefully by the Medical Inspector on his rounds of kitchens. Corners of the kitchen and spaces under boxes and bags must be watched for the accumulation of dirt and food particles. Waste water, if dirty, should be placed in the garbage cans, or in the evaporating pan of the incinerator, -it must not be allowed to contaminate the ground. Where garbage cans are provided, they must be emptied daily and the inside of the can cleansed. In camps where garbage cans are not provided, properly constructed incinerators are utilized. Kitchen waste should always he burned in camps of any duration. The following measurements and method of construction will be found suitable for a company incinerator. A pit four feet long, two and a half feet wide, and three feet deep at one end and two feet deep at the other, is dug and fdled in with loosely fitting stones to a height slightly above the level of the ground. The sides are banked and one end is left open for purposes of obtaining a draft for the fire, and also to permit of daily cleaning out of ashes. Iron bars are placed across the sides to hold the pan for evaporating the kitchen fluid waste. The solid particles, including coffee grounds, bones, parings, tin cans, etc., are burned. These incinerators require a considerable amount of attention, so as to keep them from becoming incubators for flies, and should this occur the entire affair must be rebuilt. Where soil is impervious it is necessary to furnish incinerators with evaporating pans for the liquids. Waste water from faucets, in some instances accumulates to such an extent as to become a menace to the health of the troops. Brushing the teeth and washing the hands, mess utensils, etc., at these places, and the practice of allowing considerable water to run, in order to secure a cool drink, are practices which must be guarded against, and these infractions of sanitary laws are best guarded against by frequent caution- ing of officers and men, regarding the dangers to the entire command. Incinerators for Camp Use. 62 Construction of Latrines Latrines or Rears. One latrine is desirable for each com- pany or separate organization, while in camp,-also one for the officers of each regiment. The latrine pit should be about three feet in width, eight feet in length, and six to eight feet in depth. Over this pit a latrine box is constructed or placed, with the following approximate dimensions: four feet wide, nine feet long and one and a half feet high. The sides should slope outward, from above downward, to pre- vent soiling of same. Suitable holes should be cut in the top, about two feet apart, and hinged covers provided with stop blocks to prevent the covers from being raised so they will not fall back into place of their own weight. If this precaution is not taken the covers will be allowed to remain open, and flies will breed in the latrine pit as a result. The latrine pit will be banked and ditched so that surface water cannot get into it, and at all times the minimum number of flies ought to be the aim of the Sanitary Officer. Toilet paper should be placed in boxes so that it cannot be scattered about the latrine area. The latrine pits are burned out daily, using crude oil and straw or hay for the purpose. The latrine box is lifted off the pit so that it will not catch fire, and carefully replaced after each burning out. The burn- ing does not, however, destroy the excreta but produces a charred layer on the surface which does not attract flies, and the larvae are killed. The spraying of latrine pits with a solution of lamp black and coal oil has been used with good results. The urine troughs are swabbed with crude oil daily. The urinal cans are burned out daily, the same as the latrine pits, and then allowed to stand exposed to the sun during the remainder of the day. The latrine-box seats must be scrubbed daily so as to prevent possible contamination in this manner. Where the stay of a command is 24 hours or less, straddle trenches are dug (the men squat astride of them). These trenches are supposed to accommodate 5% of the organization at a time,- allowing 2 feet for each man. An average trench for a company as described above, should be about 20 feet in length, and the width of a shovel or spade, and a depth of one foot for each 24 hours' stay or multiple thereof. A guard should be constantly present at these places to prevent fouling of the ground. If the stay is of more than 24 hours duration, these trenches should be sprayed with a lamp black-kerosene mixture several times daily, to prevent fly breeding. When the command moves, the trenches are carefully filled with dirt. 63 This subject is discussed in detail under the heading, "Water for Troops in the Field." Manure: The picket lines are raked and all manure carried away and burned daily. The areas where the horses stand should be burned over every week, using crude oil and straw for the purpose. Manure may be advantageously dis- posed of to farmers. The animals of a Division will furnish about 100 wagon loads of manure daily. Low or swampy areas are to be drained and oiled and the underbrush cut away and burned so as to prevent mosquitoes and flies breeding in these places. Fly traps and sticky fly paper should be used freely, in order to minimize the fly hazard. A mixture of Formalin Sol. (40%), one ounce to the quart of water, with a small amount of con- densed milk added, is an excellent fly destroyer. This solu- tion is placed in tin platters, wherever flies are most in evi- dence. Water Supply. 64 CHAPTER XU WATER FOR TROOPS IN THE FIELD Water is more immediately necessary to soldiers in the field than food The use of raw water for drinking purposes should be prohibited on the march and in camp until its source has been investigated, with a view to deter- mining its purity. Water supplies should immediately be under supervision and guard, in temporary camps. The approach to the supply, if it is a stream, should be protected by the laying of rails, logs, or boards, so as not to render the water muddy. Walls should be protected from the possi- bility of pollution and waste should be guarded against. Springs remote from habitations, large lakes and streams remote from habitation are the best sources of water supply on the march and in campaign. Water for drinking purposes should be used liberally but not excessively. Soldiers should train themselves to getting along on a sufficient supply and should understand that the excessive use of water is harmful on the march. The Field Service Regulations state that under ordinary conditions the canteen, holding pints of water, should last a man a day for drinking purposes. Every soldier should start the march with his canteen filled, having previously drunk enough to supply his immediate needs. Making Water Supply Safe. When the Water supply is in doubt, any one of several safety measures may be employed. The water may be boiled and thus rendered safe pending analysis and investigation. Tea or coffee may be made with boiled water. A good fdter may be made from a cask or barrel charred on the inside (that may occasionally be brushed) and pierced with very small holes through the bottom. This is sunk in the water, which will rise through the holes. Better is one barrel within another, the outer pierced through the bottom and the inner near the top, the intervening space being filled with sand, gravel, or similar material, and the whole sunk sufficiently in the stream. (Woodhull). 65 Water may be rendered safe by the Forbes Portable Sterilizer or the Darnal Filter. This latter apparatus not only filters but precipitates impurities by chemicals. The apparatus comes in a permanent, well-built crate, having handles. When the appliances are removed the crate acts as a stand. Darnal's filter consists of one filter tank and water cans, a bent perforated pipe and several flannel cloths. A little hand pump starts the siphonage. The cloths are sterilized by boiling water in one can, which is eventually emptied by siphonage. The capacity of the filter is 50 gal- lons per hour. Water is rendered safe for drinking by the use of sodium hypochorite (25 grs. per 100 gallons-time 8 to 10 hours). The Lyster Bag is in quite general use in the Army and serves its purpose excellently. Where it is used each organiza- tion should be furnished with one. These canvas, rubber-lined, collapsible bags hold 20 gallons of water, and have faucets at the bottom for drawing it off. The contents of a tube (one gramme) of Hypochlorite of Calcium, available chlorine 30-32%, is stirred in this amount of water, and allowed to stand for twenty minutes, after which time it is safe for drinking purposes. 66 CHAPTER XIII. THE RATION The government ration and the regulations concerning its use are very liberal and if a company does not have an abun- ance of good, nutritious and attractive food, the fault is nearly always in its handling after it reaches the company. On July 1st, 1910, the Garrison and theTravel rations passed from an issue to a cash basis, thus definitely placing the re- sponsibility for providing a well balanced diet upon the Organ- ization Commander. This now more than ever requires an accurate knowledge of the regulations pertaining to the ration and reliable information as to what variety and quantity of food men under normal conditions of service re- quire and simple methods of handling of accounts pertaining to the same. The army ration is divided into the Garrison ration, Travel ration, and the Reserve ration, which latter being augmented by all articles obtained on the march is called the Field ration. The Field ration however must never exceed the Garrison ration in cash value. A Ration is the allowance for the subsistence of one per- son for one day or the greater part thereof, and is the unit upon which all accounts are based. Depending upon the pre- vailing price of foods, in different localities, this ration is given a definite money value, and each organization is permitted to draw these rations from the Quarter-Master and save, for the organization, the cash difference between the allowance and the value of the food thus drawn. No saving is permitted in time of actual war, however. The Commanding Officer will designate the period for which ration returns are to be submitted, and commanding officers or companies or detachments will see that the returns are in on time. For example, if the ration period is 3 days and the ration price is 30 cents the ration return for a command of 100 men will be for 300 rations and the value $90. The procuring of rations is therefore very simple but the ingenuity of the company commander and his mess-sergeant must be exer- cised in careful supervision of the preparation of this food 67 by the cooks, and close observation of the amounts used, since waste is not provided for in the estimate of the price of each individual ration, and the cost of the food consumed each day must not exceed the cash credits for that day. The best methods of avoiding trouble in the matter of ration expenditure and lack of balance in the diet, is prep- aration of bills-of-fare for the period covered by the ration return, estimating not only the cost of the food used, but also its amount in the proportion to the entire allowance for the period. The Garrison Ration: Beef 20 Oz. Flour 18 Oz. Baking Powder 8 Oz. Beans 24 Oz. Potatoes 20 Oz. Prunes 1 .28 Oz. Coffee 1 .12 Oz. Sugar 3 .2 Oz. Milk, Evaporated .5 Oz. Vinegar .16 Gill Salt .64 Oz. Pepper .04 Oz. Lard .64 Oz. Butter .54 Oz. Sirup .32 Gill The Travel Ration: Soft Bread 18 Oz. Corned Beef 12 Oz. Baked Beans 4 Oz. Canned Tomatoes 8 Oz. Jam 1 .4 Oz. Coffee 1 .12 Oz. Sugar 2 .4 Oz. Milk, Evaporated .5 Oz. The Field Ka lion. The Field Ration consists of the Travel Ration plus any sup- plies which can be obtained locally. The cost however must not exceed the cost of the Garrison Ration. To the medical officer falls the duty of properly feeding not only the members of his command, but also, when oc- casion arises, the sick and wounded who are temporarily Food Chests for Hospitals. 68 taken care of by his company. The sick will often require a diet which differs in some respects from that of men on duty. Therefore each field hospital carries food chests which contain: Beef, Soluble, Liquid or Extract, 3 oz. containers 12 Containers Can Opener 1 Cocoa, 8 oz. Tins 12 Tins Coffee, ground, 2 lb. Tins 2 Tins Hard Bread, y^ lb. Carton 8 Cartons Milk, Condensed, Unsweetened, 1 lb Can. _ 18 Cans Pepper, Black, 1 oz in glass shaker 1 Shaker Salt, Table, 4 oz. in glass shaker 1 Shaker Soup, assorted, 1 lb. Tin 12 Tins Sugar, granulated, 4 lb. in tin 2 Tins Tea, Green or Black 1 Pound Note: This box with the special containers belonging to it, is ordinarily issued empty, with the expectation that the food for the sick will be purchased from the hospital fund. For each patient entering the hospital an allowance is made for his ration. This is now 80.30 per day for enlisted men and 80.50 per day for officers. The pay for the enlisted men comes from the quarter-master. The officer must himself reimburse the company upon presentation of the proper bill, the mess chests being refdled from these funds. When these patients are quartered with the hospital for any length of time, the mess officer requires for rations for them and charges these rations against the daily fee. Each ambulance in an ambulance company carries a box of food, which is to he used only for the nourishment of sick and wounded in the ambulances or in the dressing station. Each box weighs 36 pounds and is carried constantly in the ambulance. The contents are as follows: Food Supplies for Ambulances. Beef Extract, 3 oz Containers 6 Containers Cocoa, 8 oz. Tins 6 Tins Milk, Unsweetened Condensed 1 lb. tin___ 10 Tins Pepper, Black 1 oz. Salt 3 oz. Sugar, 4 lb. Tin 1 Tin Tea 8 oz. Can opener 1 Safety Matches 12 Boxes 69 The particular value of these boxes of food in the ambulance is that they are available for the sick man in the hour of his greatest shock which is immediately after he has received the first aid dressing upon his wound. Individual Cooking by Soldiers Individual cooking by the men is extremely important as it trains them to care for themselves when separated from the convenience of the kitchen. The cooks act as instructors for this practise. The Mess Sergeant's hand book gives examples of bills-of-fare as follows: 1. Bacon, Boiled Rice, Flap Jack, Coffee. 2. Meat and Vegetable Stew, Flap Jack, Coffee. 3. Bacon, Stewed Tomatoes, Hoe Cake, Coffee. 4. Bacon, Baked Potatoes, Rice, Flap Jack, Chocolate. Or When Time Is More Limited. 5. Fried Bacon, Fried Potatoes, Hard Bread, Coffee. 6. Corned Beef (Cold), Tomato Stew, Hard Bread, Coffee. Since the man has only his meat can and cover, tin cup knife, fork and spoon, the food must be divided so that all utensils are constantly in use. 1. Take % of a cup of water and bring it to a boil over a fire made upon the ground. Add 4 spoonfuls of rice and boil until soft; i.e., until it can be mashed by the fingers with but little resistance. This takes about 15 minutes. Add 2 pinches of salt and, after stirring, pour off the water and empty the rice out on the lid of the mess pan. 2. Meanwhile fry three slices of bacon until slightly browned in the mess pan, over a brisk fire of hot coals, and lay them on top of the rice leaving sufficient grease in the pan in which to fry the flap jacks. 3. Take six spoonfuls of flour and spoonful of baking powder and mix thoroughly. Add sufficient cold water to make a batter that will drop freely from the spoon. Add a pinch of salt and two pinches of sugar and pour the batter into the mess pan, which contains the grease from the fried bacon. Place over medium hot coals and bake from 5 to 7 minutes; see that it will slip easily in the pan and then by a quick toss turn it over and continue the baking from 5 to 7 minutes longer, or until by examination it is found done. 4. While the batter is frying wash out the tincups; % fill with water and let come to a boil, add medium heaping spoonful of coffee and stir well and if desired 1 spoonful of Preparation of Menu No. 1. 70 sugar and let boil about 5 minutes. Let simmer for about 10 minutes longer. Settle by a dash of cold water and let stand for a few minutes. A hot meal is now ready to serve and 30 or 40 minutes have been expended in its preparation. It is to be understood the above is only a suggestion and the various articles of food must be handled in accordance with the necessities in each instance, but a small amount of care and the exercise of or- dinary intelligence will suggest necessary expedients. 71 CHAPTER XIV. PERSONAL HYGIENE The subject of personal hygiene of officers and men differs from that of civilians only in the peculiar conditions under which the soldier lives and works, conditions which of neces- sity at times are not conducive to ideal personal hygiene. Facilities for bathing and other personal care are often lacking or very restricted. Proper food and shelter are not always available. Proper protection of the body from the elements is not always at hand, and under these conditions men must exercise considerable thought, some ingenuity and a great deal of effort to preserve a clean and healthy body. 1 shall only remind you of the basic elements involved in this matter of personal hygiene. First of all, the soldier must be taught and must under- stand the importance of fresh air at all times. He must have knowledge of the fact that many diseases, such as colds, sore throats, pneumonia, are caused by bacteria, and are promoted by vitiated and impure air, and are not caused by fresh cold air, that the fresh air must not be excluded from his quarters, and that it is necessary to his continued health. The soldier must not only be given the necessary exercise for his physical development and to keep him physically fit and afford recreation, but he should be taught to under- stand that physical exercise bears a direct and important relation to physical health; that properly indulged in, it increases the strength of the heart and the capacity of the lungs, promotes the stability and control of the nervous system, aids digestion, assimilation and excretion. Cleanliness An Essential Cleanliness of person, clothing and bedding must be- come a habit of life with the soldier as with the civilian. Some men are naturally filthy in their personal habits and require constant watching, constant supervision, constant instruction, frequent inspections in order to secure and to to compel personal cleanliness. 72 Recruits who have lived under ordinary conditions of civil life in families where the mother or the head of the household attends to the many matters concerned in personal cleanliness, are apt to be careless or ignorant or both as to the necessities involved in personal cleanliness under military conditions. Alcohol. Men who are the victims of drink or other vicious habits in military as in civil life are notoriously care- less as to the care of their person. Such men must be especially dealt with, and supervised by medical and line officers. Such men are generally those who introduce vermin into the barracks or the camp, and this as is well known constitutes a great danger to military commands in the introduction of camp diseases carried by vermin. It is generally conceded that the use of alcohol is always harmful, and young recruits especially should be taught its evil effects. It is the duty of the medical officer to advise and encourage temperance in the soldier, and it is particu- larly his duty to inform the soldier of the baneful effects of the cheap and ofttimes poisonous drinks served by irres- sponsible vendors in the neighborhood of camps. Every military command shows in its sick reports and in its guard records, the bad effects upon men and the loss of service to the army which result from the intemperate use of alcohol, but the army is improving in this respect, and further re- strictive measures are proposed. Medical officers, knowing the medical facts concerning the alcohol question, should limit its use in every possible way. The soldier should be taught that alcohol is not a food; that it does not promote warmth; that it does not increase strength or endurance; that its final effect is always depressing; that it predisposes to infections and injuries, to exhaustion, to heat stroke in hot weather and to freezing in cold weather, that it leads to diseases of the heart, blood vessels, kidneys and brain; that it gives rise to digestive disorders and predisposes to typhoid and other intestinal diseases; that those who drink to excess are especially liable to pneumonia and other diseases of the respiratory track, that it robs the government of a man's usefulness as a soldier and prevents his personal advancement. Water. Soldiers must understand the relation that in- fected waters bear to disease, that they must not drink water from an unknown or suspicious supply, that water is always rendered safe by boiling for twenty minutes, that it is usually Water and Food. 73 not necessary for soldiers in the field to consume more than the amount of water which can be carried in their canteen during one day's march, and that the canteen should be filled from a known safe supply before the march is begun. Food. The soldier must accept the food provided by the government, but he is free to use his intelligence as to how he shall eat and how much he shall eat. He should know how to eat and he should knov the evils of overeating. Usually there is sufficient time for the soldier to observe the ordinary proprieties of eating and to chew his food thoroughly. Except under conditions oi active campaign in the field his time of eating is well regulated. The soldier is apt to over indulge in strong black coffee, and he should be warned against this. Coffee three times a day and day after day, in the quantities of a pint or a quart, is too much. This needs no argument with medical men, but the soldier should know it and should know the reason why. Soldiers are much like children in the matter of over in- dulgence in green fruits, candies and pastries. They must be treated very much like children in regard to this matter. Over-indulgence leads to digestive disturbancesand to intestinal troubles. These matters can best be handled by the company commander in the exercise of his proper authority over the company mess, and by the camp commander in excluding where necessary irresponsible vendors of harmful foods and drinks. The soldier should be taught the value of regular habits with respect to his bowels, and in the field and on the march medical and line officers must bear this thing in mind in order that soldiers shall have the necessary opportunities to take care of the commands of nature. Soldiers Should Be Suitably Clothed. Government clothing is usually a good quality, sufficient quantity and seasonable. With the government uniform, a soldier may be neatly, properly and cleanly dressed, and except under occasional conditions in the field this should be demanded of him. The soldier pays for or does his own laundry work. The government supplies him with proper and sufficient clothing, and he should be required to keep it in a neat and clean condition. Soldiers like civilians should dress so far as possible according to the season and the climate. Neither care- lessness, perverseness nor ignorance should prevent the line 74 officer nor the medical officer from insisting upon this. Poverty cuts no figure in this consideration. The government furnishes proper clothing to meet the conditions of heat and cold and rain, and excepting under the occasional conditions of cam- paign in the field, soldiers can and should be well and suitably dressed, and should understand the effect of excessive heat and excessive cold in lowering the resistance of the body, and giving rise to disease. They should particularly be instructed to keep their feet dry wherever possible and to change to dry socks at the first opportunity. Recklessness and carelessness in this particular are as much neglect of duty, as it would be to neglect or refuse to carry out any other direction or order. Exposure to strong sunlight and the excessive heat of the sun, should be avoided where possible. The head should have suitable covering, and while it has not absolutely been demonstrated, certain colors, red, black, orange, yel- low, are supposed to exclude the actinic rays. Clothes for field service should neither be tight nor too loose, especially across the chest and shoulders. Equipment should be as light as possible, arranged in such a way as to interfere as little as may be with motion. Shoes and care of feel. Ill fitting shoes are a frequent cause of disability, but the shoes of the army have been greatly improved in recent years, and most of the shoes now issued are of good material, proper shape and the number of sizes sufficient so that, with supervision on the part of the company commander, the men may be well shod. The Munson last is quite generally worn in the army, and is an excellent shoe. A proper shoe should be of sufficient size in length and breadth. The fit should be snug, but there should be no pressure exerted anywhere which would give rise to corns or callouses. Every soldier should be furnished with two pair of shoes, and if possible the day's work should be begun with the shoes dry and the socks clean. Shoes should be kept well oiled. Care should be taken to have no wrinkles in the socks, there should be no dirt in the shoes, and the lining of the shoe should be intact, or at least all wrinkles and rough edges removed. Men should be encouraged to bathe their feet every evening if possible, and corns, callouses, blisters and ingrowing nails properly dealt with. On campaign in the field, men should not be permitted to go bare footed and without leggings, for the reason that in addition to the danger of injury to the feet, there is the added danger of infection through slight Care of Feet Important. 75 injuries which will put the man on the sick report. The soldier who cannot march is generally a burden to any command; whether or not he can march depends primarily upon the condition of his feet. Any trouble with the feet should be cared for at the first opportunity by the soldier himself, by his company commander and if necessary by the medical officer. The man himself should understand the value of bathing the feet, of clean whole socks, of properly fitting shoes, of proper trimming of nails and of the care of the corns and callouses if such develop. The hands. The soldier should understand and know the reason why the hands must be kept clean and sound, and why it is important if at all possible to wash the hands before taking food in order that such diseases as typhoid for instance may be avoided and in order that cuts and abra- sions may not result in disabling infections. For obvious reasons the hair should be kept short and the beard closely trimmed. Disease Dangers of Uncleanliness. Baths and personal toilet. Soldiers must be made to understand the importance wherever possible of using ex- clusively their own linen and toilet articles, and this must be a matter of orders. It is only necessary to refer to the fact that parasitic and other skin diseases, venereal disease, trachoma and other inflammatory infections of the eye, body vermin, occasionally typhoid fever and small pox may be transmitted through the medium of the common towel, handkerchief, or clothing. Daily baths should be encouraged where possible and where facilities exist, but soldiers should have drummed into them the fact that in summer under the ordinary conditions of the barrack or the field, baths twice a week are necessary, and in winter at least once a week, in order that they may keep their bodies clean, and that the under-clothing should be changed at least once a week, and preferably twice a week if possible depending upon conditions. The teeth. In military as well as in civil life it is well known that from a sanitary standpoint, the mouth is most apt to be neglected, and that many diseases such as digestive disorder, malnutrition, focal infections, systemic poisoning, anemia, etc., are caused or promoted by the neglect of the teeth. 76 It is only in recent years that the soldiers' teeth have re- ceived the necessary attention, and that men skilled in dentist- ry have been made use of in the army. Many soldiers when they first, go into the service, seem hardly to know the use of a tooth brush, and their mouths are in bad condition, their teeth decayed by reason of this lack of knowledge or by reason of neglect. They do not seek relief until they are afflicted by pain. In my opinion soldiers' mouths should be carefully inspected and soldiers carefully instructed in the care of the mouth. It seems to me that if it is important to inspect weekly the mules and horses on the picket line for evidence of disease, and if an officer is to be held responsible for the physical condition of his stock, just so he should be held responsible for the physical condition of his men. Com- pany commanders and medical officers should therefore in- struct every man to have a tooth brush and to use it at least twice daily. They should be instructed how to use it, in order that they may remove from the teeth and the gums all par- ticles of food or other foreign matter, brushing away from the gums in all cracks and crevices. They should understand the importance of the removal of any pieces of meat or other food by the use of a tooth pick if necessary, and above all they should be encouraged to promptly consult a dental sur- geon or medical officer concerning any trouble arising in the teeth or gums. The dental surgeon will give them proper treatment and the medical officer can at least give them proper advice. Preventing Venereal Disease. Venereal disease. The control of veneral disease has al- ways been a serious problem in all armies. In our service at the present time, it is reasonably controlled by the use of compulsory methods of venereal prophylaxis which are fully set forth in M. M. D., page 75, pars. 198, 199, 200, and in chapter on prevention of disease, but soldiers, especially young recruits, should be taught at every opportunity the evils and dangers involved and the necessity and value of preventive measures. This matter is a serious menace to all armies, and must be relentlessly and rigidly dealt with. Much disease may be prevented by the proper instruction of men and by positive orders preventing careless spitting and otherwise soiling the grounds and quarters of camps and barracks. It is only necessary to refer to the importance of this matter. Where men live in close quarters as they often 77 do under military conditions, it is more than necessary to rigidly enforce preventive measures against typhoid fever, diphtheria, pneumonia, venereal and other diseases. Men in groups, as soldiers, can always be appealed to on the score of common decency and patriotism, and where they do not respond to this appeal the necessary orders may be enforced, and where this does not correct any existing evils, and certain individuals constantly violate orders and ignore appeals, such individuals may be reached by a tactful and sensible officer, through the appeal to the group, that the interest of one and the conduct of one of their group affects the interests of all, and particularly has a bearing upon the reputation and the efficiency of the group. In other words, the development of the use of the esprit de corps. Golden Rules of Personal Hygiene. The following are laid down by Ashburn (Military Hygiene) as the Golden Rules of Personal Hygiene, and in my opinion set the matter forth in as few words as could possibly be used. They will bear repetition. 1. Be clean in person, clothing and surroundings. 2. Eat no food but good food, and only with clean hands. 3. Drink no water from unauthorized or doubtful sources, unless it is boiled,-plain, or in tea or coffee. 4. Abhor, avoid, and destroy vermin, whether lice, fleas, ticks, flies, mosquitoes, roaches, mice, rats or other varieties. 78 CHAPTER XV. DUTIES OF MEDICAL OFFICERS AT THE FRONT The Duties of Medical Officers at the front are in the order of their importance,. 1. Evacuation of wounded to the rear in order to relieve the fighting force of incompetents and to preserve its mobility; 2. The medical and surgical care of the sick and wounded; 3. The careful keeping of all records concerning the same. All other duties, as outlined in the M. M. D. are merely subdivisions of these great heads and all aim to obtain the results desired. The goal towards which all instruction and training of medical and sanitary personnel is pointed, is ef- ficiency in actual hat tie. The service of every unit should dovetail together to make a complete and perfect machine, and any break in the chain through inefficiency or ignorance will seriously handicap the whole service. The organization of the various units has been given else- where and it need only be added here that to each infantry division which is the great administrative and tactical unit of the army is assigned four ambulance companies and four field hospitals besides the various regimental detach- ments. The chief medical officer of a division is known as Division Surgeon and has the rank of Lieutenant Colonel and assigned to him as assistant is one Major. Two Majors are assigned respectively as Director of Ambulance companies and Director of Field Hospitals. All orders governing the movements of sanitary units emanate from the Division Surgeon, who is a member of the staff of the Commanding General, but these orders must pass through the hands of the Chief of Staff, for issue or approval, the ideas of the division surgeon being submitted by him in the form of recommendations. During battle the Commanding General may authorize the Division Surgeon to issue orders in his name but even under these conditions 79 the orders must be submitted to the chief of stall for approval. All roads leading to the front and rear are primarily for the use of the fighting force and it is the duty of the chief of staff to see that nothing, not even the transportation of wounded, interferes with their availability. Troops go into battle formation on orders from the Com- manding General. This order is usually known as the battle order and contains information for the disposition of every unit in the division. In paragraph four of this order will always he found the orders pertaining to the medical department units, which information has been received from the Division Surgeon as a recommendation. In the ordinary battle formation field hospitals and ambulance companies will not be ordered to pitch their stations at once as it is impossible to tell at this time where they will be most needed. They are usually ordered to hold themselves in readiness off the road at some point from which they can be easily distributed when the need arises. In this order a point will be designated as a station for slightly wounded, usually well behind the zone of fire and at a point towards which the slightly wounded will naturally drift. This station has no regularly organized personnel and one medical officer, one sergeant and seven or eight men will be assigned for this work from some available unit which is not in action. No action is taken by the Division Surgeon to establish any stations until the news from the firing line shows him that it is necessary. Division of Regimental Detachments. The Regimental Detachments are normally divided into three battalion sections, each consisting of one medical officer with his orderly, one sergeant and three litter squads. These detachments will follow their battalions into action, unless otherwise ordered and each medical officer will organ- ize a battalion collecting point for wounded. They will render all first aid and as rapidly as possible transport their patients back to the regimental aid station which is in command of the Major with a personnel of one sergeant first class and eight privates. In our present form of war- fare the battalion stations are the real first aid stations, as they will in most instances be established right in the trenches with the men. The regimental aid station will normally be further to the rear but still as close to the firing line as possible. This station is not in any sense an elaborate one, 80 but should be prepared to give shelter and readjustment of dressings to the wounded as they arrive. At this point they are separated into walking and ambulance cases and when sufficient numbers have been collected the surgeon will notify the division surgeon stating the number and character he has on hand. Diagnosis tags should be applied to all men at the time of, and by the man making, the dressing. When the Division Surgeon has been informed that suffi- cient wounded are in the regimental aid stations he will issue an order to the director of ambulance companies to establish any number or all of the dressing stations to relieve the congestion on the firing line. When the command- ing officer of an ambulance company has received his order to establish this station he will move his whole com- mand as close to the front as the zone of fire will permit. He will then leave his ambulance and wagons with the transportation personnel consisting of one officer, two non- commissioned officers, and twenty privates and will go for- ward with his dressing station section and bearer section with their equipment on four pack mules to the point designated and establish the station at some sheltered point where there is available fuel and water if possible. It is better if near a road but must at least be available for wheel transportation. When the station has been established the commanding officer will notify the Division Surgeon of the fact, giving the exact location. Scouts are now sent forward to obtain contact with the regimental stations that are to be relieved and all paths and roads leading to the dressing station are marked by red cross guidons. The bearer section of about fifty litter squads now go forward and take up the work of transporting the wounded and in normal war conditions, this work will all fall upon them, as the regimental personnel, will not work behind their own stations, except in times of direct need, and then only by specific order. This station is somewhat more elaborate than the regimental station usually consisting of two tent flies and a small field range upon which sufficient liquid food can be prepared for administration in addition to the surgical dressings. Its organization will usually be a receiving section and a forwarding section and only absolutely emergency surgery and the readjustment of dressing will Transporting the Wounded 81 be attempted at this point. Ambulatory cases will be sent to the rear in squads and always when possible in command of a non-commissioned officer to prevent them straggling over the field. Establishing Field Hospitals The Division Surgeon either upon information that the dressing stations are filling up or in anticipation of the same will order the Director of field hospitals to establish one or all of the field hospitals and will notify the director of ambulance companies of these locations with orders to evacuate the dressing stations as rapidly as possible. When the commanding officer of the ambulance company who is at the dressing station, receives this information he will bring forward his transportation section and send back the wounded at once. The field hospitals are the last stations for medical aid with the service at the front and are always situated well beyond the zone of fire. These are quite elaborate institutions, each having a normal capacity of 216 patients, with facilities for great expansion when re- quired. It is here that patients will receive their first real detailed care, and with its very complete surgical equipment considerable major surgery may be done when necessary. When these become filled with wounded the Division Surgeon notifies the Chief Surgeon of the base group of the fact and he will take immediate steps to clear these units of their wounded. The sick and wounded now pass from under the control of the Division Surgeon and into that of the Chief Surgeon of the base group. All of the Sanitary Units with the Service of the Front are Mobile in every sense, and must be prepared at all times to go forward or back with the troops that they serve. When such a movement occurs wounded men who are in their care at the time, must be left, usually in the care of one or more sanitary soldiers with sufficient dressings and food for their comfort and safety. If the movement is forward these collections of wounded will be picked up by the units of the base group as they follow up the advance, but if the movement is to the rear, the wounded must be abandoned to the enemy. Although the laws of modern war exempt medical units and personnel from capture, still it is unwise to allow any of these units to fall into the hands of the enemy, as their 82 services to our own forces will be lost for a long time, in fact probably for the duration of the war. The records which have been started by the diagnosis tags, applied in the trenches should be fully completed in the field hospitals so that all claims because of wounds can afterwards be adjusted with justice to the government and to the man. This is a very important duty and no effort should be spared to make it complete and truthful in every respect. All of the orders mentioned are worded on the assumption that every officer has a map of the country and knows how to read it. The area covered by the divisional operations may be as much as 100 sq. miles so the use of map directions is the only means of insuring anything like accurate disposi- tions. If at all available, the map used will be the contoured one as made by the War Department, or the Geological Survey, and it is absolutely essential that every officer should be familiar with its construction and meaning. 83 LHHES OF AOSnSTANCE 84 CHAPTER XVI. THE AMBULANCE COMPANY IN THE FIELD The ambulance company in the sanitary service is a very vital link in the chain of units which functionate behind the battle-line in the evacuation of sick and wounded. The purpose is the retention of effectives at the front and the movement of non-effectives to the rear without obstructing military operations; the care of sick and wounded on the march, in camp, on the battle field and after removal there- from; the methodical disposition of sick and wounded. (M. M. D. 1916) The ambulance company is of the utmost importance in relieving the fighting line of its wounded and each unit must be so systematized as to work smoothly in its designated place. Ambulances are mule drawn and motor driven. Up to the present time motor ambulances have been little used in this country in the service of regular ambulance companies. Some post and base hospitals have been equipped with motor ambulance service, adding greatly to their efficiency. Personnel of Ambulance Companies. The personnel of the mule ambulance company con- sists of five officers, captains or lieutenants, one of whom is the commanding officer; two sergeants first class, one of whom is designated as first sergeant, and one as supply sergeant, seven sergeants, one of whom is designated as mess sergeant, one as table sergeant, three as platoon sergeants, one as pack mule sergeant, and one as letter bearer sergeant; one acting cook and sixty-nine privates, first class or privates, one of whom shall be designated as farrier, one mechanic, one saddler, 2 musicians, 2 cooks, 15 drivers. In each ambulance company 1 lieutenant, 1 sergeant first class, 1 acting cook and 19 privates, shall accompany the wheel transportation. A motor ambulance company has the same personnel ex- cept that by reason of the different requirements, the duties 85 of certain of the enlisted men will vary from that indicated above. The war strength ambulance company is as above stated so far as officers and non-commissioned officers are concerned, but 11 corporals and three cooks are provided for with 123 privates first class and privates, making a total enlisted strength of 150. The materiel of a mule ambulance company is as fol- lows: 12 ambulances, 3 escort or combat wagons, 64 draft mules, 4 pack mules and 17 saddle horses with the neces- sary harness, pack saddles and riding equipment. The materiel of a motor ambulance company consists of 12 motor ambulances, 3 trucks, a touring car for officers and motorcycles for non-commissioned officers. A mule ambulance company occupies about 350 yards of road space when marching in column of ambulances. It is made up of four sections (a) litter bearer (b) pack mule (c) ambulance (d) escort wagon, each under the command of special officers and non-commissioned officers. Four Ambulance companies are assigned to a division. They march in* the rear of the column as part of the field train, one ambulance company being on duty with the division, the others being held in reserve. One or more ambulances are assigned to a regiment for the care of the disabled on the march, and when filled are ordered to the rear with the reserve. All soldiers must bear the blue ticket on their diagnosis tag to be allowed to ride in an ambulance. No one but the medical officer in charge of that battalion has author- ity to allow a man to ride. At the end of the march the men are reported to their regimental surgeon who in turn disposes of them as he sees fit. An ambulance has a capacity for four recumbent and one sitting patient, two recumbent and five sitting patients, or nine sitting patients. Each ambulance is in charge of an orderly who rides with the driver when not on duty, and stands on the foot board when the ambulance contains patients. The orderly is provided with a hospital corps pouch for use in first aid work if necessary. Under the driver's seat is a space in which is carried a reserve box of surgical dressings and an ambulance chest of food. These boxes are kept in reserve for possible use and must at all times be fully equipped for service. Materiel for Ambulance Companies. 86 Units for Field Work. For field work the Ambulance Company is divided into two working units or sections: 1- the ambulance section, and 2 - the dressing station section. The ambulance section is in charge of a junior officer, the supply sergeant and stable sergeant, with drivers and orderlies, one musician and one cook. The dressing station section is in charge of the Commanding Officer of the company with the remaining junior officers, non-commissioned officers, one cook and 36 to 40 litter bearers. When the commanding officer of the ambulance company receives orders from the Division Surgeon or the Director of Ambulances Companies to move forward, the dressing station section will immediately proceed by carefully planned route, being careful to keep outside the line of vision of the enemy and within the safety zone if possible, until it arrives near the place designated for the location of the dressing station. The exact location of this station is left to the judgment of the officer commanding the dressing station section. Matters pertaining to ready access for litter bearers from the front and ambulances from the rear, protection from enemy over- shots, the availability of supplies, wood, water, etc., must also be left to the judgment of this officer. A location may afford excellent protection and still be poor from the stand- point of accessibility or for other reasons, and thus be rendered useless, so that all elements entering into the question of the location must be carefully considered. Establishing the Dressing Station. A location having been decided upon, the order is given to establish the dressing station. This is composed of five sections, as follows:- Kitchen, dispensary, recdiving and forwarding departments, ward for slightly wounded and a ward for the seriously wounded. The kitchen is established at once. Mule No. 4 carries the kitchen equipment and is therefore unloaded at once. While a fire is being made the large water bag made of canvas and equipped with funnel and rubber hose for siphoning the water into the bag is placed on the back of the mule and sent after water at the nearby stream or well. Two boxes of food are carried on the kitchen mule. This consists of canned goods, cocoa, beans, extract of beef and condensed milk. A good cook is able to make appetizing stimulants from the contents of the food boxes. Two tent flies are the only canvas carried, so with the aid of the 12 tent pins and the W rope as a ridge pole and 87 litters or trees for uprights the wards are established. The furniture is very scant, consisting of rubber and gray blankets spread out in order on the ground under the fly as protec- tion. The dispensary and operating room consists of a litter resting on two of the boxes of reserve dressings with a rubber and gray blanket covering the canvas of the litter. The medical and surgical chest is opened and drugs and instruments made accessible. As soon as the station is established the Commanding Officer sends a message to the Director of Ambulance Com- panies that the station is ready for the reception of patients, giving the date, time and exact location of the station. In the meantime litter bearer squads in charge of sergeants are ordered forward to establish routes for the evacuation of litter wounded from the regimental aid stations. Red Cross guidons are tied to poles, trees or bushes in the vicinity of the station and strips of bandage are tied to trees and bushes along the paths marked out. This marking helps everyone, the wounded straggler to the rear who is able to walk or crawl and the returning litter squads laden with their bur- dens. It helps everyone and prevents loss of time and un- necessary hauling. Bringing in the Wounded. As soon as communication has been established with the aid stations at the front, the process of evacuation of wounded to the rear is begun. With the appearance of the first litter squad from the front the work begins. The man is brought first to the receiving ward where his name, company and regiment are listed together with the diagnosis. The medi- cal officer, in charge notes whether the patient is slightly or seriously wounded, whether he needs further treatment, as readjustment of dressings or an emergency operation, orders stimulants, hypodermics or food, if permissible, and desig- nates the ward in which the man is to be placed. Only the most urgently necessary operative work is done, the prime object of the station being to sort the men in the evacuation to the rear. When the influx of wounded begins to show signs of greatly increasing, the Commanding Officer sends word to the Director of Ambulance Companies, if he can be found, otherwise to the Division Surgeon, that his station has a certain number of wounded for transportation to the field hospitals, as recumbent and sitting patients. At the same 88 time he forwards a message to the officer in charge of the am- bulance section of his company to advance with the necessary ambulances, according to the number of ambulance cases he has in the station. The ambulance officer must exercise care and judgment in his advance toward the dressing station for fear of being sighted by the enemy. He may be unable to advance with safety at all and should therefore advise his superior officer to that effect who will in turn advise the Director of Ambulance Companies. The work of evacuation of the wounded by ambulances would then have to be accomp- lished under the cover of darkness or during a lull in the fighting. The time consumed in the removal of men from the aid and dressing stations is important as is also the question of how much material to use at just the right time and in the right place. Straub, (Medical Service in Campaign,) has devised various formulae to arrive at a quick decision and should be consulted at such times to aid in the problem. With the work of the dressing station completed, the necessary operations performed, the dressings reapplied or tightened, the stimulants administered and the ambulance cases evacuated to the rear, the Commanding Officer waits for orders to break up and rejoin his unit in the rear. Some- times in the stress of work and excitement, the Director of Ambulance Companies may forget about the dressing station and allow it to remain pitched long after it has ceased to be needed. In this case the Commanding Officer may send a message to him or to the Division Surgeon stating the conditions and asking for permission to break up and return. Not until he has received an affirmative reply may he do so, however, unless there is too long delay, and the exercise of independent judgment becomes necessary. Should a retreat be forced and a dressing station and its personnel be enveloped before the wounded can be evacu- ated, suitable personnel should be left with the wounded for their proper care when falling into the hands of the enemy. 89 CHAPTER XVII. THE FIELD HOSPITAL (Capacity 216 Beds) The personnel of a field hospital at war strength are oridinarily assigned as follows: 1 major (commanding); 5 captains and lieutenants (1 adjutant and quartermaster, 4 ward surgeons); 3 sergeants first class (1 acting first ser- geant in general supervision of the hospital and in charge of medical property and records, 1 in charge of transportation and quartermaster property and records, 1 in charge of mess supplies and cooking); 6 sergeants (1 in charge of the dispensary, 1 in charge of operating equipment, 1 in charge of patients' clothing and effects, 3 in charge of wards); 3 acting cooks; 55 privates first class and privates; (46 attendants, 1 dispensary assistant, 1 artificer, 4 orderlies, 3 supernumeraries); and of the Quartermaster Corps, 1 sergeant (wagon master) and seven privates (drivers). Field hospitals must be kept mobile if possible. The function of the field hospital is to keep in touch with the combatant organizations and to provide shelter and such care and treatment as are practicable for the sick and wounded of the division who are brought in by the ambulance com- panies until the sanitary service of the line of communica- tions takes charge of them. A field hospital can meet these requirements only when it is relieved so promptly by the sanitary units in the rear that its mobility is not interfered with. Prompt evacuation of the sick and wounded is neces- sary also to secure for them the facilities for treatment and the comforts which are available on the line of communica- tions. Use of Field Hospitals. On the march and in temporary camps, however, the field hospitals are the nightly collecting points for the divisional sick and injured who are unable to continue the march, and must provide for the care of such patients until they can be 90 turned over to the medical service of the line of com- munications or to a local hospital or hospitals. The use of the field hospitals for this purpose should be carefully regu- lated by the division surgeon. (a) So far as practicable in each division only one field hospital at a time will be used in this service, leaving the others entirely free of patients. Furthermore, only so much of the equipment of the field hospital assigned to this work should be unpacked as is required to care properly for the patients actually in the hospital and their necessary attend- ants who are to remain behind when the division moves on. The number of personnel detailed to remain will be as small as possible. (b) The equipment which has not been unpacked and the personnel who have not been detailed to remain with the patients will move with the division. (c) Every effort will be made by the division surgeon to dispose of the patients left behind. Should unusual delay in turning them over to the medical service of the line of communications occur, temporary provision for them should be made in civil or other hospitals of the locality or other- wise as may be most practicable until the medical units of the line of communications can take charge of them. (d) As soon as the patients are disposed of, the personnel detailed for the temporary care of such patients will im- mediately rejoin the hospital. For service in combat, the locations of the field hospitals and the number to be opened will be determined by the divi- sion surgeon acting under the instruction of the division com- mander. The director of field hospitals will supervise their opening, giving the necessary orders therefor to the com- manders of the field hospitals. He will report their opening to the division surgeon. (a) It is necessary that they be centrally located and beyond the zone of conflict, which will usually require placing them three or four miles in rear of the dressing stations. (b) Field hospitals should be easily seen and reached from front and rear and yet not be in the way of troops and trains. An ample supply of good water is necessary and suitable buildings are of great advantage. Such buildings should be utilized first, and only so much tentage put up as may be required. Location of Field Hospitals. 91 (c) If the enemy retires, field hospitals will be established, if possible, near the dressing stations having the greatest number of wounded, (d) A field hospital may be moved forward under the direction of the division surgeon to replace a dressing station and to take over the patients. Establishing the Field Hospital. The time when field hospitals should open will be communicated by the division surgeon to the director of field hospitals, should there be one, or, there being none, to the commanding officers of the hospitals concerned. (a) Only one will, as a rule, be opened early in the battle. This will be done as soon as the number of wounded justifies it. The other field hospitals should not be set up until the necessity for them is apparent. If the conditions are such that the wounded can be evacuated directly to the line of communications, the opening of field hospitals will be un- necessary. Field Hospital Departments. On the receipt of an order to open a field hospital the following departments will be established: 1. Dispensary 2. Kitchen 3. Receiving and forwarding 4. Slightly wounded 5. Seriously wounded 6. Operating Room 7. Mortuary. All wounded arriving at the field hospital will be received at the receiving and forwarding department, which is the administrative office of the hospital. (a) The slightly wounded, able to walk, will be immediately directed to the rear or to the station for slightly wounded, as the circumstances may indicate. (b) The seriously wounded, and the slightly wounded unable to walk, will be assigned to the proper department for treatment. (c) Records of the wounded will be made. Under ordinary battle conditions operations at the field hospitals should be such only as are needed to fit the patients for transportation to the rear. Many extensive dressings will, however, be required under all circumstances. All operations should be done under the strictest antiseptic 92 or aseptic precautions, and every effort made to dress cases so that they will not require redressing for some time. Patients should be fed, if practicable, before being sent to the rear. Every opportunity should be taken to transport the wounded to the rear. Ordinarily they will be turned over to the transportation of the line of communications, but the returning transport of the division may be utilized for this purpose in the same manner as at the dressing stations. When the number of wounded is very great and the trans- portation facilities are bad, with no rear hospitals to relieve field hospitals, the latter will, despite all efforts, become crowded with wounded which they can not dispose of. In this case the division surgeon may be compelled to concen- trate all wounded in one or two field hospitals so as to free the others for an advance. The hospitals left behind should be cleared as soon as possible, in order that they may rejoin their division. (a) When no adequate provision is made for the evacuation of the sick and wounded and a field hospital becomes the nucleus around which a camp hospital is developed, it be- comes an immobile unit, and, if the troops to which it is attached should move, another field hospital will be required to accompany them. Field hospitals ordered to close or to move will dispose of their patients as directed by the division surgeon, or the director of the Field Hospital. (a) If by reason of retreat or otherwise a field hospital is required to move before it can evacuate its patients, its commanding officer will take action similar to that prescribed for dressing stations in the like contingency. The opening, moving and closing of field hospitals will be reported by their commanding officers through the director of field hospitals to the division surgeon, who will report the same when necessary to the surgeon of the advance group of the line of communications. M. M. D., 1916. Evacuation of Patients. 93 CHAPTER XVIII. MILITARY MEDICINE When it is considered that in time of war the troops in campaign fight on an average of but one day out of each forty of service, it becomes apparent that the incidence of sickness is, or at least that without proper preventive measures it becomes, of even greater importance than the care of the wounded, from the standpoint of the effectiveness of the army. Methods employed by the army in the pre- vention of disease are therefore of vital consequence. The work of the medical officer is interwoven with every phase of military activity. In the early days of a man's training, the medical officer should advise with the com- mander so that the training may be gauged by the man's condition. Soldiers newly recruited require a number of weeks of strenuous drill and marching before they become hardened or seasoned. A march of five miles results in great exhaustion and much temporary illness when troops are first mobilized but this softness is soon overcome by in- creased physical training, drilling and marching until at times troops have been able to cover as many as twenty-five or thirty miles in the forced marches of active warfare. Safeguarding Food Supplies. The men's nutrition must be carefully watched and an adequate supply of food of good quality, with a proper balance of the essential nutritive elements, must be pro- vided. These matters naturally come under the supervision of the medical officer and his trained assistants who must also exercise a careful control of the water supply and be unremitting in their vigilance against possible contamination from extraneous sources of food supply, such as provisions brought into the camp by hucksters. Not only must cleanliness be required, but there must be strict supervision of all food supplies, including those drawn from the quartermaster for feeding the men. Products 94 offered by ice cream venders and hucksters must be excluded and ice cream furnished by restaurants on the outskirts of the camp, having concessions, must conform to a certain standard. Food supplies must be carefully conserved. Meat must be iced and the men must not go on the march in hot weather with meat sandwiches in their haversacks, thereby running the danger of contracting ptomaine poisoning from eating the meat. Men must be cautioned against eating green or over ripe fruit. Granted that the physical examination of recruits has eliminated the physically unfit and that rules of camp sani- tation are strictly observed, that part of the preventive work of the medical officer which may be characterized as military medicine is restricted to the consideration of certain types of disease. After the physical examinations have been com- pleted and before the troops are ready to take the field or even to commence their training, certain inoculations against disease are instituted. The salutary results of the anti- typhoid inoculation have been demonstrated so completely that no arguments are necessary to convince medical men as to the value of the procedure. The Method of Anti-Typhoid Inoculation. The following is the method followed in the inoculation of troops. An order is sent for the men to appear, company by company, in the order designated, at the Regimental Infirmary and the medical officers begin the inoculations, which are now done at intervals of seven days. Three doses of vaccine of a strength of 500,000, 1,000,000 and 1,000,000 killed bacilli respectively are employed. When this is done, a blank is started for each man with the name of the soldier noted and stating his rank, the company, number of years of service, whether he has ever had typhoid, (yes or no,) the year; when, if ever, vaccinated; date of the first dose; reaction, mild, moderate, or severe; date of second dose; reaction; date of third dose; reaction. All these vaccination records must be carefully preserved and when the vaccination is completed, the fact is also entered upon the man's Descriptive list. Every man has a De- scriptive list of facts from the time of enlistment to the time of discharge and this list includes the small pox vaccina- tion record as well as the typhoid record. 95 The typhoid cards also show the small pox vaccination records. Small pox vaccinations are done for every man, whether he has been vaccinated recently or not, and it has been found that this may be done during the course of the anti-typhoid inoculation, usually between the second and third doses. Where there is a large number of troops to inoculate, this saves valuable time and it has been found that it is a safe procedure and that practically no ill effects result. A record is also kept of all cases of malaria and a card record of all cases of syphilis. Small Pox Vaccination. Venereal Prophylaxis. Venereal diseases are prevented at the present time in the service by the compulsory use of methods of venereal prophylaxis. Within eight hours after exposure to venereal infection, the soldier must present himself for treatment under penalty-in case infection results-of trial by summary court, the loss of pay, the imposition of fines and the re- striction of privileges during the period of his disability to perform his military duties. In each army post, there is a room set aside in each company barrack where men report. In camp the regimental infirmary is used and there enlisted men, frequently sergeants, are on hand in their turn to carry out the measures of prophylaxis. Venereal prophylaxis consists in washing the parts with soap and water, followed by a weak bichloride solution and an injection of 5% protargol into the urethea and inunction of a 25% calomel ointment to the glans. This, like all other means of prophylaxis, is by no means effective in 100% of cases. It is, like some other preventive measures such as for typhoid or diphtheria, a remarkable preventive, however, and is probably efficient in 80% of the cases. While it will prevent syphilis, it seems to be much less effective in the case of chanroids though even these do not occur as frequently as when no precautions are used. When men are made to realize that this is for their own good, very few neglect to present themselves for treatment. Malaria. The prevention of malaria comes under the head of Camp Sanitation. On the march or in bivouac, however, it is not always possible to avoid mosquito bites when in malarial districts. Isolation of malaria patients and, if need be, the prophylactic use of quinine are then resorted to. 96 Exanthemata. The spread of acute exanthematous diseases is avoided by prompt isolation. The present practice in most camps is to remove all patients having temperature of 101 or higher from the camp to camp hospitals or base hospitals for a period of observation. Thus the spread of exanthemata and also of typhoid or any other acute infectious febrile disease is prevented. A large number of patients are ad- mitted to camp hospitals or base hospitals with the diagnosis, "Fever-type undetermined." Semi-Monthly Inspection. During 1916 the innovation of requiring a semi-monthly inspection of troops was adopted, its purpose being to ascer- tain the state of personal cleanliness of all soldiers, the presence of venereal diseases and particularly the presence of vermin. On Saturday morning all troops are inspected as to condition of clothing, rifle, equipment, etc. On alter- nate Saturdays, the men are called to quarters where they take off their clothing down to the underwear. After the medical officer has looked them over for personal cleanli- ness, the men are stripped and are inspected for venereal disease and the presence of vermin. A man may not be conscious of the presence of lice or scratch marks on his body or of insects in his garments. If undetected, the vermin soon spread through the tent and the entire camp. Typhus Fever. When it is realized that one of the chief endemic diseases in Northern Mexico is typhus fever, that practically every household in Mexico is infested with the carrier of typhus, the pediculus vestimentorum, and that troops going to Europe are quite apt to encounter the disease, the importance of a vigilant and unrelenting campaign against the body louse is self evident. It is almost impossible to prevent its appearance when men are not in a position to take frequent baths and have clean underwear, as often happens in the field. This is absolutely impossible unless the question is dealt with on a large scale, as is being tried in Europe. The louse differs from ordinary insects in not passing from the egg to a larval state. It is hatched from the nit as a developed insect, though not full grown. In its growth. 97 like the Crustacea, it sheds its outer shell and molts at periods of three days until about the ninth day when it reaches full growth. The eggs are nits and take about six days to develop. The microscope shows the various stages of development. During this six days-although they have been known to go twelve days before hatching-the chitin covering of the nit is very resistant to germicides and must be attacked in a certain way. The lice are not particularly difficult to get rid of with adequate facilities for cleanliness. Heat and various germi- cides, particularly those containing the essential oils, ethers, or benzines, are used principally. A louse lives about five days if deprived of nourishment. Hang out a dirty shirt containing the lice and leave it long enough and the lice will die. Leave it out longer and the nits in the shirt will hatch and these lice will also die. This makes it clear that rather close personal contact, such as in sleeping quarters, is necessary for the spread of these pests. Extend Measures to Occupied Territory. The direction and execution of preventive measures among the inhabitants of occupied territory is obviously as neces- sary from a humanitarian standpoint as for the protection of the troops. It is arranged for by detailing troops of the line, under the direction of medical officers, who shall in- sist upon and secure the cleaning up of towns, the proper disposal of waste, and the protection of the water and food supply from contamination. Provision is also made for the isolation and medical care of all cases of infectious or con- tagious diseases and for medical treatment of the civil population which is not infected. Cerebro Spinal Meningitis. Cerebro Spinal Meningitis, "Cerebro Spinal Fever," "Spotted Fever" is an infectious disease which occurs both sporadically and in epidemics. It is caused by the Diplo- coccus Intracellularis. It is characterized by inflammation of the cerebro spinal meninges, and follows a very irregular course. It is most common in children and young adults. According to the experiments of Flexner and others, the infection is spread through the medium of the nasal mucous membrane and its discharges. The intimate connection be- tween the nasal membrane and the cerebral meninges, ex- plains the ease and rapidity of infection by this route. 98 Like every other infectious disease, there is great variability in the virulence of the infection. In the most virulent types, death occurs within a few hours or a day, and the brain and spinal cord show few if any changes beyond violent congestion. Where the case is prolonged beyond this time, characteristic changes present themselves. The meninges are thickened, there is pus and there is fibrinous exudate covering the brain and cord, occasionaly abscesses or small hemorrhages and the brain substance is softened. There may be pneumonia, pleurisy or endocarditis. The incubation period is not known. The disease usually occurs suddenly with chills, headache, muscular pains, vomiting, lowered pulse, somnolence, moderate temperature, great prostration, a purpuric rash. The prostration may be rapidly followed by unconsciousness and death in from five to twenty-four hours in the malignant type of the disease. In the usual form, there is a prodromal period, headache, the symptoms are less violent, temperature 101-102, loss of appetite, perhaps vomiting, the pulse is full and strong, muscles of the neck are stiffened and movement is painful. There is photophobia and may be strabismus, paralysis of the extra-ocular muscles and facial paralysis. The patient is acutely sensitive to sounds. There may be spasm of the extremities and the muscles of the back and neck are rigid and in contraction. These symptoms may be followed by delirium, stupor, coma. The temperature curve is apt to be irregular. It may be low or it may reach 106 or higher. There is a petechial rash in 50% of the cases. Sometimes there is erythema, herpes or "rose spots" resembling typhoid. There is a massive leuco-cytosis, as high as 40,000 per cm, which is persistent. The spleen is usually enlarged and constipation is the rule. The urine usually shows albumen and sometimes blood and sugar. Kernigs sign is positive. The above is a mere outline of some of the most prominent symptoms which are met with in most cases. Meningitis in the Army. Epidemic meningitis is a most serious and destructive disease, especially liable to occur in armies and where large bodies of men are brought together from various parts of the country, and perhaps housed in crowded quarters. 99 It is therefore extremely important that Medical Officers be on the lookout for its invasion and take every necessary step for its prevention. Wherever it appears the patients must be immediately segregated and a systematic search for the meningo-coccus carriers be made. The carriers are more numerous than the patients as has been pointed out by recent experience among English and Canadian Troops. It is therefore important where epidemic meningitis occurs to immediately establish contact with laboratory facilities for the study of the carrier. Under the most favorable condi- tions, the death rate from this disease is apt to be high. Prompt resort must be had if possible to the intro- spinal injection of a reliable anti-meningitis serum, and such will doubtless be furnished through the Army Medical School or other Government Laboratories. The carriers should be isolated and likewise all men who have been in close contact with a case. Every military organization should if possible have at least one man who has a practical familiarity with the sub- ject of epidemic meningitis from both the clinical and the bacteriologic side. There can be very little question as to its occurence in our Army as soon as large numbers of men are brought together from all parts of the country, and we must be ready to meet the situation when it arises, and bring to bear upon it the most modern knowledge on the subject, which is for this country at least the work of Fexner and others done at the Rockefeller Institute. Recent experiences, as reported from the Mexican border and from the armies in Europe, would seem to justify the following Consideration of Paratyphoid Infections. Paratyphoid organisms are of two varieties "Paratyphosis A. and B." of Schottmueller. They resemble the B. typhosis morphologically and in staining reactions, differing in that Paratyphoid produces gas in glucose-containing media. Paratyphoid organisms possess agglutinating properties, which are specific in the proper dilutions, and are Agglutinated by Typhoid Immune Sera, but Paratyphoid Immune Serum does not agglutinate the typhoid organism. Bac. Para- typhosis B., the more common, agglutinates more closely with the typhoid organism than does Paratyphosis A. The infection probably occurs from fecal contamination as does typhoid so the principal factors are "Fingers, food, and flies." Paratyphoid Infections. 100 B. Paratyphosis A. and B., may each set up disease that clinically is indistinguishable from typhoid, excepting by bacteriological examination, but in addition to this the same organisms may cause local diseases, viz., (1) Gastro-Enteritis Paratyphosa, (2) Pyelitis Paratyphosa, (3) Cholecystitis Paratyphosa, with its resultant paratyphoid carriers, (4) Meningitis Paratyphosa. The Gastro-Enteritis and the abdominal form are the most common. Gastro Enteritis Paratyphosa. Usually caused by Bac. Paratyphosis B. The onset is sudden with violent abdominal pain, frequent stools for one or two days followed by constipation, the fever is not high. There is nausea and vomiting, herpes and rose spots appear, and great thirst is complained of. In fatal cases which are rare, there is delirium and convulsions. Diagnosis-Clinical picture indicates gas- troenteritis, laboratory shows causative organism to be Bac. Paratyphosis. Paratyphosis Abdominalis. The picture is that of typhoid: Onset with chills, fever is milder, duration brief, spleen is enlarged, rose spots and herpes occur. Intestinal hemorrhage and perforation are rare. The cardinal symptoms are headache, chills, diarrhoea, general abdominal pain, aching in limbs, extreme weakness, backache and epistaxis. The temperature reaches its maximum in 48 hours, the fever being usually remittent. The pulse is very slow, soft, easily compressible, and often dicrotic. The blood shows Leuco- poenia with relative Lymphocytosis as in typhoid. Diagnosis: A disease resembling typhoid, but beginning with chills, abdominal pain, diarrhoea, and herpes is sus- pected of being Paratyphoid. Laboratory evidences will differentiate. Prognosis: The disease is usually mild, but may be com- plicated and severe. The treatment is symptomatic and as in typhoid. Prophylaxis: Extreme cleanliness and supervision about kitchens and all breeding places for flies and supervision of those handling food including investigation to discover carriers. Preventative Vaccination. There are two types, Widal advises vaccination in three doses twice the strength of typhoid vaccine. Mendelsohn after his vast experience in Serbia, Macedonia, and Albania, advises the use of a Tetra- 101 vaccine, composed of Bac. Typhosis, Paratyphosis B., Para- typhosis A., and Vibrium of Cholera. This Vaccine contains per C. C. B. Typhosis 500 Million B. Paratyphosis A 250 Million B. Paratyphosis B 250 Million V. Cholerae 1000 Million Dose: 0.5-O. 6 C. C. injected subcutaneously at deltoid insertion, repeated after one week and again two weeks after the original vaccination. Simple swabbing of the arm with iodine has been found sufficient preparation. The reactions are mild; a small area of redness, slight local temperature and some tenderness. When general reactions were complained of they were only slight headache and general lassitude. Mendelsohn and Castellani used this vaccine for about 60,000 men in the disease ridden Balkan states and cleaned those injected of all infections. This would seem to be ab- solutely necessary, and is doubtless contemplated, for our American troops to be equally prepared to withstand all these diseases before entering any infected zones. Infectious disease processes always mean the growth and development of definite living organisms, bacterial as in diphtheria meningitis and typhoid fever, protozoal as in malaria. Every case of infectious disease is of course de- finitely connected with a previous case. Many cases, severe in nature, arise by contact with overlooked mild cases of the same disease, and through the medium of carriers. The most difficult problem in connection with the control of contagious disease are the mild cases and the carriers. Contagious diseases usually spread by contact, immediate or mediate, by fomites, air, water, food, insects. It goes without saying that the best way to handle epidemic diseases in the Army, is to avoid them, that is to say, to take all the measures in the way of vaccination against diseases controlled by this method and to promptly isolate such cases as may reasonably be expected to be suffering from some form of contagious disease, to resort to immunization when such measures are effective and to the approved methods of disinfection. In the matter of quarantine, where strict quarantine i§ necessary, positively no one but the physician, and the immedi- ate attendant, should comein contact with the patient, and the persons who must come in contact with the patient, must 102 resort to the well recognized precautions on entering and leaving. Neither any person nor any thing must be allowed to pass out of quarantine without adequate disinfection. The quarters of the sick should be stripped of everything not absolutely necessary to the comfort and health of the patient and attendants. Adequate toilet facilities must be provided in order to carry out efficient quarantine. Nasal, throat, urinary, fecal and other discharges must be disinfected and efficiently destroyed. Specific directions in detail for the carrying out of the above may be found in any good work on Practical Sanitation. When the infectious element of any disease gains entrance to the body, it requires some time for it to develop and multiply. The time between the entrance of infection and the appearance of the first symptoms is the incubation period, which is more or less constant for each disease. The consideration of this incubation period, is of value therefore in determining the time and place of infection and in enabling one to decide the length of time that exposed persons or sus- pects should be isolated, and therefore in tracing and con- trolling epidemics. The following table from Ashburn's Military Hygiene is useful as representing with reasonable accuracy the in- cubation period in the more common infectious and contagious diseases: Diseases Incubation Periods Small pox 8 to 20 days, oftenest 12. Typhus fever 12 days or less. Chicken-pox 10 to 15 days. Scarlet fever 1 to 7, oftenest 2 to 4 days. Measles 7 to 18, usually 14 days. German measles 14 days or more. Mumps 14 to 21 days. Whooping-caugh 7 to 10 days. Influenza 1 to 4 days. Cerebro-spinal meningitis unknown. Diphtheria 1 to 7 days, usually 2. Tonsilitis f. 1 to 3 or 4 days, usually 2. 103 CHAPTER XIX. SICK CALL In the daily routine of camp life or of life on the march, a certain hour is set aside as sick call, during which hour any members of the military organization who feel the need may present themselves at the regimental infirmary and receive medical attention. As the surgeon has the power to relieve a man of duty or return him to duty as his condition warrants, the infirmary is a favorite refuge for men desiring to escape from the monotony of incessant drilling or marching. The variety of causes for which these men consider themselves unfit for duty are many and the symptoms described are oftentimes not to be found in medical literature. Some men, however, possess a fair knowledge of medicine and are ex- ceedingly clever in simulating certain ailments. While the sur- geon must be constantly on his guard, he must also exercise great care in making a diagnosis of malingering. In case of doubt it is better to relieve a man of duty and place him under observation than to have him remain in the ranks when in distress. The first object of sick call is to determine for the informa- tion of the commanding officer the number of men unfit for duty on account of illness or injury. In order that the adjutant may make up his morning report of effectives, sick call must necessarily be limited to rapid yet thorough examination of all applicants, those in need of further medical attention being confined to quarters or sent to hospital while those mildly ill or suffering from minor injuries, not disabling are returned to duty. Various hours in the daily routine have been considered favorable for the holding of sick call but directly after break- fast and before morning drill is usually best. On the march, sick call is held immediately following arrival in the new camp. In the infantry, foot conditions prove to be the most troublesome cases. Blisters, caused by ill-fitting shoes and abnormally shaped feet, are numerous. In view of the fact that the march may continue early the next day, it is better 104 to take care of foot trouble in the evening, after the men have carefully cleansed and aired the feet. When camp is broken early in the morning, there is no time for morning sick call and any new cases arising are transported in an ambulance and examined and treated en route. On arriving at the new camp they are taken to the infirmary for further treatment. In the field or during an engagement, sick call occupies all the hours of the twenty-four. It is at this time that the sanitary units fulfill their mission of giving aid and comfort to those who have made the supreme sacrifice. The entire personnel is on duty continuously, snatching a few hours of sleep during a lull in the influx of patients. The clearing of a field of battle is usually carried on under cover of darkness and the work of giving first aid goes on uninterruptedly dur- ing an engagement. In view of the variety of circumstances that tend to alter the routine of military life in camp, on the march, or in the field, it can readily be seen that the administration of medical attention is determined to some extent by existing condi- tions, which must be met in accordance with the conditions. In conducting sick call it is important that the morning Sick Report be accurately handled in accordance with in- structions printed thereon. 105 CHAPTER XX. TUBERCULOSIS IN WAR Tuberculosis is one of the new war problems with which medical officers have to deal, the experience of European countries having proved in a most startling way that it has become a serious menace, not because measures for its prevention are wanting or inefficient but because they have not been applied, both before and since the outbreak of the war, in an efficient way. Following the presentation before the National Association for the Study and Prevention of Tuberculosis at its annual meeting in Cincinnati, May 9-11, 1917, of some appalling facts and figures on the situa- tion in France, where over 150,000 soldiers have been re- turned to their homes because of tuberculosis, Dr. Hermann M. Biggs of New York, who made a personal investigation of the French situation for the Rockefeller Foundation, outlined a war tuberculosis program for the United States which contains many suggestions of practical value for medical officers. He graphically calls attention to the fact that England, which has carried on an efficient anti-tubercu- losis campaign for years, has suffered the least of any of the warring nations from an increased tuberculosis problem. His advice to medical officers to exercise the greatest care in preventing the development of tuberculosis in the United States Army is seconded most convincingly in a paper on "Lessons from Canada's War Experiences With Tubercu- losis," presented at the same convention by Dr. Jabez H. Elliott, Captain, Canadian Army Medical Corps. The following extracts from these two papers relate specifically to the work and the responsibility of the medical department in protecting the army from this disease. Europes Experience a Warning. Dr. Biggs says: "This experience of European countries during the present war indicates that tuberculosis under the conditions of modern warfare is greatly to be dreaded by the military authorities. 106 "It is unnecessary more than to refer to the great ultimate economic loss involved in enrolling men who later develop pulmonary tuberculosis. The expense to the Government from the long subsequent care (when the disease develops) and the cost of pensions for the men and their families will be very great, aside from the loss of lives which under or- dinary conditions might have been long and productive to the country instead of being a continuous drain on its re- sources. "Measures adopted to prevent the introduction and de- velopment of tuberculosis among our troops as they are mobilizing can not be too careful or too stringent. "Recognizing this fact the National Association at the request of the Council of National Defense has appointed a special committee to work with the War and Navy Depart- ment of the Government and with the Anti-Tuberculosis Agencies of the country in devising and executing a war program for the prevention and control of tuberculosis. "In the opinion of this committee the work of the medical corps of the Army and Navy could be much facilitated and expedited if the services of voluntary experts in tuber- culosis were employed in various parts of the country to assist in the examination of those recruits for the army who show any signs of symptoms suggestive of pulmonary disease, or in whom the history indicates its possible existence." Classes for Special Examination. The following classes should be subjected to rigid examina- tion by a specialist in tuberculosis provided the medical officer making the examination is not himself expert in the diagnosis of chest diseases: First. Every man whose history shows that he has at any previous time had any illness resembling in character pulmonary tuberculosis. Second. Every man who gives a history at any previous time of an attack of pneumonia or pleurisy. Third. Every man whose history shows that one or more members of his immediate family (father, mother, brother, sister, etc.,) has had pulmonary tuberculosis or has died of this disease. Fourth. Every man with a flat chest whose weight as compared with his height is fifteen per cent below the normal. 107 Fifth. Every man who gives a history of chronic catarrh or who has a cough or any symptoms of any disease of the chest. Sixth. Every man in whom any abnormal physical signs of any kind are found in the chest. (Recommendations of Committee.) Other Recommendations. In any instance in which there is a cough with sputum suggesting tuberculosis, the sputum should be examined, and, if negative, it should be re-examined at least two or three times. Any man with even a very limited amount of pulmonary tuberculosis that is latent or arrested, is almost certain to break down under the physical strain of military training and army life, and a focus of disease previously latent or arrested will almost certainly become active. Systematic and complete periodic re-examinations should be made of all troops within three months after enrollment and at intervals of three months thereafter. These re- examinations should be as complete and thorough in all respects as the original examinations and should include the taking of the evening temperature of every man who gives a history of the signs or symptoms of being ill-con- ditioned. Every soldier who has had a cough for a period of two weeks, or any other symptoms of pulmonary disease, or whose general physical condition has undergone a serious deterioration, should if necessary be isolated and referred to an expert for re-examination, and every soldier showing any definite signs or symptoms suggestive of pulmonary disease (when a positive diagnosis is not possible) should be placed under expert observation until a positive diagnosis can be made, or until the existence of pulmonary tubercu- losis can be definitely excluded. Cases in which a positive diagnosis of pulmonary tubercu- losis has been made should receive sanatorium or hospital treatment, preferably, in institutions located in their home states, since homesickness is likely to counteract the beneficial effects of climate in remote localities. When the disease is apparently arrested the question of occupation should be determined. It is a matter of common experience that when a tuberculosis subject returns to in- door and factory occupations a relapse is likely to follow, while outdoor employment especially on farms may result 108 in a clinical cure and self-support. The establishment of Government farm colonies is therefore worthy of careful consideration. In discussing the problem in southwestern France, Dr. Leurte wisely remarks: "Left to themselves, they will be apt to drift into crowded factories and sleep in close crowded rooms, sealing their own doom and infecting others." Lesson from Canada's Experience. Dr. Elliott also emphasizes the importance of the main points upon which Dr. Biggs places stress. Dr. Elliott says: "We must eliminate at the preliminary examination all men definitely tuberculous or who have had a definite pul- monary tuberculosis. * * * After being attached to his unit, the recruit is under the observation of his battalion Medical Officer, who should watch carefully every man with evidence of bronchial trouble. Each man should be examined once in three months as a routine measure and a most thor- ough medical examination is essential when warned for departure overseas. "Let us recall that we believe that at least forty to fifty per cent of adults of military age react to tuberculosis-these have received at some time an implantation of tubercle bacilli which are now more or less walled off and harmless under ordinary conditions but may become active again and extension of the disease result. Under the strenuous con- ditions of active service, we must expect a certain number of cases to develop. Our efforts are to be directed to the control of these conditions which cause a latent tuberculosis to be- come active. "1. Reinfection. Any open case is to be removed at once from active service. All know the danger of infection and reinfection. "2. Fatigue. Through lowered resistance to invading organisms, fatigue, repeated and continuous, stands in close causal relationship to awakened activity in a tuberculous focus. Fatigue is bound to occur and if not undue may be beneficial rather than otherwise. The careful Organization Commander and Medical Officer will see that training in camp is so regulated-as is exercise in a sanatorium-that no ill effects follow. "3. Acute Infections. Again and again we get this history from our tuberculous cases, 'I was never sick in Measures for Control of Disease. 109 my life, but we had a lot of hard marching or I had a severe wetting and got a cold, then became feverish and I have never been able to shake the cough.' Whatever we do to lessen the acute respiratory infections in camp, we lessen the incidence of tuberculosis. In summer camps, when living in tents or in huts accommodating eight to thirty, we find few respiratory catarrhs amongst the men. In winter camps, with the men in large barracks, many of them big, drafty, barnlike structures, we find influenza, measles, colds, coughs a frequent complaint. An outbreak of measles in a military hospital or camp has been followed in our experience by an increasing number of cases of tuberculosis. It is advisable, therefore, to house the men in tents of eight or in huts of not more than twenty to thirty beds so that epidemic diseases may be controlled by the quarantine of a smaller number of men. "Sanitation in general bears indirectly upon the in- cidence of tuberculosis and must be mentioned in a complete scheme for lessening this disease. The water supply, latrines, sewage disposal, garbage collection, facilities for bathing, are all of the utmost importance. "More or less directly connected with the tuberculosis problem is that of liquor. We know that the use of spirituous and malt liquors does increase the incidence of tuberculosis, both through its effect upon the individual and its indirect effect upon the family. "When a man goes sick in a training camp, he is admitted to the camp hospital and if his illness is more than temporary, he is evacuated to the base hospital. Should he be found tuberculous, he is transferred to the sanatorium at once. If doubtful, he is kept under observation as long as he is febrile or ill. When convalescent, if diagnosis is not yet arrived at, he is transferred as a casualty to one of the con- valescent hospitals for further observation and diagnosis. "A casualty in an English training camp is similarly dealt with. If in France, he is passed back from the Regimental Aid Post to the Field Ambulance, thence to the Casualty Clearing Station, to the Stationary or General Hospital and to the Convalescent Depot for transfer to England. Here he enters the Primary Hospital where, after his history is written and examination made, he is passed on, if tubercu- lous, to a Sanatorium for treatment. As soon as his disease Care of the Tuberculous. 110 is quiescent, he is transferred to a convalescent hospital if a closed case (e. g., pleural tuberculosis) and there, or at the sanatorium, awaits his medical board when he is passed on to the Canadian Casualty Assembly Center to await transportation to Canada. "Two classes of tuberculous are returned to Canada, those quite convalescent and those hopelessly ill for whom further treatment in England gives no promise of arrest of the disease. "On December 2nd, last, we had 450 tuberculous patients under treatment in Canada in 18 Sanatoria. Five Sanatoria are exclusively for soldiers. In others they are cared for with civilian patients. * * * We are adding to our sanatorium equipment vocational workshops, all of which are under the general direction of a vocational officer assigned to organize this work in all the convalescent hospitals of the Dominion. "Speaking generally of our casualties, we need thorough organization and the keenest scientific aid in dealing with the men coming back disabled. By neglecting to restore every man to the highest efficiency he is able to maintain, we should be adding to the country's burden in two ways; First by the greater pension to which he will be entitled and which will form a burden for later generations and secondly, the heavier burden laid on the country by the loss of these men's industry. The tuberculous soldier, inefficiently or incompletely treated, is a further burden in that he may be a focus for further spread of the disease." 111 CHAPTER XXL MILITARY DENTISTRY It has been said that an army fights by its stomach and its teeth. It is obvious that a healthy condition of the oral cavity and its organs is of prime importance in maintaining the health of a soldier. He must get the maximum nutritive value from his food. He must be free from pain. Observa- tion has shown that it is impossible for men with toothache, abscesses and other afflictions of the teeth to do their best work, either mentally or physically, as pain not only causes nervous depression but also destroys energy and activity. The soldier suffering with toothache or dental abscess can- not stand the long hours of strain in the trenches or in the field. Modern warfare demands the maximum degree of physical and moral resistance and the dentist has an im- portant part in the development of a nation's war power to its fullest extent. The importance of the military dentist has been recognized but recently but the Eurpoean war has demonstrated clearly the necessity of dentists in camp and on the field of battle. In the beginning of the war many men with afflictions of the mouth had to be sent to the rear from the firing line, as they were useless as long as the affliction lasted. Dentists are now employed in the first line trenches and on the battle-fields as well as in the hospitals and the result is that men with dental troubles are returned to service with com- paratively little loss of time. The service of dentistry to the army ranges from the treatment of men who have been rejected as recruits because of poor teeth, thus putting them in condition for acceptance, to caring for wounds of head and face as well as of the mouth and to extensive restoration of destroyed or mutilated features. If the soldier entered the service with perfect teeth, the need for the dentist would still be great. Conditions under Army's Need of Dental Service. 112 which men are compelled to live on the modern battle field, exposure to weather conditions, sometimes lack of nourish- ment, and the absence of means for keeping the teeth clean and in good condition, make them especially susceptible to various afflictions of mouth, teeth, and gums. The situation is aggravated by the fact that many men, rejected at re- cruiting stations because of bad teeth, have the work done hurriedly and as cheaply as possible. Old broken down and decayed roots are covered with crowns and bridgework and as a result of this poor work the dental surgeon has for treatment a great number of dento-alveolar abscesses and resultant disorders after the men have been in service a short time. Under plans contemplated for army reorganization, ac- cording to the provisions of National Defense Act, approved June 3, 1916, the standard unit of organization for active service in the theater of operations is assumed to be an Infantry Division. An Infantry Division mobilized for field service should have at least fifteen operating dental surgeons and one executive. In camps of mobilization the dental officers may be quartered with other officers of sanitary units of the re- spective commands and operating space given them at Camp Hospital, Regimental Hospitals, or, in emergency, at Camp Infirmaries. The character of the treatment is subject largely to such conditions as the number seeking relief, the permanency of the camp, and the facilities of the dental officer's field equipment and supplies. The first aim is to give such "Emergency Treatment'' as will afford relief to patients and place them at the earliest possible moment on the status of effectives. The second is the conservation of teeth and efficient masticatory function by such methods of treat- ment and filling as may be required and can be performed with the equipment at hand. One of the problems of the army is the avoidance of gastroenteric troubles, the diet of the soldiers being in large proportion of meat. Without thorough mastication of food, malnutrition, constipation, and loss of appetite result and ultimately lowered vitality may render the soldier unfit for service and susceptible to disease. Character of Treatment. 113 Under actual field conditions in the zone of advance, the duties of the dental corps are largely of an oral surgical nature for gun-shot wounds of the jaws and bones of the face, in addition to the necessary emergency dental treat- ment for those who are suffering. Dental Work Allowed. Work which the dental surgeon can do for the enlisted man is prescribed by the army regulations. According to these regulations, the enlisted man is allowed treatment of roots with silver or cement fillings, porcelain crowns or plate- work being authorized only in cases where the teeth were damaged in line of duty. No gold work of any description is allowed the enlisted man, it being held that good cement and combination cement and silver fillings will serve all purposes during the term of enlistment. Officers are allowed gold work on payment of cost of material. The military dentist must solve many problems not met with in private practice. He must avoid pulp capping, large silver fillings in vital teeth and attachments to vital teeth, any operation, in fact, which might cause disturbance at a time when the soldier might be most needed and the dentist inaccessible. He must be on his guard against the man who tries to shirk duty. He should insist on the pre- sentation of the dental appointment slip at each sitting and its destruction when the work is completed, thus making it impossible for the slip to be used as an excuse to leave camp after the work is done. Each dental surgeon should have as an assistant an en- listed man, generally a private, first class, who is attached to the base hospital. Properly trained, he is indispensable in the management of a military dental practice, taking charge of records, appointments, sterilization of instruments and other office details. 114 CHAPTER XXII. BALLISTICS AND TOPOGRAPHY It is imperative that every medical officer should have at least a working knowledge of these two subjects, which although apparently widely divergent in principle, merge very closely into the working of medical military problems that present themselves on the battlefield. The knowledge of ballistics renders the treatment of wounds by missiles more intelligent and also makes it possible for an officer to avoid the danger areas of overshots in the placing of his stations or in the transportation of wounded. The value of knowing topography is obvious as in these days of immense battlefields visual direction is impossible and orders are all based upon the knowledge of map reading. By combining the knowledge of ballistics, especially con- cerning range and slope of falling missiles with the knowledge of topography relating to degrees of slope of hills and roads, the officer is enabled to intelligently place his stations in the least exposed areas. In all fire arms the moment the missile leaves the muzzle of the piece, no matter how high the initial velocity, it starts to fall to the ground from gravity and the long ranges are obtained by elevating the muzzle of the piece to various de- grees up to 45. The course of the bullet from the muzzle of the piece until it strikes is known as the trajectory and the highest point of the projectile from the ground is known as the maximum ordinate. We will take up I he various fire arms in use in the United States Army in their relative order. Pistol. 45 caliber. Extreme range 1950 yds. Maximum ordinate 2219 ft. Up to 75 yds. the trajectory is very flat, about 1° angle and at 250 yds. the bullet will penetrate 4" of white pine. The efficiency of this is shown by the fact that 1" penetration is considered equivalent to a dangerous wound. One shell is carried in the upper chamber of the pistol and seven shells in the handle and it can be fired just as fast 115 as the finger can pull the trigger. The pistol is essentially a defensive weapon. The size and shape of the bullet with its high velocity causes an ugly wound and effectively stops the opponent even where it does not kill. At close ranges the bullet shows an explosive effect, the wound of entrance being small and that of exit being large. Rifle. .30 caliber. All of the leading armies use approxi- mately the same caliber rifle, though there are some differ- Actual Size German Cartridge Actual Size U. S. Cartridge ences in the character of the bullets. Most of these are made with a lead core and are steel jacketed but the English have a nickle covering while the French bullet is made of solid copper. The extreme range is about 5,465 yds. Time of flight is 31 seconds and the maximum ordinate 6844 ft. At 1000 yds. the bullet would penetrate 12.8" of white pine. 116 At that range the maximum ordinate is 14 ft. The rifle can be fired 25 shots per minute aimed from the shoulder and 35 shots per minute fired from the hip. Practically all rifle wounds up to 800 yds. range cause explosive wounds due to the high velocity while beyond that range the wounds are very clean or the bullet stays in the body. If by any chance a jacketed bullet strikes the ground or a tree, the jacketed surface is broken and the bullet tumbles and in this condition Actual Size English Cartridge. Actual Size French Cartridge. causes a terrible wound when it enters the body. The so- called dum-dum bullets can be improvised by cutting the nose off of the jacketed bullet exposing the lead core or by reversing the bullet in the cartridge exposing the base of the core. When a missile of this description strikes the body it mushrooms on entering and causes a great destruction of tissue. 117 Machine Gun. .30 caliber. The machine gun is really an improved rapid fire rifle, fires the same shell as the service rifle, and weighs 70 lbs. The shells are fed in on a canvas belt 250 at a time and the gun is capable of firing 400 to 500 shots per minute. Overheating of the piece is controlled by a water cooling system. The gun can be swung from side to side or raised and lowered while under fire and has become a very good arm in present warfare. Fuse used in common shrapnel. Common Shrapnel. In this country at the present time we have only three sizes of artillery, the 3" and the 4.7" field guns and the 12" naval gun used for coast defense. In the field the 3" gun is the most important because of its possibility of rapid fire and rapid mobility. It fires both shrapnel and high explosive shell. Extreme range is 7500 yds. Longest effective range is 6650 yds. Angle of elevation of 15 degrees, maximum or- dinate of 2000 ft. 3500 yds. is called the range of election and the maximum ordinate is 378 ft. The muzzle velocity is 1750' per second. The high explosive shell is constructed to explode upon contact although at the present time nearly all of the countries are using what is known as the delayed fuse causing the explosion to occur a few seconds after contact. The shell under these conditions bounds into the air and ex- plodes 5 to 7' from the ground causing great destruction. Shrapnel is shell of practically the same construction but in- stead of being fdled with high explosive it is fdled with 350 118 Actual size of shrapnel bullets, pieces of shell, and a German bullet (upper right hand corner) removed from wounds: and (lower left hand corner) an English and French bullet for comparison. 119 small bullets imbedded in a matrix of wax. This is timed by a fuse to explode in front of or about 50' above the target and these bullets are thrown with extra force into the enemy. All field gun fire is now what is known as indirect fire and smokeless powder is used. The gunners cannot see the target they are shooting at and the enemy cannot see the guns that are shooting at them. The fire is controlled by the Battery Commander on some nearby hill where he can see both the Battery and the target or else by aeroplane. Each projectile weighs 15 lbs., and costs about §12.00. Although the 12" gun is essentially a naval gun it is the largest we have in this country and a few points of information regarding it will not be out of place. Extreme effective range is 11 miles. Time of flight 40 seconds. Muzzle velocity 2250 ft. Weight of charge 3251 lbs of powder. Weight of projectile 10461 lbs. Cost of the gun is §43451.00. Cost of each shot is §150.00. Life of the gun is only 200 shots. In the French army the 75 M. M. is their most popular field piece. It has an effective range of four miles and they claim can be fired 20 times per minute. Beside this they have a 120, 380 and 420 M. M. but these heavier pieces are used mostly for reducing permanent fortifications. The German and British guns are practically the same as those of the French with the exception that the British light field piece is of 3.29" caliber. The Germans have also per- fected a trench mortar capable of throwing 187 lbs of high explosive 300 to 400 yds. forward with a very high ordinate so as to drop directly into the trenches. Wounds by bayonets and lances are very frequent in the present war and the mortality is very high. Only about 4% ever reach the hospitals. In the present trench warfare hand grenades and bombs have been used a great deal for close work and as opposing trenches are often only from 30 to 40 ft. apart the opportunity for this form of offensive is plentiful. The hand grenades are practically of the same general con- struction. They are simply round or pear shaped shells filled with high explosive and fired by a time fuse. The thrower has a leather strap around the wrist with about four feet of rope attached. A hook in the end of this rope is hooked into a ring of the fuse on the surface of the grenade and when the latter is thrown the fuse is withdrawn by the act and explodes within two or three seconds after leaving the thrower's hand. The artillery and grenade wounds are 120 Types of shrapnel in modern use. 121 infected because in every case dirt and clothing are carried into the wound and the various antiseptics that we have up to the present time depended upon to control this infection have proved to be of little or no value. The slope of fall of missiles at the various ranges are as follows: 1000 yds. 1 on 38 1500 yds. 1 on 15 2000 yds. 1 on 8 3000 yds. 1 on 3 Rifle Artillery 3000 yds. 1 on 7 3500 yds. 1 on 7 6500 yds. 1 on 2 In our earlier wars it was not absolutely necessary for medical officers to know topography because every battle- field was in plain view and orders could be given by visual direction. At the present time due to the increased range of fire arms, especially that of artillery, the fighting line of a division of 25000 men may cover as much as 50 sq. miles. Visual directions under these conditions would, of course, be worthless and all orders are given upon the basis that everyone knows how to intelligently read a military map. Maps are illustrations of portions of the earth's surface and are usually plain, showing roads, towns, rivers and other con- spicuous objects but the military map to be of any value must show more than this. The various elevations and de- pressions must be shown and the relative slopes and heights must be true to scale. All maps are drawn to scale. With- out a scale a map is practically useless. The maps that show the elevations and depressions are known as contoured maps and in this country are obtained from two sources. One is known as a natural scale map which is the regulation map of the War Department and the other is that of the geological survey. These maps differ in one respect. The geological survey map has no fixed relation between the scale and the contour interval, the latter being governed by the character of the ground, while in the natural scale map there is a con- stant fixed relative between the scale and the contour in- terval and because of this degrees of slope can be readily figured on a map of any scale. 688" horizontally on a one degree slope gives a rise of one foot and on any natural scale map .65" between contour intervals is always equal to one degree slope. The figure 60 divided by the contour interval will give the scale of the map and to reverse this the figure 60 divided by the scale of the map will give the proper contour interval. Topography 122 Scales are made in one of three different ways. First: in words and figures, as -3" equals one mile. Second: by the graphic scale which is --- - 1000 yds. Third By 1 the representative fraction R. F. . The numerator sig- 63360 nifies units of distance on the map and the denominator units of distance above the ground. Map 1 in. 1 R. F. Ground 1 mile 63360 This is the most generally used form of scale and the maps are usually made in three different scales with the R. F. of which everyone should be familiar. 1 R. F. = 1 in. to 1 mile. 63360 1 R. F. =3 in. to 1 mile. 21120 1 R. F. =6 in. to 1 mile. 10560 1 A 12" map R. F. is used for instruction purposes and 5280 for war games but is never used in the field. These maps are sometimes photographed and reduced or increased in scale and it must be understood that under these conditions the fixed relation between scale and contour interval is naturally disturbed. The geological survey map is usually a very fine one and is issued in three sizes. 1 R. F. = 1 in. to 1 mile. 62500 1 R. F. = 1 in. to 2 miles. 125000 R. F. 250000 With a thorough knowledge of the principles of the natural scale map an officer will have no trouble in transposing the data of the geological map so that he can make fairly accurate readings. (J. W. Frew). 123 CHAPTER XXIII. MILITARY SURGERY General Considerations. The problems that present themselves to the military surgeon are these: 1. To guard the health of the troops individually and collectively. 2. To rid the army in the most effective way of sick and wounded, the non-effectives. 3. To treat disease and wounds incident to the service and return as many as possible, in the shortest time, to duty. The military medical officer then must combine in himself the qualities of the good doctor, the skillful surgeon, the sanitarian and the executive. In the military medical serv- ice, as in civil life, prevention is of far more importance than cure. It is now fully realized and acknowledged by both line and staff of all modern armies that the most important factor in military success is the health of the command. The military medical officer must therefore study care- fully the general situation with reference to the health and safety of the command. He must fortify himself in advance by a knowledge of special conditions which may be in- volved in any scheme for conducting a campaign and he must be able to make that knowledge promptly available under those conditions. Medical officers are thus called upon to study the plans of proposed operations in order that they may be so prepared and equipped that the campaign will not end in disaster on account of the ravages of disease and disability; that it will on the contrary, be facilitated by the speedy and effectual ridding of the troops of the non-effectives, sick and wounded; and that the medical officers will be able to furnish to the sick and wounded prompt and efficient medical care and treatment in line with the best and most modern knowledge on the subject. 124 The average civilian surgeon, no matter what his skill strictly as a surgeon, is all but useless on the battlefield or in campaign unless he has had some training as a military medical officer. The man who has sufficient ingenuity to repair the broken leg of a chair, with a little special infor- mation added, may do a very good job at the amputation of a limb, but this is the least important of the considerations involved in the proper handling, treatment and disposition of men wounded in battle. The present war has proved that time has not changed the two great principles of the treatment of wounds in war laid down by Baron Larrey, the master surgeon of the Napoleonic wars, and that these principles still have their direct applica- tion to the military surgery of the present day. First, is the "twenty-four hour principle," as it was spoken of by Larrey, which meant that if operation was needed at all it was best done in most cases within the first twenty-four hours after the receipt of the wound. This of course was an application of the principles of asepsis, later laid down by Lister, for, while Larrey did not realize it, he practically recognized that during the first 24 hours he was operating upon as clean wounds as he would ever have an opportunity of dealing with. The second principle Larrey called "the principle of humanity," by which was meant the completion of the operation in the minimum of time with the minimum of pain and distress to the patient. It still remains true that what happens to an injured man during the first twenty-four hours following his injury is of the greatest importance, and it is a source of great satisfaction to note that in the English, French and German services, at least, the trans- port system by which wounded are removed from the battle- field to the Field, Evacuation, Base and Reserve hospitals is all that could be expected. It is of common occurence that men wounded in Flanders reach the hospitals in England within the first day after the receipt of the wound, and like- wise the Base and Reserve hospitals in Germany and France, over a system of transportation which, so far as can be de- termined by description, cannot be much improved upon. The 24 Hour Principle. Bacterial Infection of Wounds. In an address by Sir Almroth Wright, British Medical Journal, October 30, 1916, it is pointed out that the dis- tinction between sick and wounded is from the point of 125 view of science an entirely improper one. Those who are classed as wounded are as universally, perhaps even more universally than those classified as sick, suffering from bacterial infection. Since the days of Lister very little study has been devoted to the bacterial infection of wounds. The emphasis has been placed upon prevention rather than the successful treatment of septic infections of wounds. One lesson of this war has been to demonstrate that account must be taken of the effective treatment of infected wounds with regard to the various bacteriological considerations involved, and Dr. Wright points out the growing conviction that effective treatment will not be arrived at "without strenuous study of the infecting microbe, the conditions in the wound and the therapeutic agents which we employ, and the defensive operations of the organism." Since Lister first impressed his teachings in antisepsis and asepsis upon the medical profession, it has been the object of surgeons to obtain healing by first intention in the treatment of wounds. The effect of the great war in Europe has been very largely to compel surgeons to go back to the days when most wounds suppurated. It has demonstrated the uselessness of many of our supposed advances in surgery. Wounds in the present war are largely infected even before the possibility of first aid. The conditions surrounding the present methods of warfare and inherent in them are such as to favor and almost guarantee the infection of most wounds, especially shrapnel, high explosive, etc. The battlegrounds of Europe are on fields that have been occupied and cultivated for centuries and the soil of which is permeated with the fecal discharges of domestic animals and men. The bodies and clothing of the soldiers are per- meated with the mud and dust of infected soil. Facilities for bathing and changing of clothing are under these conditions necessarily limited or absent altogether, and days, weeks or months pass without the men having much opportunity for personal cleanliness. The lowering of physical vitality and the exhaustion incident to exposure, anxiety, loss of sleep and physical exertion, naturally lower the powers of resist- ance, and the wounded soldier becomes the more easily the victim of infection. Forces and battles are being fought on the most gigantic scale. Methods of warfare hitherto unheard of are being used. Trench warfare seems largely to have supplanted the open methods of battle. More powerful guns are being used. 126 Battles are being fought which last for weeks or months. In some instances they are almost continuous and the area, both in front and behind the troops on the firing line, is almost constantly swept by artillery. Present War Brings New Problems. Necessary and desirable cessation in hostilities for the purpose of the removal of the wounded has been less con- sidered than ever before, and the rendering of surgical aid made much more difficult. Enormous numbers have fallen in all the armies involved. It has been necessary to bring in the wounded during lulls in the fighting or under the cover of night. Transport facilities in all the armies have been strained to the utmost, but notwithstanding this the medical departments of all the countries at war seem to have met the needs in a way that on first consideration would seem to be beyond human possibilities. Much has been learned, much has had to be unlearned and some things have been relearned -why the earlier surgeons found it necessary to make such free and deep incisions; why amputation was so frequent; why they insisted upon the surgeon knowing his gross anatomy so intimately, why the simple circular amputation with the open, exposed stump seemed preferable, and why large, wet dressings were so much in favor. The character of the wounds, the nature of the infection and the enormous damage to tissues is far different under present war conditions than under those of previous wars. Surgeons everywhere are endeavoring to meet the new conditions and doubtless will do so, but for the present we must consider that most wounds in war are infected and that the means of combating this infection, up to the present time at least, have not been and are not the most desirable and the most efficient. But surgery has made distinct advances and methods are now being employed with better understanding and better reasons. The X-ray is a wonderful advantage and enables the sur- geon to do more directly and more intelligently what would have been impossible previous to the introduction and de- velopment of this wonderful aid. Laboratory methods leading to life saving suggestions are being rapidly developed. For working purposes those wounded in battle fall natur- ally into three classes: (1) Those very severely wounded General Consideration of Wounds. 127 who cannot stand transportation any distance and show marked symptoms of shock, where transportation would probably rob them of any chance of recovery; (2) Those severely wounded who must and can be transported, with- out material hazard to themselves; (3) Those slightly wounded, who can walk if necessity requires. Whether a wound is or is not serious often depends upon the physical condition of the man, and his person and cloth- ing at the time of the injury-whether clean or dirty: in short whether or not the surrounding conditions were favorable to infection. Filth favors infection while exhaustion and exposure encourage shock or collapse. A large propor- tion of all gun shot wounds produce relatively little serious injury and do not give rise to great shock; but those wounds which involve internal organs, blood vessels, bones and the central nervous system are in most instances serious, and are accompanied by more or less shock. Aside from infection, shock is the most important con- dition to be immediately dealt with in one wounded in battle. Pain, hemorrhage, exhaustion, exposure, psychic impression and later sepsis are the principal concomitants of wounds which produce serious effects upon the nervous system. It is of course difficult to handle seriously wounded men under the conditions of battle without in many instances adding to the shock. Under the best of transportation facilities, twenty-four to forty-eight hours must elapse before the wounded can reach the Base Hospital. Many of them will be in a condition of shock and require immediate treatment, stimulation, rest and nourishment before any operative procedure is possible. The treatment of the wounded naturally comprises first the treatment and care given them immediately behind the firing line, and second, the more careful measures and surgical procedures provided them on arrival at the properly equipped hospital on the line of communications or at the base. What First Aid Comprises. First aid must be limited to the control of hemorr- hage when necessary, the treatment of shock, the im- mobilization of fractures, the application of first aid dressings, and the relief of pain. In the control of hemorrhage the tourniquet and pressure bandages are used. Where the tourniquet is applied care must be taken that it be not permitted to remain on longer than an hour or two 128 before loosening, lest gangrene result; and of course this means that someone must be charged with the duty of over- seeing these cases. It is not usually advisable to attempt the control of hemorrhage by packing the wound, because of the danger of carrying into the wound and retaining infective material. The immobilization of fractures must be made by the use of such wire or other splint material, often improvised, as may be at hand and suit the purpose; but, if at all possible, it must be made certain that the bones are sufficiently immobilized so that the wounded may be transported with as little pain and discomfort as possible. The transportation of those suffering from fractures, and abdominal and chest wounds presents the greatest difficulties and calls for every resource and surgical ingenuity. It is often wise and neces- sary in abdominal cases, to allow the patient to remain several hours, if possible, at the first dressing station in order that he may have rest and an opportunity to recover, in part at least, from the shock, so that he may be transported with the least possible danger. Where serious symptoms develop during transportation such a patient should, if possible, be left at the Clearing Station or other hospital along the route, where he may receive the necessary surgical care. Penetrating wounds of the thorax, where not immediately fatal, in a large percentage of cases recover, but this per- centage of recovery depends to a considerable degree upon the immediate treatment at the front, and upon the care and attention which the wounded receive while being trans- ported to the Base. Every effort therefore should be made to control hemorrhage, to provide against infection, to immobilize fractured ribs and to control pain in order that the patient may reach the Base Hospital in as good condition as possible. Here again the skill of the Surgeon at the First Aid Station or at the Dressing Station will be called upon to institute the necessary immediate treatment, but particu- larly to put the wounded man in shape for safe transportation. Infection a Specific Problem. In the immediate first aid treatment of wounds the most important consideration is the percentage of infection. The bacteriology of wounds in war at the present time differs from that met with in civil practice. The baccillus tetanus, the baccillus aerogenes capsulatus, certain forms of the streptococcus, and also the baccillus pyocyaneus and the colon baccillus, streptococcus fecalis, are those said to be 129 most commonly found in wounds. The first two are those that have given the greatest trouble and concern in the European War, and Military Surgeons in Europe have come, or are rapidly coming, to the belief that the safest course to pursue is to assume that any wound may be infected by tetanus and to administer a dose of anti tetanic serum at the front or at the earliest possible time thereafter in doses of from 500 to 1000 units. There has been a large mortality recorded in tetanus by different observers, ranging from fifty to ninety percent. The baccillus aerogenes capsulatus of Welch, the gas baccillus causing so called gas gangrene, has been parti- cularly met with in wounds of blood vessels with large destruction of tissue and consequent devitalization. In- fections develop rapidly and death often results in a few hours. The action of the gas producing organisms is greatly enhanced by the presence of staphylococci and other bacteria. The gas producing organism has been found in wounds as early as five hours after infection and death has followed in less than twenty-four hours. In some of the armies of Europe a serum is being used as a prophylactic in the same manner and at the same time as the anti tetanic serum, and of course should be used at the earliest possible time, preferably before the patient is started for the Base Hospital. In the German Army, I am told, anti tetanic serum is injected in one breast and the serum for the control of the gas baccillus in the other. Hemorrhage. Hemorrhage is to be considered as either primary or secondary. Primary hemorrhage, as already indicated, must be controlled at the front by a pressure bandage or tourni- quet, by the use of haemostats, by the ligation of vessels if possible. Where a large vessel has been severed the condi- tions on the firing line are such that the patient may bleed to death before necessary steps can be taken to control the hemorrhage, so that the handling of these cases calls for prompt judgment and the utmost skill and coolness on the part of the Surgeon. Where it becomes necessary to ligate an artery under these conditions, the vessel may usually be exposed by an incision parallel to its course. The external maxillary, (facial'), the subclavian, and the external iliac are exceptions to this rule, and the incisions to expose them must be trans- verse. It must not be forgotten that veins usually lie with 130 arteries and often in close relationship with important nerves. Important vessels are frequently found between the muscles and not within them and in such case the muscles must be separated and not divided in exposing an artery. A single No. 3 silk ligature is employed, and the wound closed with cat gut or silk, or left open as conditions warrant. While it is true that nothing more should be done than is absolutely necessary in the zone of advance, still the above, measures are often imperatively necessary. It therefore follows that the Regimental Surgeon and the Surgeons of Ambulance Companies should at least be skilled in Emer- gency Surgery. Shock and Collapse. As the result of severe trauma, there may develop a con- dition of profound depression of the vital activities, marked muscular relaxation, loss of strength, rapid weak pulse, low pressure and greatly depressed respiration. The respiration may be rapid and very shallow or slow and very deep. Shock may develop with or without great loss of blood. When it occurs with little or no loss of blood, the condition is usually referred to as "shock" whereas when it follows extensive hemorrhage, it is usually termed "collapse." The conditions are probably not essentially different and we shall make no distinction in the terms. We will consider the conditions in which shock develops, the mechanism involved and the remedial measures at hand. 1. Shock may develop as the result of trauma with little or no loss of blood. The volume of circulating blood may be decreased and its specific gravity increased due to water passing out of the blood vessels into the tissue. 11. Shock may result from prolonged and intense stimula- tion of sensory nerves, for instance, very severe pain. As a result the vasomotor center becomes exhausted and as a consequence relaxation of the circulatory system follows. In such a condition blood accumulates in the splanchnic area and the patient is said to bleed into his own abdominal vessels. This vascular relaxation causes a pronounced fall of blood pressure. It has been suggested by Porter that diastolic readings should be made at half hour intervals and that when the pressure falls to 50 mm., recovery will not take place without therapeutic aid. The part played by the heart in shock must also be con- sidered. In certain cases a slow irregular pulse occurs. This Heart and Shock. 131 is undoubtedly due to a reflex stimulation of the vagal center. In the vast majority of cases, however, the heart plays but a secondary role and is not directly responsible for the shock. Thus in the condition of splanchnic engorgement referred to previously, the heart receives much less blood than normally in its chambers so that its output is greatly reduced and the pulse becomes weak, rapid and thready in character. The heart as a direct factor in shock can be ignored excepting those few cases in which the pulse is slow and irregular due to vagal stimulation. This over activity of the vagus can be easily controlled by treatment, which will be taken up later. One must keep in mind the possibility of acute cardiac dilatation complicating the ordinary mechanism underlying shock. As stated before, in the vast majority of cases, the circulating blood volume is reduced either by dilatation of abdominal vessels, loss of its water content or direct loss from hemorrhage. The remedial measures are directed toward an increase in blood volume either by infusion of salt solution or loosening the caliber of the blood channels. However, when cardiac dilatation is present, such measures are absolutely contraindicated, since we already have a heart over distended by fluid and instead of increasing blood volume, the condition may require an actual reduction of volume by means of vene- section. It becomes evident therefore that each case becomes a problem unto itself and no set rule applies in every instance. In the vast majority of cases, the following general measures are indicated, keeping in mind, however, the exception noted above. 1. Posture. The patient must be kept in the recumbent posture, preferably with the feet and buttocks higher then the head. The object here is to enlist the help of gravity in getting the blood from the legs and abdomen to the heart and medulla. Litter bearers and others transporting patients must be directed to preserve this inclined posture. Allowing a case of shock to assume the erect or even sitting position may result fatally within a few minutes. The recumbent posture with head lower than extremities is one of the most important therapeutic measures at hand, a measure which can be applied easily and under all circumstances, no matter what the nature of the environment may be. 2. External Application of Heat. If the skin is cold and the body temperature subnormal, hot water bags and blankets should be applied. General Measures. 132 3. Promote Comfort. If the patient is conscious, a hypodermic injection of morphin sulphate, I gr., repeated as necessary, often produces great improvement. Intra muscular injections are decidedly preferable. 4. Increase Blood Volume. Depending upon the situa- tion, all or part of the measures to be suggested are applicable. At dressing or first aid stations, one may not be able to render all the aid necessary. The choice of remedies must depend upon circumstances yet with adequate preparation and re- sourcefulness, most of the measures to be advocated can be applied when the patient first conies into the hands of the surgeon. (A) Constriction of legs and abdomen by means of tight bandages applied from the distal end towards the heart. The abdominal binder should leave the chest free for re- spiratory movements. This procedure will reduce the blood channels and therefore increase the supply of blood to the heart and brain. (B) Sterile 0.9 sodium chlorid solution at a temperature of 100 to 104 degrees F., should be infused. 500 cc. can be in- jected subcutaneously, or better by the intravenous route. By means of a 50 cc. syringe, 300 to 500 cc. of saline can be readily injected directly into a vein without difficulty. Intravenous therapy has become a very common procedure and repeated injections of 50 cc. over a period of eight to ten minutes are readily made. By means of thermos bottles holding a saline solution at the desired temperature, such intravenous injections could be made almost anywhere. If improvement does not follow or is not maintained another 500 cc. of saline can be injected, over a period of eight or ten minutes. If relief does not follow the second series of injections, this form of treatment can be abandoned. (C) Diastolic pressure. It is extremely desirable to estimate diastolic blood pressure before making intravenous injections of saline and also following the procedure. Ob- viously such an examination is only possible at a Field Hospital or other station where assistance and equipment will permit such refinement. As stated previously, when the diastolic pressure falls to 50 mm., saline infusion should be practiced. 5. Atropine. Atropine should only be used when the pulse is very slow (30 to 50 per minute). As mentioned previously, this slow pulse results from vagal stimulation and the atropine is used to paralyze the vagal endings. The dose 133 required may vary from 1 /150 to 1 /60 of a grain. Atropine should not be used to stimulate respiration (Loevenhart). 6. Epinephrin. (Adrenalin). 5 to 15 minims of a solution of epinephrin, 1 to 1000, should be mixed with 50 cc. of a saline solution and slowly injected intravenously. This injection should require many minutes as a sudden injection of this dose might result fatally. 7. Strychnine sniphate. This drug should be admin- istered subcutaneously in doses of 1 /30 to 1 /15th of a grain in order to stimulate the respiration and also the vasomotor center. It should not be used too strenuously or repeated too frequently since it may do great harm. It is perhaps the best stimulant for the respiration now in general use. 8. Camphorated Oil. Camphorated oil may be used subcutaneously in the usual doses. 9. Caffeine Citrate. May be given subcutaneously or black coffee may be administered by the rectum. Caffeine citrate may also do harm if pushed too far, or repeated too often. 10. Sodium Cyanide. (Loevenhart) As a last resort in desperate cases, 5 cc. of a sodium cyanide solution containing one milligram per cc., may be injected intravenously. Recent investigation has shown this drug to be an excellent stimulant for the respiratory center in animals and has given similar results in a few cases in man. No harm has been observed in man or animals from this dosage. The stimulation does not last long in most cases. The longest observed was thirty minutes in dog. The injection may be repeated at intervals of ten minutes, if necessary. 11. Artificial Respiration and Heart Massage. Are obviously the very last resorts. Obviously the first and most important thing is to stop the hemorrhage. The treatment outlined for shock without hemorrhage applies with equal force to shock with hemorrhage. Where the circulating medium must be rapidly increased, an intravenous administration of saline is imperative. If, after the administration of 1200 cc. of saline, improvement does not result and the blood pressure is not raised (if it is possible to estimate the latter) blood transfusion is in- dicated. When considerable amounts of fluid are injected in the treatment of shock, it is better to employ a medium that more nearly approaches plasma in its salt content. While a 0.9 % saline is looked upon as physiological and in emergency 134 may be used, it is better practice to employ a fluid that con- tains besides the sodium chloride, a proportionate amount of potassium and calcium. These salts properly balanced, that is, sodium chloride, potassium chloride and calcium chloride, dissolved in water, constitute Ringer's solution. Locke's solution contains in addition to the above mentioned salts a small amount of sodium bicarbonate and glucose. It has long been known that a disturbance of a normal bal- ance of salts found in blood plasma retards the activity of tissue, particularly the heart muscle, therefore when large infusions of saline alone are made, the normal salt balance of the blood serum is disturbed and as a consequence heart ac- tion is probably affected adversely. On the other hand physioloical conditions can be maintained byresorting to either Ringer's or Locke's solution when infusions are necessary. Either of these solutions can be made up as readily as 0.9% saline. We understand that a tablet is on the English market which contains these necessary salts in proper amounts. In this country an effort will be made to have such tablets manufactured, thus obviating the need of weighing small amounts of substance under conditions where it would be impracticable. With tablets at hand containing the neces- sary salts for a definite amount of solution, the use of either Ringer's or Locke's solution in preference to saline for in- fusion, is recommended. The necessity for a new method of treatment of wounds arose from the failure of our common antiseptics to prevent gas gangrene and wound infection, with their train of mor- tality and complications. It has been estimated that the indication for amputation was infection in 80 per cent of those operated, while extensive loss of tissue accounted for only 20 per cent of the sacrificed parts. Contractures, pain- ful stumps and a series of complications of amputation result from infection. On good authority, 75 per cent of deaths after the first twenty-four hours are attributed to infection; secondary hemorrhage results from infection in 95 to 98 per cent. The results of the studies of Sir Almroth E. Wright have been set forth in his book on Wound Infections, published in 1915, the essential features of which may be stated as fol- lows: The Treatment of Wounds. Infection is Immediate. In this war wounds by missiles, when seen immediately after arrival from the front, present a mixed infection of 135 streptococcus and fecal organisms, especially the gas bacillus and tetanus bacillus. These two are anaerobic, and are an infection of the imprisoned discharges or of the tissue. So soon, however, as a free outlet is provided an ordinary pyrogenic infection of the granulating surfaces and flowing discharges becomes dominant and is due chiefly to strep- tococcus, staphylococcus and B. Proteus. In treating such wounds there are three main methods: Treatment of Wound Infections. 1. By antiseptics. 2. By physiological methods, such as opening and drain- ing, and bringing to bear the antibacterial action of the blood. 3. Vaccine treatment-to reinforce the antibacterial power of the blood. Of these three methods, the second is by far the most im- portant, the other two being but ancillary methods. Before discussing these methods of treatment, Wright asks the question: What are the physiological processes going on in such wounds? Chiefly two, as follows: a. Growth and multiplication of the infecting organisms. Experimental grounds are given for classifying the in- fecting organisms as serophytes, which are at home and grow readily in the blood serum, such as the strep- tococcus; and sero-saprophytes, which cannot grow in the body juices until these have undergone some degenerating change. The organisms of both these groups, but especially the latter, only grow when the anti-bacterial action of the serum is in some way over- come; e. g., by the mass action of many organisms or by heat. (Confirmed by experiments with trypsine in vitro.) b. Emigration by leucocytes. Not much is definitely known about this, though results and some experiments are given. 1. By antiseptics. Antiseptic solutions are nothing more than antiseptic prophylactic applications, and were Lister's great discovery, namely, the means of keeping wounds clean, etc., etc. The principle has its great field in modern operative surgery, but has no special use in wound infections of war, except as an adjuvant, the reason being that antiseptics can not sterilize an infected wound, 136 for if only a few organisms are left in the wound, on account of their rapid multiplication in the digested lymph, the number in a few hours is as great as before antiseptic solutions were used. The mere fact of frequent necessary redressings of the wound occurring means that a tryptic discharge is present, one that digests the skin and granulating surfaces, affords a medium for the sero-saprophytes, and indicates that we are back where we were at the last dressing. Moreover, antiseptics may do harm, both by diminishing the anti-tryptic power of the blood, and sometimes also by actually stimulating bacterial growth. 2. Treatment by physiological methods. Fundamentally this consists in bringing the antibacterial power of the blood serum into play. Methods of Treatment. I. Methods in practice. It is accomplished: a. By opening and draining pus cavities. b. By free incision through infected tissue from sound skin to sound skin, and down to healthy tissue below. c. By unrestricted mechanical drainage when amputating through infected tissue, even to the point of sacrificing flaps altogether if necessary in cases of gas bacillus in- fections. All of these three means act, and only act, by bringing the anti-bacterial agencies of the blood into play. For example- in opening and draining an abscess we prevent the mass action of the bacteria from overcoming these anti-bacterial agencies. We drain away the white blood cells in the abscess, because they are paralyzed and killed and the antibacterial power of lymph in the abscess has been lost. The supplemen- tary surgical procedures contribute to the same end, namely: Drainage Tubes which help to keep up and permit an effluent anti-bacterial lymph stream to pass through the walls and into the cavity. Free Incisions in infiltrated tissue only partly succeed on account of the lymph spaces being blocked by leucocytes and coagulable discharge. Hot Fomentations. By inducing active hyperaemia, permit lymph flow and also soften and macerate inflammatory exudates. Leaving Wounds Wide Open gives mechanical, un- restricted drainage. 137 II. Desiderata in physiological treatment of wounds, which from this point of view are regarded as of two types: Type 1. Recent projectile wounds, suppurating cavities, old suppurating wounds that have just been washed clean. There is desired here a free outflow of lymph to wash organ- isms out of the walls, to carry in phagocytes, and be a good medium for phagocytosis; and it is desirable also that this lymph have the power to repress bacterial growth, and also that its antitryptic power should be high. Type 2. Infection and infiltration in the wall of a cavity and in the adjacent tissues. Here the same principles apply as in Type 1, though sometimes it would be desirable to have the ability to repress emigration of leucocytes, and also to render lymph uncoagulable. To realize these desiderata we require: 1. An agency powerfully to increase lymph flow. 2. Probably, at certain times, an agency to repress or promote emigration of leucocytes. This is not possible to present knowledge. 3. A means of increasing the anti-bacterial power of the lymph, both with respect to the infecting organisms as well as the serosaprophytes. This, however, is vaccine therapy, q. v. As aids to an increased lymph flow, we have hot fomenta- tions and the application of Wright's solution, namely a 5 per cent sodium chloride and a per cent sodium citrate, solution. This solution, he says, has proved pre-eminently useful in the war. Practically, therefore, treatment by physiological methods means continuous irrigation or con- tinuous baths, up to the point when the wound is thought to be sterile, then it should be closed, or allowed to heal under a scab, always, however, proceeding by the method of trial and error. Treatment by Vaccine Therapy. As before stated, this is always ancillary to the physio- logical methods, and is often of the most striking value, though not, unfortunately, in the worst cases, e. g., strep- tococcus septicaemia. Vaccine therapy is considered under five sub-headings: 1. Prophylactic. Not used in this war to any extent, as it does not appeal to the medical officers, but from experience with cholera, typhoid, etc., we know that it would be of value. 138 (Note: This statement must be modified in the light of later reports on prophylactic use of anti-tetanus and anti-gas bacillus serum.) 2. Employment of vaccines when the infecting organisms invade neighboring tissues, either as lymphangitis or cellulitis (erysipelas). Here the use of vaccine is most successful, just as in civil practice. 3. Employment of vaccine in connection with well drained wounds; strikingly favorable results are obtained. 4. Employment of vaccines in imperfectly drained wounds. Not sufficient experience as yet, but possibly of some use. 5. Employment of vaccine in wound septicaemias. Here their use is wholly unfavorable, though the hope is expressed that further experiment may find a favorable way of employing them. Sir A. E. W. thinks that all treatment of infected wounds should be regulated by orders and instructions, and gives the following outlines of organization of the Service for the Treatment of the sick and wounded: There should be a Head for this service, who would, of course be subordinate to the Director General. This Head should have the aid of an advisory committee of men who would be, or had been, workers at the front, and should in- clude surgeons, medical men, specialists and laboratory men, and the head of this service, with their aid and advice, would draw up and issue, and as occasion occurred, revise and reissue orders and instructions for the care of wounded. To this service also should be attached a research department. (H. V. Ogden.) Dakin's solution was introduced in the latter part of 1914 and the Dakin-Carrel method of treatment was introduced in the early part of 1915, following many months of experi- ment by Dakin and Carrel, and since the summer of 1915 the present technique has been in constant and widespread use, particularly in the armies of England and France. It is not claimed by its authors to be successful in all cases of infection, but it is claimed that infection can be prevented or aborted in the vast majority of cases. The approved technique for the making of Dakin solution must be followed. It is of great importance to use it early. The solution should penetrate all parts of the wound. The products of infection, namely, pus, decomposed or necrotic material, are expected The Dakin-Carrel Method. 139 to disappear in from a week to two weeks. Granulations take on a healthy appearance, the discharges become free from odors, the healing process progresses and the early suture is permitted. Success is claimed for the Dakin- Carrel treatment in 80 per cent of the cases, presupposing that the solution is properly prepared and that the treat- ment is thoroughly and intelligently carried out. In a recent address at the Army Medical School, Washing- ton, Dr. Carrel says, (Military Surgeon, April, 1917): "The clinical researches made at the experimental hospital at Campeigne have shown that by using proper technique wound infection can be almost entirely controlled and that pus can be eliminated completely from the hospitals. This conclusion was the result of the work that Dr. Dakin and I started at the end of 1914, in France, and continued later with the help of Drs. Dehelly, Dumas, Daufresne, Jaubert, Woimant, Vincent, Bernond and Lecomte de Nouy. It had become apparent to me at the beginning of the war that the main cause of mortality among the wounded was infec- tion and that all our effort should be directed toward a method by which infection could be suppressed. It was also evident that on account of the difference of the resist- ance of tissues, with normal circulation, and of micro- organisms, sterilization by a chemical substance was possible, and that a bactericidal substance applied under a certain concentration and during a certain time would kill the mi- crobes without markedly injuring normal tissues. Dakin found a number of substances which, being but slightly caustic for the tissues, can be used in a wound in a sufficiently strong concentration and during the time necessary to bring about sterilization. We selected the simpler of these sub- stances; that is, sodium hypochlorite without alkali in a concentration of 0.5 per cent. This surgical hypochlorite is designated under the name of Dakin's Solution and it should be prepared exactly according to the directions of Dakin and Daufresne. If not, it becomes caustic for the tissues or inefficient against the bacteria. "It should be understood that the application of Dakin's solution by means of ordinary surgical technique does not bring about the sterilization of a wound. The success of the method by which an infected wound is made aseptic is due not only to the bactericidal power of the substance used, but mainly to the procedure by which the substance is applied. Proper Technique Imperative. 140 Certain conditions of contact, of concentration and duration of application make its action efficient. The method must be used as a whole with no modification of its parts. I am not able, in this short time, to give a description of the technique which is used in the sterilization of a wound. The principle of the method is to bring the bactericidal substance in close contact with the microbes under a given concentration and during a given time. Therefore, the tissues are to be very widely opened, any foreign bodies removed and small rubber tubing inserted in every recess of the wound. Afterwards the fluid is brought in contact with every part of the wound at the proper concentration. The concentration can be maintained constant only by bringing fresh fluid, all the time, to every part of the wound. Therefore, every two hours, the wound is flushed with Dakin's solution. The antiseptic should be used until all microbes have disappeared from the wound. This means about forty-eight hours for a surface wound, and generally from six to ten days for other wounds. It means also that bacteriological examinations of the wound should be made every two or three days, because clinical appearances of the wound alone do not show at what time complete sterilization has taken place. When both clinical and bacteriological examinations of the wound show that it is sterile, its edges are brought together by adhesive plaster or stitches, and union takes place in a few days. "The method is not complicated, but it is impossible to learn the procedure in a few hours. About three weeks are required for an experienced surgeon to learn how to steri- lize a wound. When the surgeon applies, exactly, the tech- nique, sterilization results rapidly, especially if it is freely opened and treated during the first twenty-four hours. If the patient be treated when the wound has begun to suppurate, disappearance of the pus takes place rapidly-after from two to four days generally-and the sterilization can be obtained and the wound ultimately sutured. Saves Time and Money. "The saving of time and of money brought about by the complete sterilization of wounds is very striking. Of 136 wounds treated in my hospital in December, 1915, 121 were closed before the twelfth day. As the normal cicatrization of most of these wounds would have taken, by ordinary methods, from thirty to sixty, or even 100 days, it is easy to understand the saving of money which was effected. If we assume that every wounded man costs $2 per day, it 141 will cost the country $180 if he stays ninety days in the hospital. If the wound is healed in twenty days, it represents a saving to the country of $140, and for 1,000 wounds, the saving of $140,000. In cases of fracture it is also possible to decrease in a large measure the length of treatment. It happens often that a badly infected fracture of the femur is still suppurating after 300 days. However, if we take the trouble to sterilize such a wound, we can close it after twenty days. A patient discharged after 100 days instead of after 300 days, means a saving of $400. Therefore, 100 fractures of the thigh treated in the proper way will save the country $40,000. Besides, the degree of permanent disability and the amount of pension paid to a man whose wound has not suppuratedis very much less than when infection has required his remaining in the hospital for a year or more. When we consider that statistics based upon more than 50,000 am- putations show that 70 per cent of these amputations are due to infection, we can readily see that 50 per cent of the amputations might be avoided by proper treatment." Dakin's Soln lion. The following is from a paper read before the French Academy by II. D. Dakin, Ph. D., the title of which is: "On certain active antiseptic substances suitable for the treatment of infected wounds." "The relatively low germicidal action of the more com- monly employed antiseptics is, as is well known, still further reduced when these antiseptics act in the presence of serum or other protein substances. It is probable that the killing of micro-organisms by antiseptics is largely a chemical reaction between the antiseptic and the protein substances of the micro-organisms. Since the practical employment of antiseptics invariably occurs in the presence of large quantities of protein substances other than those of bacterial origin, it is probably true that no relatively simple chemical antiseptic can be found which will react solely with the micro-organisms and not with the adjacent protein substances. In seeking an efficient antiseptic for use in infected wounds it would appear that the following points, among others, are of the first importance. "(a) To employ substances of such high germicidal activity that even when the activity is reduced by the presence of serum or other protein powerful antiseptic action may still persist. Or, in other words, to employ sub- stances which give actively antiseptic substances after com- 142 bination with proteins. The complete failure of mercuric chloride to respond to this demand may be cited, (b) It would appear probable that soluble salts, nonprecipitable by proteins, which may penetrate and be absorbed to some extent, are preferable to substances of other type in which the possibility of absorption and penetration are slight, (c) The toxicity and capacity for inducing local irritation of an antiseptic should be as low as possible in proportion to its bacterial activity in order to permit of the local em- ployment of a sufficiently large quantity of the antiseptic without unfavorable results. It is clear that if germicidal action is essentially a chemical reaction in which other pro- teins than those of bacterial origin may take part, it is most important that the active mass of antiseptic should be as large as possible. To Prepare Hypochlorite Solution. "Among the antiseptics which have already been con- sidered in connection with the treatment of infected wounds the hypochlorites most nearly respond to the criteria above set forth. Unfortunately, however, the hypochlorites of commerce are of very inconstant composition and generally contain either free alkali or free chlorine. Such substances are irritating and when used in moderate concentration may produce very unfavorable results. It appeared desirable to try and find a mode of preparing a solution of a hypochlorite of constant composition which would show high bactericidal activity and low toxic or irritating qualities. The following method has proved successful: "Two hundred grains of bleaching powder are added to 10 liters of water, in which 140 grains of dry carbonate of sodium have been dissolved. The mixture is well shaken, and after half an hour the clear liquid is siphoned off from the precipitate of calcium carbonate and filtered through cotton. To the clear filtrate enough solid boric acid is added to render the liquid acid with an aqueous suspension of phenol- phthalein, but alkaline to tournesaL About 25 to 30 grains may be required. The exact amount of boric acid to be added may be conveniently determined by the titration of 10 c.c. of the alkaline hypochlorite solution with a solution of boric acid of known strength (31 grains per liter). In preparing a dilute solution of hypochlorite as the above, which will contain about 0.5 per cent NaClO, an excess of boric acid is unobjectionable, but in the case of stronger solutions an excess must be avoided. 143 "A solution prepared as above described, containing 0.5 per cent NaClO, kills staphylococci in 2 hours when diluted to a concentration of less than 1 to 500,000 NaClO, while in the presence of blood serum the necessary concentration of NaClO is between 1 to 1,000 and 1 to 2,500. Such a solution has proved to be a useful antiseptic in the treatment of infected wounds when properly applied by methods which will be described later by Dr. Carrel. Wounds may be con- stantly irrigated for many days without producing noticeable irritation, and bacteriological examinations of the wound secretions demonstrate a vigorous antiseptic action. In addition to its antiseptic action, the solution exhibits marked capacity for dissolving necrotic tissue and has some hemo- static action. From a practical standpoint, the property of assisting the dissolution of necrotic tissue is important. "It is probable that the antiseptic action of hypochlorites is due to their containing chlorine in an active state which may replace hydrogen atoms attached to nitrogen in the (NH) groups present in proteins, forming substances of the group known as chloramins. It was of interest to investigate substances of this type, and with the co-operation of Prof. J. B. Cohen, of the University of Leeds, a large number of these derivatives have been prepared and tested. The most encouraging results have been obtained with the sodium salts of aromatic sulphochloramids, particularly the benzene and paratoluene derivative. "These substances are active antiseptics, practically non- toxic, and their aqueous solutions can be employed for the antiseptic treatment of wounds in a far higher concentration than is possible with the hypochlorites; but, on the other hand, as would be expected from their structure, the chlorine being already bound to nitrogen, they show little capacity for assisting in the dissolution of necrotic tissue. "Paratoluene sodium sulphochloramid kills B. per- fringens in water acting for 2 hours at a concentration of less than 1 to 10,000,000, while in the presence of serum the concentration necessary is between 1 to 2,500 and 1 to 5,000. With staphylococci the concentration is about 1 to 1,000,000 in water and 1 to 2,000 in serum, while pyocyaneus requires about 1 to 1,000,000 in water and 1 to 1,500 in serum for complete sterilization in 2 hours." The Dakin-Carrel treatment does not guarantee a cure for all wounds but presents the best results yet produced in The Dakin-Carrel Treatment. 144 their treatment. It consists of the application of the Dakin hypochlorite solution according to an established technique of Carrel. The solution is a constant factor and the variable, which explains so many failures, is the careless application of Carrel's technique. Note: The Dakin solution is a 0.45 per cent to 0.50 per cent solution of sodium hypochlorite and is prepared as follows by the technique of Daufrcsne. For 10 liters stock: a. Put 200 grams of the chloride of lime (containing 25 per cent active chlorine) and 5 liters of water into a 12 liter flask. Shake vigorously until all large and floating particles disappear. Then set aside for 6 to 12 hours. b. At the same time dissolve 100 grams of sodium car- bonate, dry, (soda of Solway) and 80 grams of sodium bicarbonate, dry, in 5 liters of cold water. After 6 to 12 hours pour b into a, shaking well and setting aside to permit calcium carbonate to precipitate. Siphon off liquid and filter through double paper. This stock solution is bottled in brown or blue containers well stoppered and stored in a cool, dark place. It is unstable and should be tested frequently. The original Dakin's solution was too strong, 0.5 per cent to 0.6 per cent hypochlorite; above 0.5 per cent is irritant, below 0.4 per cent ineffectual. Reactions Needed to Test Dakin Solution. I. To determine free active chlorine in bleaching powder or chlorine of lime: mix 20 grams of the submitted sample in 1 liter of water and leave in contact for 2 hours. Then take 10 c.c. of this liquid and add 20 c.c. of a 10 per cent potassium iodide solution and 2 c.c. of acetic acid (to free the hydriodic acid). Next titrate drop by drop with decinormal sodium hyposulphite (2.48 per cent). End point-the complete decolorization. By the multiplication of the number of cubic centimeters of hyposulphite used by 1.775 the weight of active chlorine per 100 grams of bleaching powder is derived. II. The determination of free active chlorine in Dakin solution: To 10 c.c. of Dakin solution add 20 c.c. of 10 per cent potassium iodide solution and 2 c.c. acetic acid. Titrate with decinormal sodium hyposulphite. End point-complete decolorization. Cubic 145 centimeters of sodium hyposulphite solution times 0.03725 equals the weight of hypochloride of soda in 100 c.c. of Dakin solution. III. Alkalinity of Dakin solution: Tested by dropping dry phenolphthalein on the solution in question. No change in color with Dakin but Lebarraque's and eau de Javel give intense red due to free caustic alkali. Dakin solution is non-toxic and can therefore be used in any quantity without fear of toxic reaction. In its present modified form Dakin solution is non-irritant. It is strongly bactericidal to all pyogenic micro-organisms. Then, too, the hypertonicity of the hypochlorite solution causes a pour- ing out of lymph and toxemia from absorbed bacterial pro- teins is uncommon. (Note: A new compound, chlorazene, has been found quite effectual. It is stable, contains chlorine in a combined form, which is liberated in the presence of the protein of the tissues. Chlorazene has many of the virtues of Dakin solution and may be used in a paste with sodium stearate as a base. Its chief recommendation is its stability.) Wounds treated with Dakin solution in an early stage do not become infected. If infected, the Carrel-Dakin treat- ment changes the purulent discharge to a serous one, granu- lations become healthy, the fetor is lost and necrotic tissues disappear in 5 to 7 days. The application of the Dakin solution after the method of Carrel spells the success of the treatment. Its fundamental points are the intermittent rather than continuous use of the hypochlorite and the insured contact of the same with every contaminated or traumatized tissue. Carrel outlines the following routine: 1. First dressing at the field station: Surround area involved with tincture of iodine. Pack wide open wounds loosely with gauze saturated with Dakin solution. Deep wounds with narrow skin aperture are injected with this solution. 2. At the base hospital: The general surgical methods for the ligation of vessels, the removal of shell fragments, etc., are followed. The shell tract is opened and devitalized tissues removed. Then Carrel tubes are carried to the bottom of the wound and gauze loosely packed between and about the same. Determine before completing the dressing the amount of solution necessary to flood the wound and the Routine of Treatment. 146 thoroughness of the irrigation. The final dressing to be placed over the whole is a gauze pad saturated with Dakin solution. On top of this a large pad of non-absorbent cotton (to prevent absorption of solution) or Turkish toweling is placed. Hypo- chlorite is very destructive to cotton fabrics. Certain apparatus in the shape of a glass irrigating bottle graduated in cubic centimeters, glass drips to regulate the flow of the solution and rubber tubing to the manifold glass outlets needs no further explanation. The Carrel tubes, however, leading from the glass outlets to the bottom of the wound are an innovation. They are pure rubber tubing (fabric will not collapse and is quickly destroyed by hypo- chlorite), 15 to 25 cm. long, with an outside diameter of 5mm. and a lumen of 3mm. The distal end is tied off with Pagenstecher linen or strong silk. Then with a special punch, holes ^mm. in diameter are put in tube at intervals of J^cm. The alternate holes, of which there should be 6 to 12, are placed at right angles. Every precaution is taken to carry the tubes and the loosely packed gauze to the depths of the wound. The number of tubes depends entirely on the extent of the wound and care is exercised not to kink or place these tubes under pressure. The flow of the hypochlorite solution is controlled by the height of the irrigating bottle, three feet elevation being the rule. The wound is kept flooded. Pain is an indication either of too great pressure or of alkalinity in the solution. The intermittent flooding at two hour intervals day and night has been attended by the best results. Carrel advises daily redressing, using the forceps and never touching the skin or wound with the hands. The edges of the wound are protected with gauze of No. 4 bandage width, saturated in yellow liquid vaseline. The wounds heal by first intention without drainage or reaction in 90 per cent of cases treated by the Carrel-Dakin method from the be- ginning. Precautions to be Observed. Certain precautions must be observed in the pursuit of this treatment: 1. Never heat the solution nor bring it into contact with alcohol. 2. Keep cool and dark. 3. Never use in eye. 147 4. Do not use intravenously since Dakin solution is hemolytic. 5. Compound fractures, which are to be operated later, should not be supported by metallic braces when the hypochlorite is being used, on account of its oxidizing action. (Note: I am indebted for this resume of the technique and use of the Carrel-Dakin treatment to the article by Sherman (Surgery, Gynecology and Obstetrics, March, 1917), and to 1st Lieut. W. C. Middleton, M. R. C., Madison, Wis.) A preparation of sodium hypochlorite is manufactured by the General Laboratories, Madison, Wis., under the name of "Hyclorite." This preparation has been in use for several years and has been favorably reported upon and success- fully used by a large number of surgeons, in a great variety of surgical conditions to combat infection. It is used in solutions of the strength of 1 to 200 (|%) to 1 to 1000 (1 %) as a rule, and some surgeons have used it in stronger solutions than 1 to 200. It appears to have excellent keeping qualities. It may be used for hand-sterilization up to full strength, and this substance properly diluted may be substituted for Dakin's solution wherever sodium hypochlorite is in- dicated. Hyclorite. The Use of "Kalk" Solutions in the Treatment of Wounds. Dr. Wilhelm Muller under the title "Eines 'Neue' Behand- lungsmethode Schwerinfecierter Wunden Ohne Wattege- brauch," (Kriegschirurg. Hefte 30 heft 7th Band 1st Heft 1916, p 135), reports the successful use of a solution of "Kalk" in the treatment of wounds. lie uses saturated sponges over the wound and under the bandage, which are squeezed through the bandage every two hours to supply the irrigation. The dressing is applied as soon as possible after the wound is received. Ordinary large coarse sponges are used and they are boiled daily. Muller reports wonderful results in 327 of the severest types of wound infection. The solution is made by dissolving 1 Kilogram of bleaching powder or Kalk (Calcium Hypochlorite) in 8 Liters of water. This is allowed to stand ten or twelve hours until settled, and the supernatent fluid is then filtered through filter paper. In this way about four liters of clear fluid are secured for use. 148 In the conduct of treatment, the wound is bathed daily for hour with a basin of the fluid. Deep wounds are freely irrigated under the pressure from irrigators 2 to 3 meters high, the finger assisting the tube to hunt out all the recesses. Open fractures are put in provisional splints until healthy granulations begin, which in the worse cases is at the end of one week it is claimed. After this immovable splints are applied. This is, to say the least, a simple and economi- cal method of treatment. 149 CHAPTER XXIV. REGULATIONS GOVERNING THE EMPLOYMENT OF THE RED CROSS In time of war In the regulations covering the organization of the Medical Department of the army, the President is authorized to detail not to exceed five officers of the Medical Department for duty with the military relief division of the American National Red Cross, one of these officers to be designated as the Direc- tor General of the Department of Military Relief. The Amer- ican National Red Cross is authorized by the Act of Congress approved April 24, 1912, to render aid to the land and naval forces in times of actual or threatened war and the following regulations, governing the status, organization and operations of this society, have received the approval of the President; (War Department Bulletin, Dec. 18, 1916). 1. The organized Red Cross Units serving with the land forces will constitute a part of the sanitary service of the land forces. 2. When the War Department desires the use of the services of the Red Cross in time of war, or when war is imminent, the Secretary of War will communicate with the chairman of the central committee of the society, specifying the character of the service required, the kind and number of Red Cross units desired, and designating the place or places where the per- sonnel and material will be assembled. 3. When any member of the Red Cross reports for duty with the land forces of the United States, pursuant to a proper call, he will thereafter be subject to military laws and regulations as provided in article 10 of the International Red Cross Conven- tion of 1906, and will be provided with the necessary brassard and certificate of identity. 4. Except in cases of great emergency, Red Cross personnel serving with the land forces will not be assigned to duty at the front, but will be employed in hospitals in the home country, at the base of operations, on hospital ships, and along lines of communications of the military forces of the United States. 150 5. Before military patients are received in a Red Cross hos- pital specific authority must in the first instance be received from the Secretary of War, and the director must be a com- missioned officer of the Medical Corps or, in special cases, an officer of the medical section of the Officers' Reserve Corps designated by him to command it. Such officer will be held responsible for the management, discipline, and records of the institution; he will regulate admissions and discharges and see that the interests of both the Government and the patients are conserved. Under specific authority, however, military patients may be sent to Red Cross general hospitals not com- manded by a commissioned medical officer under such con- ditions as to allowances, reports, and the control of military patients as the Secretary of War may prescribe. 6. No units, sections, detachments, or individuals of the American Red Cross will be accepted for service by the War Department, unless previously inspected by a medical officer of the army, and found qualified for the service expected of them. 7. The American Red Cross may, when war occurs or is imminent, be called upon by the War Department to assist the sanitary service by furnishing organized units, sections, detachments, or individuals whose services may be necessary, such as physicians, surgeons, dentists, chaplains, laboratory experts and their assistants, pharmacists, nurses, stenog- raphers and clerks, hospital personnel, sick transport per- sonnel. Authorized by Secretary of War. Standing of Personnel. 8. Persons enrolled by the American Red Cross in its units or as individuals who are accepted for the sanitary service under paragraph 7, and become a part of it under paragraph 1, shall be paid by the National Government according to the nature of their services whenever authority of law exists for such payment either on military rolls or as civilian em- ployees. Red Cross volunteers are persons who give their services without pay, and such volunteers serving with Red Cross organizations, or as individuals under Red Cross commissions, warrants, or letters of appointment, shall, during the period of such service with the sanitary department of the Army, be given the respect due to their positions and services and shall be furnished such appropriate quarters, beds, food, and 151 transportation as may be necessary for the discharge of their duties. They shall be entitled to wear a distinctive badge approved by the Secretary of War and issued by the American Red Cross. All units, sections, detachments, or individuals of the American Red Cross, upon being accepted for duty by the Secretary of War in time of war, or when war is imminent, shall from the date of such acceptance be subject to the orders of the proper military authorities, and such Red Cross personnel when serving with the Armies of the United States in the field, both within and without the territorial jurisdiction of the United States, are subject to the Articles of War. Classification of Personnel. 9. To facilitate the enrollment and training of Red Cross personnel it shall be divided into three classes: Class A. Those willing to serve wherever needed. Class B. Those willing to serve in home country only. Class C. Those willing to serve at place of residence only. Only persons belonging to Class A shall be enrolled in Red Cross organizations intended for service at military bases or along the line of communications. Individuals whose services may be needed in the zone of the line of communications and base may be also enrolled in Class A. Class B will be enrolled for service in hospitals and other sanitary institutions that may be established in the home country. They may be organized into such units and receive such training as may be deemed advisable. Class C will be composed of individuals of local Red Cross societies, who on account of their occupation or experience in the care of sick and other hospital duties, may be expected to render efficient service in military institutions established in their locality. Red Cross Units for Army Service. 10. The Red Cross units organized for service with the Army or for the purpose of training personnel therefor are: 1. Ambulance companies. 2. Base hospitals. 3. Hospital units. 4. Surgical sections. 5. Emergency nurse detachments. 6. Sanitary training detachments. 152 7. Information sections. 8. Refreshment units and detachments. 9. Supply depots. 10. General hospitals. 11. Convalescent homes. Ambulance Companies. 11. Ambulance companies will supplement and assist the organizations of the Regular Army engaged in the trans- portation of the sick and wounded from the zone of the ad- vance to base hospitals and from the base to general hos- pitals. The personnel may be used to man ambulance trains, hospital trains, hospital ships, and other agencies for sick transport by land and water, or for the establishment of emergency hospitals. The organization will be as follows: 1 captain. 4 lieutenants. 1 first sergeant. 11 sergeants. 5 mechanics. 2 cooks. 2 assistant cooks. 20 chauffeurs. 2 musicians. 43 privates. And such other personnel as may be approved by the Secre- tary of War. The training of ambulance companies should include in- struction in first aid, elementary hygiene, and the drill of sanitary troops. The personnel of such companies should be made practically familiar with the use of the various ap- pliances (including improvisations) for transporting sick and wounded, such as litters, ambulances, and other vehicles, with the fitting up of trains and ships for patients, and with other similar duties. Instruction should also be given in the organization and conduct of rest stations. Some personnel of each company should also be made proficient in methods of disinfection. Base Hospitals. 12. Base hospitals are enrolled by the Red Cross for service at a military base. Their organization will correspond ap- proximately to that of an Army base hospital as prescribed in 153 the Tables of Organization, except that the male adminis- trative personnel may be in time of peace one-third of the enlisted strength of that of an Army base hospital, and such additional specialists and volunteers may be enrolled as the Secretary of War may approve. When called into the service of the United States, Bed Cross base hospitals will be fur- nished by the Quartermaster Corps of the Army with trans- portation, and subsistence for all except commissioned officers, for the personnel and equipment to the designated station and with such buildings or tentage or both as may be needed for the care of the patients and the administration of the hospital. The Quartermaster Corps will provide suitable quarters, beds, and subsistence for the personnel, including duly enrolled Red Cross volunteers. The medical equipment when not furnished by the War Department will conform as closely as possible to the stand- ard Medical Department equipment, and will be stored when practicable by the War Department at a point as con- venient as may be advisable to the parent of the unit. The organization of a base hospital will be: A director, who will be assisted by the following staff: An adjutant, a quartermaster, who are staff officers, and a registrar who maybe an officer, noncommissioned officer, or specially qualified civilian, and such sub- ordinate administrative personnel as may be necessary. When mustered into the United States service the director shall act as assistant to the commanding officer of the hospital, when one is designated under section 5, and in addition to his duty as assistant he shall be chief of the surgical, medical, or laboratory service of the hospital. A surgical section, which will include a chief of the sur- gical service and eight staff surgeons, including an orthopedist and one or more specialists in the treat- ment of diseases of the eye, ear, nose, and throat. A medical section, which will include a chief of the medi- cal service and five staff physicians including a special- ist on nervous and mental diseases. A laboratory section, which will include a chief and two assistants who will have competent knowledge of path- ology, bacteriology, serology, and roentgenology. Two dentists, skilled in oral surgery. In cases where the American Red Cross organize a reserve for a base unit the relief of officers of the pro- 154 fessional staff of such unit by officers of the reserve may be authorized, when the interests of the service permit. 50 nurses, members of the Red Cross nursing service, one of whom shall be chief nurse and one of whom may be a dietitian. 25 volunteer nurses' aids. 150 male administrative personnel, who may be members of the Enlisted Reserve Corps or may agree to enlist in the sanitary service when called into active service. This personnel will have the proper quota of noncom- missioned officers, as prescribed by the Tables of Organization for base hospitals. 15 employees. Such Red Cross volunteers as may be authorized by the Director General of Military Relief, upon the approval of the Secretary of War. 13. Hospital units are intended to supplement and assist established military hospitals. Sections of hospital units may also be assigned to duty on hospital trains and ships and to other military sanitary organizations. Hospital units are organized as follows: 1 director, 1 adjutant, 2 chiefs of service, 4 staff surgeons, 4 staff physicians, 1 head nurse, 20 nurses, 3 clerks, who may be women, and such number of orderlies as may be necessary. 14. Surgical sections are special detachments intended to reenforce the operating staffs of hospitals in times of emer- gency. They consist of: 1 director. 3 surgeons. 1 head nurse. 6 nurses. 2 orderlies. 1 recorder, who should be a stenographer, and may be a woman. Hospital Units and Surgical Sections. 155 The recorder should prepare the reports and records of cases and conduct the official correspondence of the section with such other clerical work as may be required by the commanding officer of the unit to which the section may be attached. The individual members of these units shall be kept intact and not be detached from them for other duty except by order of the commanding general of an Army corps or separate division. Emergency and Training Detachments. 15. Emergency detachments of nurses are organized to meet sudden calls from the sanitary service of the Army, or other emergencies. They will be used to supplement the nursing service of military hospitals already established, or be assigned to duty on hospital ships, hospital trains, or any other service where groups of nurses may be needed. Each detachment consists of 10 nurses, one of whom is designated as head nurse and acts as such until the group is assigned to duty under the supervision of an Army chief nurse, when her duties will be the same as those of the other members of the detachment. 16. Sanitary training detachments are organized pri- marily for the purpose of instructing men so that they may perform efficiently the duties pertaining to the enlisted medical service of the front and line of communications with the Regular Army or with Red Cross units in time of war. When so trained these detachments may be used by the Red Cross in times of national disaster. Sanitary training detachments will be organized as follows: 1 commandant. 1 assistant commandant. 1 quartermaster. 1 pharmacist. 5 section chiefs. 4 mechanics. 4 carpenters. 2 cooks. 2 clerks. 40 privates. The section chiefs will have the title and rating of ser- geants, and one of them, selected by the commandant, will act as first sergeant. The commandant and assistant com- mandant will be physicians in good standing. 156 17. Information sections are composed of a section chief and such clerical assistants as may be necessary. They may be attached to base hospitals, general hospitals, or to the office of the senior medical officer of prisoners' camps, or other military establishments where their services may be necessary. They will conduct, under the supervision of the commanding officer of the organization to which attached, the correspondence of the patients or prisoners, report the addresses, physical condition, and such other information as may be authorized to the Red Cross information bureau at Washington, and conduct the correspondence with that bureau. 18. Refreshment units and detachments: A refreshment unit is an enrolled organization equipped to furnish refresh- ment to the sick and wounded and to troops at halting places and places of transshipment. Its organization and equipment is such as may be prescribed by the American Red Cross. Refreshment detachments are temporary or- ganizations for the same purpose. 19. Supply depots are depots for the care, preservation, and issue of Red Cross property. When located on Govern- ment reservations they shall be entitled to military protec- tion like Government property. Other Units and Detachments. General Hospitals and Convalescent Homes. 20. Red Cross general hospitals may be organized at such places in the home country as the Secretary of War may ap- prove for the reception and treatment of sick and wounded soldiers. They may be organized in connection with a civil hospital or group of hospitals, or where there are suitable buildings and grounds, public or private, available. Such general hospitals when organized shall be registered in the Office of The Adjutant General. Red Cross general hospitals may be taken over by the War Department and administered as Army hospitals under such conditions as may be mutually agreed upon, or they may be administered as Red Cross units under such conditions as to allowances, reports, and the control of the military patients as the Secretary of War may prescribe. The organization of general hospitals shall in general con- form to that of the Army general hospitals, but as to the num- ber of beds and personnel and details of organization shall be such as the Secretary of War may approve upon the recom- 157 mendation of the Surgeon General. Acceptance for regis- tration shall be regarded as evidence of approval. Provision will be made in the organization of Red Cross general hos- pitals for a visiting staff and for resident physicians or internes. All medical officers of the above units shall be physicians, surgeons, or specialists in good standing who have been selected by the Director General of Military Relief of the American National Red Cross. 21. Convalescent homes will be such private residences or other buildings or institutions as are accepted by the Amer- ican Red Cross as complying with the necessary conditions for providing accommodation for disabled officers and men who require no further active medical or surgical treatment, and who are awaiting discharge from the service on account of permanent disability. The expenses in connection with the upkeep of convalescent homes will be met entirely by private funds, except that an allowance for subsistence may be made by the Government when desired. Convalescent homes will be at all times subject to inspection by duly authorized representatives of the War Department. Registry of Units. 22. A register will be kept in the office of the Surgeon General of the Army, upon which will be entered the name, place, strength, equipment, and efficiency of organized Red Cross units. No organization will be entered on the register, however, unless it shall have been inspected and approved by a representative of the War Department. When specially authorized, medical officers of the Army detailed for duty with the Red Cross may act as representatives of the War De- partment for the purpose of inspecting general and base hospitals and other military Red Cross units. In such cases their reports shall be made directly to the officer giving such authorization, a copy being furnished the Director General of Military Relief. A Red Cross unit that has been inspected and found qualified will be carried on the register for one year after date of such inspection. Applications from Red Cross organizations for entry upon the Surgeon General's register will be forwarded through Red Cross channels to The Adjutant General of the Army. Applications from Red Cross organizations borne on the Surgeon General's register, for continuance on said register, will be submitted annually on or before June 1 through Red Cross channels to The Adjutant General of the Army. 158 23. Uniforms: Members of organized units serving under the Medical Department will wear, if members of the Officers' Reserve Corps or Enlisted Reserve Corps, the uniform of these corps. Otherwise the uniform prescribed by the central committee and approved by the War Department will be worn. Their equipment will be similar to that used in the sanitary service. 24. The personnel serving with the land and naval forces in time of war or threatened hostilities will, while proceed- ing to their place of duty, while serving thereat, and while returning therefrom, be transported and subsisted at the cost and charge of the United States. Red Cross supplies that may be tendered as a gift and accepted for use in the sanitary service will be transported at the cost and charge of the United States. 25. Suitable quarters or tentage will be provided by the Quartermaster Corps for Red Cross units called into the sani- tary service by proper authority. 159 CHAPTER XXV. THE GENEVA CONVENTION In a paper written shortly after the beginning of the European War, I made the following reference to the Geneva Convention: "With advancing civilization during the past century the brutality of war has been modified. The Geneva convention is one of the great achievements of the white race. "It provides for reasonable consideration of belligerents as well as non-combatants against unnecessary suffering, want and cruelty. "It defines their rights and obligations and even in the face of many reports of cruelty on the part of the European armies now at war, I make this statement with confidence, for I believe that when the true history of the present con- flict is written, it will be found that only individual instances of such cruelty are true and the last authority will show these reports to be largely unwarranted and untrue." Since the writing of that paper, events have transpired which lead one to believe that the confidence expressed above was mistaken and which force one to recognize that at least some of the belligerent nations, signers of the Convention, have reverted to the barbaric practices of former times, that they have ignored the provisions of the Convention and without warrant or excuse have violated their obliga- tions. They seem, indeed, to have gone mad to such a de- gree that their barbarism suggests the necessity of an inter- national commission on lunacy to determine what disposition shall be made of them for the safety of the world, now and in the future. Notwithstanding this almost unbelievable spectacle of violated treaty and convention obligations, this exhibition of the madness of a nation, the Government of the United States, as one of the signers of the Geneva Convention, will, without doubt, scrupulously live up to its solemn obligations and steadfastly maintain the necessary and the humane provisions of this great and until recently unbroken agree- ment between nations. 160 EXTRACTS FROM THE GENEVA CONVENTION. [Acceded to by the United States ] ARTICLE I.-Ambulances and field hospitals shall be recognized as neutral establishments and, as such, shall be protected and respected by belligerents as long as they contain sick or wounded. ARTICLE II.-The personnel of hospitals and ambu- lances, including the administrative and supply depart- ments thereof, the medical service, the transport service for wounded, and likewise chaplains, shall participate in the benefit of neutrality while on duty and as long as there re- main any wounded to bring in or to succor. ARTICLE III.-The persons designated in the preceding article may, even after occupation by the enemy, continue to fulfill their duties in the hospital or ambulance which they serve, or may withdraw to rejoin the body of troops to which they belong. Under such circumstances when these persons shall cease from their functions the occupying army shall take care to deliver them to the enemy's outposts. ARTICLE IV.-As the equipment of military hospitals remains subject to the laws of war, persons attached to such hospitals cannot, in withdrawing, carry away any articles except such as are their private property. Under the same circumstances an ambulance shall, on the contrary, retain its equipment. ARTICLE V.-The inhabitants of a country who may assist the wounded shall be respected and shall remain free. It shall be the duty of the commanding generals of the bel- ligerent powers to notify the inhabitants of the appeal ad- dressed lotheir humanity and of the neutrality resulting there- from. Any wounded man received and nursed in a house shall act as a safeguard thereto. Any inhabitant who shall have entertained wounded men in his house shall be exempt from the quartering of troops, as well as from a part of the contributions of war which may be imposed. ARTICLE VI.-Wounded or sick soldiers shall he collected and treated, to whatever nation they may belong. Commanders-in-chief are authorized to deliver to the enemy's outposts at once all soldiers wounded in combat when circumstances permit and both parties consent to such action. Those who, after their wounds have healed, 161 are recognized as incapable of serving shall be sent back to their country. The others also shall be sent back, on condition of not again bearing arms during continuance of the war. Evacuations, together with the personnel conducting them, shall he protected by absolute neutrality. ARTICLE VIL--A distinctive and uniform flag shall be adopted for hospitals, ambulances, and evacuations. It must on every occasion be accompanied by the national flag. A brassard for the neutralized personnel shall also be allowed, but the delivery thereof shall be regulated by military authority. Flags and brassards shall show a red cross on white ground. ARTICLE VIIL-The details of execution of the present convention shall be regulated by the commander-in-chief of belligerent armies, according to the instructions of their respective governments and in conformity with the general principles laid down in this convention. ARTICLE IX.-The high contracting powers have agreed to communicate the present convention to those govern- ments which have not found it convenient to send pleni- potentiaries to the international convention at Geneva, with an invitation to accede thereto. The protocol is for that purpose left open. ARTICLE X.-The present convention shall be ratified and the ratifications exchanged al Berne in four months, or sooner if possible. Additional Articles. (The additional articles now are generally accepted and have acquired the force and effect of an international treaty.) ARTICLE I.-The persons designated in Article II of the convention shall continue, after the occupation by the enemy, to take the necessary care of the sick and wounded in the ambulance or hospital which they serve. When they request to withdraw the commander of the occupying troops shall fix the time of departure, which he shall not be allowed to put off for more than a brief period, in case of military necessity. ARTICLE II.-Arrangements shall be made by the bel- ligerent powers to insure to neutralized persons fallen into the hands of the enemy's army the enjoyment of their entire salary. 162 ARTICLE III.-Under the conditions provided for in Articles I and IV. of the convention the name "ambulance" applies to field hospitals and other temporary establishments which follow the troops on the field of battle to receive the sick and wounded. ARTICLE IV.-In conformity with the spirit of Article V. of the convention and with the reservations contained in the protocol of 1864, it is explained that in the apportion- ment of the burdens relating to quartering of troops and contributions of war an equitable allowance only shall be made for the charitable zeal displayed by inhabitants. ARTICLE V.-In addition to Article VI. of the conven- tion it is stipulated that, with the reservation of officers whose detention might be important to the fate of arms and within the limits fixed by the second paragraph of that article, the wounded who may fall into the hands of the enemy, even if not considered incapable of serving, shall be sent back to their country after they are cured, or sooner if possible, on condition, nevertheless, of not again bearing arms during the continuance of the war. ARTICLE VI.-The boats which at their own risk and peril, during and after an engagement, pick up the ship- wrecked or wounded or which, having picked them up, convey them on board a neutral or hospital ship, shall enjoy, until the accomplishment of their mission, the character of neutrality, as far as the circumstances of the engagement and the position of the ships engaged will permit. The appreciation of these circumstances is intrusted to the humanity of all the combatants. The shipwrecked and wounded thus picked up and saved must not serve again during the continuance of the war. ARTICLE VIL-The religious, medical, and hospital personnel of any captured vessels are declared neutral, and on leaving the ship may remove the articles and surgical instruments which are their private property. ARTICLE VIII.-The personnel designated in the pre- ceding article must continue to fulfill their functions in the captured ship, assisting in the removal of the wounded made by the victorious party; they will then be at liberty to re- turn to their country in conformity with the second para- graph of the first additional article. The stipulations of the second additional article are applicable to the salaries of this personnel. 163 ARTICLE IX.-Military hospital ships remain subject to laws of war in all that concerns their equipment and supplies; they become the property of the captor; but the latter must not divert them from their special assignment during the continuance of the war. ARTICLE X.-Every merchant vessel, to whatever nation it may belong, loaded exclusively with sick and wounded being removed, is protected by neutrality, but the mere fact, noted on the ship's books, that the vessel has been visited by one of the enemy's cruisers, renders the sick and wounded incapable of serving during the con- tinuance of the war. The cruisers shall even have the right of putting on board an officer to accompany the convoy, and thus verify the good faith of the operation. If the merchant ship carries a cargo its neutrality will still protect it, provided that such cargo is not of a nature to be confiscated by the belligerents. The belligerents retain the right to prohibit to neutralized vessels all communication and any course which they may deem prejudicial to the secrecy of their operations. In urgent cases special con- ventions may be entered into between commanders in chief in order to neutralize temporarily and in a special manner the vessels intended for the removal of the sick and wounded. ARTICLE XI.-Wounded or sick sailors and soldiers, when embarked, to whatever nation they belong, shall be protected and taken care of by their captors. Their return to their own country is subject to the provisions of Article VI of the convention and of additional Article V. ARTICLE XII.-The distinctive flag to be used, with the national flag, in order to indicate any vessel or boat which may claim the benefit of neutrality, in virtue of the prin- ciples of this convention, is a white flag with a red cross. The belligerents may exercise in this respect any mode of verification which they may deem necessary. Military hospital ships shall be distinguished by being painted white outside, with green strake. ARTICLE XIII.-The hospital ships which are equipped at the expense of the aid societies recognized by the governments signing this convention, and which are furnished with a commission emanating from the sovereign, who shall have given express authority for their being fitted out, and with a certificate from the proper naval authority that they have been placed under his control during their fitting 164 out and on their final departure, and that they were then appropriated solely to the purpose of this mission, shall be considered neutral, as well as the whole of their personnel. They shall be respected and protected by the bel- ligerents. They shall make themselves known by hoisting, together with their national flag, the white flag with a red cross. The distinctive mark of their personnel, while per- forming their duties, shall be a brassard of the same colors. The outer paintings of these hospital ships shall be white, with red strake. These ships shall bear aid and assistance to wounded and shipwrecked belligerents without distinction of nationality. They must take care not to interfere in any way with the movements of the combatants. During and after the battle they will act at their own risk and peril. The belligerents shall have the right of controlling and visiting them; they may refuse to cooperate with them, order them to depart, and detain them if the gravity of the circumstances demands such action. The wounded and shipwrecked picked up by these ships cannot be claimed by either of the combatants, and they will be required not to serve during the continuance of the war. ARTICLE XIV.-In naval wars any strong presumption that either belligerent takes advantage of the benefits of neutrality, with any other view than the interest of the sick and wounded, gives the other belligerent, until proof to the contrary, the right of suspending the convention as regards such belligerent. Should this presumption become a certainty notice may be given to such belligerent that the convention is suspended with regard to him during the whole continuance of the war. ARTICLE XV.-The present act shall be drawn up in a single original copy, which shall be deposited in the archives of the Swiss confederation. 165