TM 8-220 WAR DEPARTMENT TECHNICAL MANUAL MEDICAL DEPARTMENT SOLDIER’S HANDBOOK March 5, 1941 TM 8-220 TECHNICAL MANUAL 1 No. 8-220 WAR DEPARTMENT, Washington, March 5, 19^1. MEDICAL DEPARTMENT SOLDIER’S HANDBOOK Prepared under direction of The Surgeon General Page Foreword 2 Paragraphs Chapter 1. Rules of land warfare 1-14 2. Basic anatomy and physiology 15-111 3. Minor surgery and medical aid 112-186 4. Nursing and ward management 186-242 5. Applied hygiene and sanitation 243-289 6. Administration 290-347 7. Medical side of chemical warfare 348-383 8. Veterinary food inspection 384-401 Page Appendix I. List of references 466 11. Acknowledgment 470 Index 71 1 TM 8-320 MEDICAL DEPARTMENT FOEEWOED The Medical Department of the United States Army has mani- fested considerable foreknowledge in its realization that its efficiency has and will always depend to a considerable degree upon the in- struction and training of its enlisted personnel. In 1862, Surgeon General Hammond, realizing a long-felt de- ficiency in the training of the hospital stewards, wardmasters, and attendants, commissioned Assistant Surgeon J. J. Woodward to pre- pare a manual to be known as The Hospital Stewards' Manual, was subsequently adopted for the training of this personnel, and as an authority in all military hospitals in the United States. Soon after Congress authorized the organization of the Hospital Corps for the Army in 1888, Assistant Surgeon General Smart wrote and published a handbook for the Corps which was successfully used for a number of years. The adoption of a regular scheme of instruction for the Hospital Corps necessitated a handbook which would include in a concise form and in one volume all the various subjects to be taught. To supply this need Major Surgeon Mason edited and published, in 1906, a comprehensive handbook for the Hospital Corps of all the armed forces of the United States. Specialization necessitated a new handbook in order to present up-to-date instructions, and in 1927 Colonel Tuttle edited and pub- lished his handbook for the Medical Department soldier. Since the formation of the Medical Corps more than 50 years ago under the authorship of Smart, Mason, and Tuttle, a handbook has been in use without interruption throughout the entire period, and has served a most valuable training role. It has provided an inherited culture and an enduring inspiration to the medical soldier. With the decision of the War Department to take over the publica- tion of this work, its title and much of its material were borrowed. This material represents the understanding, experience, and knowl- edge of the several authors and as a sound training medium has stood the test of time. TM 8-220 SOLDIER’S HANDBOOK 1-4 Chapter 1 RULES OF LAND WARFARE Section I. Laws of war in general 1-2 11. The Hague Conventions 8-6 111. Geneva Convention 7-12 IV. Voluntary aid societies 13-14 Paragraphs Section I LAWS OF WAR IN GENERAL Paragraph General 1 Laws of war 2 1. General.—The laws of war are the well-established and gen- erally recognized rules that regulate the conduct of war both on land and on sea. In this chapter, only such laws as apply to land war- fare will be considered. 2. Laws of war.—These include— a. Unwritten rules not formally agreed upon, although generally observed. Such rules change with the times, as public opinion changes and new means of waging war are devised. h. Rules agreed upon in international conference binding only those that agree to the rules in writing. Section II THE HAGUE CONVENTIONS Paragraph General 3 Declaration of war 4 Belligerents and nonbelligerents 5 Prisoners of war . 6 3. General.—The Hague Convention and several international conferences have been held to consider, among other things, the treat- ment of prisoners of war and of inhabitants of occupied territory, and the general conduct of hostilities. The last Hague Convention was held in 1907. 4. Declaration of war.—No nation may commence hostilities against another without first making a formal declaration of war. 3 TM 8-220 4-7 MEDICAL DEPARTMENT This law of war is frequently violated today; yet, curiously enough, it was the one rule that the framers of The Hague Conventions agreed upon unanimously. Neutral powers are supposed to be notified of the state of war. 5. Belligerents and nonbelligerents.—The laws of war separate the population of a nation at war into two classes—belligerents (those belonging to recognized military forces) and nonbelligerents (the civil population). a. Belligerents may engage in any of the acts of war recognized as legal by the laws of war without forfeiting protection guaranteed to prisoners of war in case they are captured by the enemy. b. Nonbelligerents are prohibited from engaging in combat and in other forms of direct action against the enemy except in self- defense. If they violate this law of war and are captured by the enemy, they are not entitled to the protection guaranteed prisoners of war and may be punished. 6. Prisoners of war.—Prisoners of war must be treated humanely. They are permitted to keep their personal property, but all mili- tary equipment and papers are taken from them. Except commis- sioned officers, they may be required to work, provided the labor is not excessive and has no connection with military operations. Work connected with the care of the sick and injured has been considered proper, and prisoners of war have been required to assist in medical service. Every prisoner of war is required, when asked, to give his true name and grade, and he may be punished for refusing so to do. He is not required to name his organization. Section 111 GENEVA CONVENTION Paragraph General 7 Care of sick and wounded 8 Abandonment of sick and wounded 9 Duties of belligerent after engagement 10 Protection of medical troops and property 11 Medical service emblem 12 7. General.—The laws of war applying to every aspect of warfare, other than the problems associated with sick and wounded, are in- cluded in The Hague Conventions (see sec. II); but The Hague Conventions merely approve the rules established in the Geneva Con- vention in these words: “The obligations of belligerents in respect to the sick and wounded are regulated by the Geneva Convention.” 4 TM 8-220 SOLDIER’S HANDBOOK B—l4 8. Care of sick and wounded.—Officers, soldiers, and other per- sons officially attached to armies, who are sick or wounded, will be respected and cared for, without distinction of nationality, by the belligerent in whose power they are. 9. Abandonment of sick and wounded.—Whenever it becomes necessary to abandon sick and wounded to the enemy, if military conditions permit, a detachment of medical troops with essential equipment and supplies must be left with the sick and wounded to care for them until the enemy has taken them over. 10. Duties of belligerent after engagement.—After every en- gagement, the belligerent who remains in possession of the field of battle will take measures to search for the wounded, and to protect the wounded and dead from robbery and ill treatment. He will see that a careful examination is made of the bodies of the dead prior to burial or cremation, and will make every effort to record the identity of dead enemies as well as of his own men. 11. Protection of medical troops and property.—Medical troops, installations, and equipment are to be protected so long as they are not used to commit acts injurious to the enemy. This pro- tection is extended to the dental, hut not to the veterinary service. 12. Medical service emblem.—The distinctive emblem of med- ical service (the Red, or Geneva, Cross) must be displayed on all flags and brassards, as well as on all equipment, used by the medical service. This emblem cannot be used by any other branch of the militarv service. Section IV VOLUNTARY AID SOCIETIES General 13 American National Red Cross 14 Paragraph 13. General.—Voluntary aid societies who provided a great part of care and treatment of the sick and wounded prior to the develop- ment of the medical service of the Army, have no responsibility to the Government for such care and they are now restricted for the most part to providing comforts and luxuries not obtainable offi- cially. Their personnel and equipment while so engaged are pro- tected by the Geneva Convention in the same manner, and are sub- ject to the same provisions, as those of the Medical Department. The Medical Department cannot share its responsibility for care or treatment of sick and wounded soldiers with any agency. 14. American National Red Cross.—See AR 850-75. 5 TM 8-220 MEDICAL DEPARTMENT Chapter 2 BASIC ANATOMY AND PHYSIOLOGY Paragraphs Section I. Medical 15-60 11. Dental 61-62 111. Veterinary 63-111 Section I MEDICAL General structure 15 Minute anatomy 16 Development of body 17 Varieties of tissues 18 Skeletal system 19 Development of bone 20 Joints 21 Muscular system 22 Relationship of bones and attached muscles ; 23 Activity of voluntary and involuntary muscles 24 Posture 25 Effect of exercise on muscle ! 26 Heart and circulation 27 Blood vessels : 28 Heart 29 Blood 30 Lymphatic system 31 Respiratory system 32 Air passages 33 Nose 34 Pharynx 35 Larynx 36 Trachea 37 Lungs 38 Chest cavity 39 Mechanism of respiration 40 Digestive system 41 Foods 42 Proteins 43 Carbohydrates 44 Fats 45 Composition of foods 46 Enzymes 47 Absorption 48 Paragraph 6 SOLDIER’S HANDBOOK TM 8-220 15-16 Paragraph Metabolism 49 Excretory system__ 50 Skin 51 Urinary system 52 Nervous system 53 Glands and their products 54 Special senses 1 55 Eye 56 Vision : 57 Ear 58 Mechanism of hearing : 59 Male genital system 60 13. General structure.—The human body consists of a bony or skeletal framework which supports the soft parts or tissues. As a preliminary to the description of the gross appearance of the sepa- rate parts of the bddy it is appropriate that consideration be given to the finer structure of the tissues. 16. Minute anatomy.—a. The structural unit of every part of the human body is the microscopic animal cell, and the various activities of the body result from the activities of the cells which compose it. b. These body cells vary in size and shape, but all are very minute, the largest rarely exceeding one-fifth of a millimeter in diameter. In some parts of the body they lie side by side; in other parts they may be separated from one another to a varying degree by an inter- cellular substance. They differ greatly in structure and function, muscle cells are long fibers having the power to contract; bone cells form the hardest and most enduring tissue in the body; nerve cells possess elongated processes whose special function is conductivity; the cells of the skin are very flat, especially those comprising the outermost layers, and their function is principally a protective one, c. A cell may be defined as living matter called protoplasm, sur- rounded by a membrane and containing a smaller, denser inner body called tde nucleus or kernel. The protoplasm is a colorless, semi- transparent, gelatinous, mobile, and irritable substance which is the “physical basis of life.” One of the principal constituent parts of the protoplasm of the nucleus is chromatin, which carries all of the hereditary potentialities of the individual and is directly con- cerned in the reproduction, or division, of the cell. d. When cells with similar structure and function are grouped together there is formed what is known as tissue. Between these cells there are always small spaces even in the most compact tis- sue. There are points of union between cell and cell, but the 7 TM 8-220 16-18 MEDICAL DEPARTMENT intercellular spaces are necessary in order that each cell may be in contact with the fluids of. the body in which nourishment is carried to the cell and waste products are removed. This interchange takes place through the cell membrane. e. In considering the properties of protoplasm we find that it is a mixture of complex organic and simpler inorganic substances. The organic substances comprise principally proteins, fats, lipoids, and carbohydrates, while the inorganic substances are water and many chemical elements. /. Protoplasm has the power to absorb oxygen and oxidize, or burn, some of its substance, thus producing heat energy. It is able to take up certain chemical compounds, or non-living materials, as food and convert them into its own substance, causing repair and growth. This power of nutrition is known as metabolism. Proto- plasm is irritable and responds to stimulation. It has the capacity for motion. 17. Development of body.—The human body is developed from a single cell called the ovum. The ovum divides and subdivides, and the daughter cells thus formed arrange themselves as a membrane comprising three layers of cells. The outer layer is the ectoderm, the middle layer the mesoderm, and the inner layer, the entoderm. These three layers of cells later in the process of development assume differ- ent sizes and shapes forming the various types of cells found in the body; for example, from the ectoderm come the skin and nerve cells; the muscle cells derive from the mesoderm; the entoderm pro- vides the lining cells of the intestines. As stated above, collections of cells of like structure and function form tissues. Combinations of tissues form body organs or structures. The characteristics of tissue depend upon the type of cells and the intercellular substance composing it, and the structure of any organ depends upon the properties of the tissue of which it is composed. 18. Varieties of tissues.—Some tissues perform but one phys- iologic function, others perform several. It is therefore difficult to classify tissues in this way except by the most important of their physiological functions. The following arrangement has been sug- gested by several authorities: a. Undifferentiated tissues.—Composed of cells which have de- veloped along no special line but retain the properties of the cells forming the very young body before cell differentiation takes place. Lymph and white blood corpuscles are examples of this tissue. h. Supporting tissues.—This type of tissue is used to support and protect more delicate tissue and to resist strain or pressure. 8 TM 8-220 SOLDIER’S HANDBOOK 18-10 0. Nutritive tissues.—These form a large group and include assimilative, eliminative, and respiratory tissue. d. Storage tissues.—These tissues are composed of storage cells of which fat cells and liver cells are examples. These cells store reserve supplies of food which they supply when needed. e. Excitable or irritable tissues.—Tissues which are especially sus- ceptible to changes in their surroundings and are therefore useful in giving to the body information as to what is going on around it. Any change in the environment which serves to arouse response in an excitable tissue is called a stimulus. f. Conductive tissues.—Serve to bring into communication the various parts of the body. This is exhibited to a very high degree by nervous tissue. g. Motor tissues.—The two best examples of this type of tissue are muscular tissue and the ciliated cells which line certain organs of the body. These cells have fine thread-like appendages which are kept in constant motion. These appendages are called cilia. The constant motion of the cilia causes material on the surface to be moved along in one direction or another. h. Protective tissues.—As the name indicates these tissues line or • protect certain parts of the body, as the enamel of the teeth, the epithelium covering the body, etc. 1. Reproductive tissues.—These tissues are concerned in the pro- duction of new individuals. The different sexes have different types which conjoin for the origination of offspring. Various types of these tissues are combined to form the different parts of the body. 19. Skeletal system.—a. The skeletal or bony structure of the body is made up of over 200 bones. It has a threefold function: To support the body; to afford protection to certain organs of the body which might easily be injured; and to furnish a system of levers which when acted upon by the muscles causes the body to move. h. The skeleton may be divided for descriptive purposes into the axial' skeleton, which includes the skull, the spine, the breastbone, and the ribs, and the appendicular skeleton, which is composed of the bones of the arms and the legs and the bones by means of which these appendages are attached to the axial skeleton. c. The skull is made up of 22 bones, 8 of which form the cranium, and 14 the face. Of the cranial bones, the one forming the fore- head is the frontal bone. The top of the skull is formed by the two parietal bones. In the back is the occipital bone, and at either side is the temporal bone, the upper part of which corresponds to the 9 TM 8-220 19 MEDICAL DEPARTMENT temple, the lower part including the ear. In addition to these there are the sphenoidal bone, which forms a part of the floor of the cranium, and the ethmoid, which lies in front and forms the roof of the nasal cavity. The more important bones of the face are the nasal bones, which form the bridge of the nose; the two malar, or cheek, bones; the two upper and one lower jaw bones. These bones of the skull, with the exception of the lower jaw bone are, in the adult, immovably joined together. At the back part of the base of the skull is the large opening through which the spinal cord passes from the spinal column on its way to the brain. d. The spine or vertebral column consists of 26 irregularly shaped bones, all possessing a general sameness in outline except for modi- fications in the several parts of the column. Each has a flattened body at the back of which appears the arch which serves to enclose and protect the spinal cord. Spinous processes project posteriorly and lateral processes from the' sides of the vertebral arches, their principal purpose being to limit the movement of the intervertebral joint. e. The thoracic wall consists of the sternum, or breastbone, 12 ribs on either side, and the vertebral column at the back. While all of the ribs articulate with the vertebral column, only the upper seven pairs are connected directly, by means of cartilage, with the sternum. These are called true ribs. The next lowermost three pairs of ribs have their cartilages attached to the rib above. The remaining two pairs have no anterior cartilaginous attachments. These five pairs of ribs are spoken of as false ribs. /. The shoulder girdle consists of the scapula or shoulder blade, and the clavicle or collar bone. The scapula lies embedded in the muscles on the outside of the ribs and at the sides of the vertebral column and to it is articulated the arm bone. The clavicle serves to keep the scapula in place. g. The pelvic girdle consists of the hip bone on either side and the wedge-shaped base of the spinal column, the sacrum, at the back. Each hip bone possesses a deep socket into which the head of the thigh bone articulates. A. The upper and lower limbs may be considered at one and the same time, for each contains 30 bones, the arrangement of which in each is very similar. The differences in structure have resulted from changes in function resulting from adaptation of the upper limb to prehensile purposes and the lower to weight bearing and locomotion. The socket of the scapula into which the round head of the humerus fits is shallow and this fact together with the relative looseness of TM 8-220 SOLDIER S HANDBOOK 19 Figube I. Bony skeleton. 11 TM 8—220 19-20 MEDICAL DEPARTMENT attachment of the shoulder girdle permits a wide range of motion at the shoulder. The articulation of the arm and forearm at the elbow permits not only flexion and extension, but also pronation and supination of the forearm by reason of the rotating power of the radius over the ulna. The eight small wrist bones are loosely con- nected together by ligaments, allowing great freedom of movement. Then, too, the elongated digits, more especially the thumb which is opposable to any of the other fingers, permit the hand to grasp and manipulate objects readily. The lower limb would serve no good purpose were its flexibility as great as that of the upper limb. Since it must bear the weight of the body, its bones must be sturdier, therefore heavier, than the corresponding bones of the upper ex- tremity. The hip girdle, unlike the shoulder girdle, is firmly fixed; the socket of the hip bone, into which the femur fits, is much deeper than the socket of the scapula; consequently, while there is a limi- tation of flexibility at the hip joint there is also considerably Jess of a liability to dislocation than there is at the shoulder. In the knee there is very little more than a forward motion, and because the fibula, the more slender of the two leg bones, is attached firmly to the upper end of the tibia, pronation and supination are lacking in the leg. The bones of the foot which correspond to the bones of the wrist are larger, and being closely bound together by ligaments do not possess a similar degree of freedom of motion. But because there must be elasticity to permit springiness in the step so as to avoid jarring, the bones of the foot are arranged in arch formation. The bones of the toes are much shorter than those of the fingers, consequently, they are less flexible, and because the great toe cannot be opposed to any of the other toes the foot lacks prehensile qualities. 20. Development of bone.—a. When a child is born the bones of the body, although formed, are not continuous masses of bony tissue. Each is partly composed of cartilage. The process of bone formation is very complicated and in these areas of cartilage starts from small points or centers of ossification. These centers finally enlarge and when adult life is reached have replaced all of the car- tilaginous tissue. h. In the large bone of the arm in a child both ends are separated from the shaft by cartilage and it is in these areas that the bone grows in length by new cartilage appearing and later being replaced by bone. The bone grows in thickness by new bony tissue being formed beneath the covering membrane or periosteum. 12 TM 8-220 SOLDIER S HANDBOOK 20-22 c. The bones of children are quite flexible but as old age comes on this flexibility is slowly lost and they become very brittle. 21. Joints.—Where two bones of the skeleton come into apposition they form a joint or articulation. Some joints permit of no motion while others permit motion in many directions. The principal kinds of joints are the following: a. Fixed joints.—Best illustrated by the union between certain bones of the skull which permit no motion and are called sutures. b. Ball-and-socket joints.—As the name implies, in a joint of this type the rounded end of one bone fits into a hollowed surface of the other and its characteristic is that it permits a greater degree of motion than do other joints. The shoulder and hip joints are exam- ples. At the hip joint the thigh may be flexed, that is, moved up- ward and forward, or extended, that is, moved backward. It may be moved toward or away from the other thigh, and it may be made to produce a cone-like motion, the apex of the cone being at the joint, which is in reality a combination of the other possible motions. c. Hinge joints.—A joint of this type permits of a movement in one plane as in a hinge. The knee joint is one of the best examples of this kind of joint. d. Pivot joints.—The best example of this type is between the first and second bones of the spine. One bone rotates around another which remains stationary. e. Gliding joints.—ln the closely packed bones of the wrist, for example, little motion is permitted except that provided by one of the bones sliding a short distance over the surface of the other. 22. Muscular system.—The muscles make up the main motor organs of the body. There are three types of muscle tissue: a. Voluntary muscles, which are under our control and may be moved at will. These make up the mass of skeletal muscles and on account of their appearance under the microscope are sometimes called striped muscles. h. Involuntary muscles are not fixed to the skeleton, but largely surround cavities or tubes in the body. These muscles act without our will and from their microscopic appearance are called smooth muscles. The muscles surrounding the stomach are examples of this type. c. Heart muscle is involuntary muscle but differs somewhat from other involuntary muscle tissue when examined under the micro- scope. In fact, it more closely resembles voluntary muscle. 13 TM 8-220 23-26 MEDICAL DEPARTMENT 23. Relationship of bones and attached muscles.—a. Muscles are attached by means of tendons to the bones of the body and by their contractions cause parts of the body to move. The point where one tendon is attached is called the origin of the muscle and where the other end is attached is called the insertion. The origin is usually in that part of the skeleton which is less freely movable than the part to which the insertion is attached. Muscles are of various sizes and shapes and may have a tendon only at one end or along one side, depending on the function of the muscle. h. When the muscles serve to move bones they act as levers. The most common muscular movements used are levers of the third order, where the power is between the weight and the fulcrum. An ex- ample of this may be seen in bending the forearm. The fulcrum here is the elbow joint and the power is applied by muscles having their insertion in the bones of the forearm and the weight being the weight of the hand itself. Some other.motions of the body illustrate levers of the first and second order; for example, the nodding move- ment of the head illustrates a lever of the first order and the act of standing on the toes illustrates one of the second order. 24.. Activity of voluntary and involuntary muscles.—When we send a nervous impulse to a voluntary muscle, the muscle moves either rapidly or slowly, as we will it to do. On the other hand, in- voluntary muscle acts without any direction sent to it by our will and may contract at varying intervals like the muscles of the stomach and intestines or may stay in an almost permanent state of contraction. 25. Posture.—The posture of the body is applied to those posi- tions of equilibrium of the body, such as standing, sitting, or lying, which can be maintained for some time. When the body is held in any one of these positions there is always a slight, sustained con- tracture of the muscles to prevent the joints from bending. This is called tonus. If the position is held for any considerable length of time a certain amount of fatigue is produced, and should the muscles not be in a healthy condition this fatigue is produced earlier than if they were healthy. The result of this fatigue causes relaxation of the muscles and improper posture. When a person not well de- veloped stands erect for a long period the muscular relaxation or lack of tone causes him to slump. 26. Effect of exercise on muscle.—a. Good food, pure air, and a proper functioning of the body are necessary for the healthy working of the body. In addition to these, the muscles must be exercised. In fact, a muscle must be exercised in order to get the proper nourish- ment, as each muscle acts as a sort of chemical engine and the contrac- 14 TM 8-220 SOLDIER S HANDBOOK 26-29 tion and relaxation are required to throw off waste products and take in new fuel from the surrounding body fluids. b. When a muscle is not used at all it becomes much smaller and wastes away. This is called atrophy of the muscle. On the other hand, when any muscle or group of muscles is used over and over again in excess of normal the muscles become larger or undergo hypertrophy. The calf muscles of runners are examples of this. In hypertrophy the muscle cells become larger but do not increase in number. 27. Heart and circulation.—The heart, together with the blood vessels, form what is known as the cardio-vascular system. This sys- tem consists of a series of closed tubes of various sizes (arteries, veins, and capillaries) through which the blood circulates, being propelled by a muscular pump, the heart. This system of vessels leads to and from all the tissues of the body. 28. Blood vessels.—The tubes or blood vessels which carry the blood away from the heart are called arteries, while the vessels re- turning the blood to the heart are called veins. Connecting the ar- teries and veins in the various tissues are minute hair-sized vessels known as capillaries. These have very thin walls and form dense networks throughout the body, and it is through these networks that the blood comes in close contact with the tissues of the body in order to give up food and oxygen and take away the various waste products. 29. Heart.—a. The heart is a large hollow, cone-shaped organ of muscular tissue about the size of a fist. It is enclosed in a tough fibrous sac, the 'pericardium. The heart is situated between the lungs near the front part of the chest where it is well protected by the bony skeleton. b. The heart is divided vertically into two lateral halves which do not have any opening between so that we really have two hearts, a right and a left. Each side of the heart is made up of two cavities, an auricle and a ventricle, the auricles being smaller, thinner walled, and situated above the ventricles. c. The right side of the heart is called the venous side, as it re- ceives into its auricle the impure blood collected by the veins. From the right auricle the blood passes to the right ventricle and then to the lungs to be purified. When purified it is returned to the left auricle and from there to the left ventricle, which by its powerful contractions forces the blood out through the arteries to the various parts of the body. d. It will be seen from c above that there are really two circulatory systems connected with the heart. The one going through the lungs 15 TM 8—220 29 MEDICAL DEPARTMENT Piqdkk 2.—Blood vascular system. 16 TM 8-220 SOLDIER S HANDBOOK 29-30 is called the pulmonary circulation and the one going through the body, the systemic circulation. e. There is still a third circulatory system although this is not directly connected with the heart. This is the portal system. When that portion of the blood leaving the heart in the systemic circula- tion goes to the stomach, intestines, spleen, and pancreas, it is col- lected in a vein called the portal vein, which enters the liver and breaks up into capillaries. The blood subsequently is collected by ordinary veins for return to the heart. This portal system is very important, as it brings food material from the alimentary tract to the liver to be acted upon by that organ and either placed in circulation or stored for future use. 30. Blood.—a. The total quantity of blood is usually estimated at one-twelfth of the weight of the body, approximately a gallon and a half for an average adult. b. The color of the blood, due to variation in its oxygen content, is bright red in the arteries and dark red in the veins. It is composed of cells or corpuscles floating in a liquid called the plasma. c. The plasma is composed of fibrin and a true liquid element called serum. The fibrin is the active agent in causing the blood to clot or coagulate when bleeding occurs. The serum, which is plasma less fibrin, contains the food elements of the blood. There are three types of cells or corpuscles: (1) The red cells or erythrocytes are round, flattened discs, slightly concave on each side and composed largely of hemoglobin. This sub- stance contains iron and has the capacity of carrying large amounts of oxygen. The number of red corpuscles is 5,000,000 per cubic mil- limeter in the male and 4,600,000 in the female. (2) The white cells or leucocytes are spherical in shape and slightly larger than the red cells. They number between 5,000 and 7,000 per cubic millimeter. They are capable of changing their form and passing through the unbroken walls of the blood vessels. These cells are capable of destroying disease-producing organisms. In the presence of most infections the number of these cells greatly increases. They form the first line of defense against infection. (3) The blood platelets are very small and almost colorless cells. The average number may be given as 300,000 per cubic millimeter. It is believed that their function is to aid clotting of the blood and to maintain immunity against certain diseases. In addition to the cells described above there are several other cells occurring in small numbers of which very little is known. TM 8-220 31-35 MEMCAL DEPARTMENT 31. Lymphatic system.—a. The lymphatic system is much like the blood circulatory system except that the fluid is clear and there is a heart to propel the blood. h. The lymph is a clear fluid of essentially the same composition as blood plasma. This lymph circulates between the cells of the body and the capillaries of the blood vascular system. c. The lymph vessels begin in the small spaces between the in- dividual cells, unite to form larger channels, and finally empty into the venous blood system by way of a large lymph vessel called the thoracic duct. d. The lymph nodes are lenticular-shaped bodies occurring along the course of the larger lymph vessels. Where these nodes are present the lymph passes through the substance of the node and is filtered and purified. In case of infection these nodes usually become in- flamed, They are of great aid in localizing and overcoming infections. 32. Respiratory system.—The term respiration, as commonly used, means the function of gaseous interchange between the blood and air taken into the lungs. This is really only a part of respiration and is external respiration as there is an exchange going on all the time between the tissues of the body and the minute blood vessels, which is called internal respiration. 33. Air passages.—Air reaches the lungs through the nose, pharynx,' larynx, and trachea. 34. Nose.—Air enters from outside the body through the nose under ordinary conditions, although it may be taken in through the mouth. The nose is divided inside into two nasal passages by a septum and nature has so shaped the nasal passages that the cooler outside air is slightly warmed and certain foreign material, such as dust particles, may be removed prior to the air reaching the lungs. Leading from the nasal passages are irregularly shaped recesses called the sinuses. The inner surfaces of the sinuses are lined by a moist membrane similar to that found in the nose. Inflammation of these recesses is called sinusitis and may arise from an extension of an ordinary cold in the nose. 35. Pharynx.—a. The pharynx is the large opening back of the cavity of the mouth. It is a common passageway for both food and air as it also communicates with the nasal passages. The pharynx continues downward as the larynx in front and a tube for food, the esophagus, in the rear. h. At the root of the tongue there is a small triangular-shaped flap covering the opening into the larynx; when food is swallowed this 18 TM 8-220 SOLDIER S HANDBOOK 35 Pigdkk 3.—Longitudinal section through nose, throat, and mouth. 19 TM 8-220 35—40 MEDICAL DEPARTMENT flap closes and prevents food from entering the larynx. This flap is called the epiglottis. 36. Larynx.—The larynx or “voice box” is that portion of the respiratory tract connecting the pharynx and the trachea. It is com- posed of nine cartilages and muscular and connective tissues. This organ contains two bands of tissue called the vocal cords. When the vocal cords are placed in a certain position and air is driven past them they are set in vibration and emit a certain sound. The strength of the blast of air determines the loudness of the sound, the size of the larynx itself determining the pitch. In women and children the larynx is smaller than in men and the pitch is higher. The sounds made by the vocal cords are strengthened by the resonance of the air in the pharynx and mouth and are altered by the movements of the tongue, cheeks, throat, and lips into speech. 37. Trachea.—The trachea, or windpipe, is a tube extending from the lower part of the larynx to the lungs. It is about 4 inches long and at its lower end divides into two parts, the bronchi, one of which goes to each lung. The trachea is composed of irregular rings of cartilage connected by supporting tissue. 38. Lung’s.—a. The lungs are two in number, a right and left. Each has a bronchus connecting it with the trachea. These bronchi continue into the lung dividing and redividing until they end in a minute dilation or sac. As the bronchial tubes divide and redivide they become smaller and their walls become thinner until the smallest one as well as the terminal sacs or alveoli consist of but a single of cells. This single layer of cells is all that separates the inspired air from the very thin-walled capillaries surrounding them so that the diffusion of gases may take place readily. b. The lungs are covered by a thin membrane, the pleura, and are not connected with any other tissue except at the hilum or root. The arteries, veins, and bronchi enter at the roots of the lungs. 39. Chest cavity.—The chest cavity or thorax is a cone-shaped cavity with the narrow end upward. It is surrounded on the outside by the ribs, breastbone, and spinal column, the bottom being closed by the diaphragm. In addition to the lungs the thorax contains the heart, trachea, and esophagus. The chest cavity is lined by the same kind of membrane that covers each lung, the pleura. In fact, the membrane covering the lung folds back on itself to line the chest wall so that between the lung and the chest wall it forms a sac called the pleural cavity. 40. Mechanism of respiration.—a. The respiratory movements are to a certain extent under the control of the will in that we can 20 TM 8—220 SOLDIER S HANDBOOK 40—44 breathe rapidly or slowly or take either deep or shallow breaths. But this is limited in extent, as our ordinary breathing goes on involun- tarily. This ordinary type of breathing is controlled by certain centers in the brain which are excited by the type of blood flowing through them. That is, when venous blood flows through them the respirations are increased and the greater the demand of purification of the blood the greater the stimulation. h. When a breath is taken in, the chest increases in size in all diam- eters. The diaphram, which at rest is dome-shaped, contracts and flattens the dome, which in turn increases the vertical diameter of the chest. By movement of the ribs on their articulations with the vertebrae the diameters from front to back and side to side are also increased. Inspiration, or the taking in of a breath, requires consid- erable muscular action. Expiration, on the other hand, requires very little, as the chest simply returns to a resting position. c. The lungs contain a certain amount of air at all times, even after a forced expiration. The lung capacities of different indi- viduals vary greatly but in an average size man, even after forced expiration, the lungs contain about 1,000 cubic centimeters of air, called the residual air. Under ordinary circumstances we do not make forced expirations so that in addition to this amount there are between 1,500 and 2,000 cubic centimeters left, known as the supple- mental air. These two make up the stationary air. The air ordi- narily taken in is known as the tidal air and in addition that taken in on forced inspiration is known as the complemental air. 41. Digestive system.—The digestive system is made up of the alimentary canal and various organs or glands attached to it. The function of this system is to prepare food so that it can be used by the various parts of the body. 42. Foods.—In order to provide energy for the body and to maintain and repair the tissues it is necessary to furnish material which can be made available for this purpose. Foodstuffs are usually classified as being carbohydrate, fal, or protein. In addition to these the body requires water, certain inorganic salts, and certain food constituents which are known as vitamins. 43. Proteins.—Proteins are required to replace worn-out tissue. They also furnish much of the fuel supply of the body. Meat, eggs, cheese, and beans are all rich in proteins. 44. Carbohydrates.—Carbohydrates are oxidized in the body to give it energy to carry on its work. They are mostly of vegetable origin. Flour, sugar, and rice are examples of food rich in carbohydrates. 21 TM 8-220 45-49 MEDICAL DEPARTMENT 45. Fats.—Fats may be of animal origin, as in butter, or may occur in vegetables, as in olives. They act very much like the carbo- hydrates in furnishing energy to the body machine. 46. Composition of foods.—Most foods contain more than one nutriment. Milk, for instance, contains two proteins, several fats, and a carbohydrate. In addition there are several salts and vitamins. 47. Enzymes.—Food to be used by the body must be reduced from a complex substance to more simple compounds. This reduc- tion is carried on by means of substances called enzymes. There are enzymes for the various types of food; they split carbohydrates into simple sugars, fats into fatty acid, and glycerine and'proteins into acids. These enzymes are present in the various secretions of the alimentary canal, each secretion having its specific enzyme. Some of the secretions contain more than one enzyme. 48. Absorption.—a. After the food has been acted upon by the digestive juices it must be taken to the various tissues of the body in order to supply them with nutritive material. The transfer of food from the alimentary canal to the circulatory system is called absorp- tion. This takes place almost entirely in the small intestine. b. The simple food compounds are taken up by the receptive cells of the small intestine and pass either directly into the blood stream, or into lymph vessels which later discharge them directly into the blood stream. As the blood itself comes in contact with very few tis- sue cells there has to be some way of getting food to these cells. This is done by a process called diffusion which goes on between the blood in the capillaries and lymph outside. This same interchange goes on between the tissue cells and the lymph. The interchange of fluid is governed by osmotic pressure. 49. Metabolism.—Metabolism is that process by means of which foods are broken down and rebuilt into living tissue. a. The mouth is the first organ taking part in the preparation of food for absorption. The food after it is taken into the mouth is broken apart by the teeth in the act of chewing and is mixed with a substance called saliva. This is secreted by a group of glands located inside of the cheeks, under the tongue, and under the lower jaw. Saliva contains an enzyme (ptyalin) which acts on starches to reduce them to maltose. After the food becomes semi-liquid it is swallowed and passes down the esophagus or gullet to the stomach. h. The stomach is a muscular, sac-like organ which lies just below the diaphragm and is lined with cells which secrete the gastric juice. This juice is an acid liquid which contains pepsin, an enzyme acting on the proteins to break them up into simpler compounds. At either 22 TM 8-220 SOLDIER S HANDBOOK 49 Fioobe —Digestive system. 23 TM 8-220 49-50 MEDICAL DEPARTMENT end of the stomach there are rings of muscular tissue which, when contracted, close the openings and keep the food in the organ until gastric digestion has been completed. When this has occurred the muscle fibers in the wall of the stomach contract and force the food into the small intestine. c. The small intestine is a long tube (about 22 feet) which lies coiled up in the abdominal cavity. It is in this organ that digestion is completed and from which the food is absorbed. (1) There is a small opening in the small intestine which receives juice from the 'pancreas and bile from the liver. These two organs are very important accessory glands of digestion. (a) The pancreas, which secretes pancreatic juice, is a long, narrow gland located back of the stomach. This juice carries on the work of breaking down the proteins and starches already started in the stomach and in addition acts on the fats. (h) The liver is the largest gland in the body and lies on the right side of the abdomen just beneath the diaphragm. Bile is formed by the liver cells and is collected in ducts which unite to form the one opening into the intestine. Some of the bile is by-passed up a small duct to a sac called the gall bladder. Here it is stored for future- use. Bile does not contain any specific enzyme used in digestion, but it does aid the action of the pancreatic juice, especially in its action on fats. (2) Certain cells of the small intestine secrete the last digestive juice to come into contact with the food. This intestinal juice com- pletes the breaking down of the proteins and starches. d. The large intestine or colon is between 3 and 4 feet long and is much larger in diameter than the small intestine. It starts in the right lower part of the abdomen where the small intestine empties into it, extends upward to the under-surface of the liver, then across the upper abdomen, and down the left side to end in the anus. Most of the nutritive matter from the food has been absorbed in the small intestine, but the contents discharged into the colon are very liquid and as these are churned around whatever remains of value is ab- sorbed together with much of the water content. The material re- maining consists of undigested substances, bacteria, and some waste products which collect in the lower part of the colon and are passed as fecal material. 50. Excretory system.—Waste material of the body is gotton rid of through the skin, lungs, and urinary system, as well as the large intestine. The liver also acts as an excretory organ as it separates waste material from the blood and also changes certain harmful 24 TM 8-220 SOLDIER S HANDBOOK 50-53 excretory substances into harmless ones and returns them to the blood for excretion through the skin and in the urine. 51. Skin.—The skin, in addition to being a protective covering, acts as an excretory organ. Skin consists of two layers, the cuticle or epidermis and the true skin. Located in the true skin are many very small glands, the sweat glands. These glands secrete the sweat, which varies greatly in amount, depending upon the environmental temperature, activity of the individual, and certain other conditions. Sweat contains a certain amount of waste products similar to some contained in the urine. 52. Urinary system.—The urinary system consists of the kidneys, ureters, bladder, and urethra. a. The kidneys are two in number each one lying on the side of the spinal column in the back of the abdomen. They are bean-shaped organs between 4 knd 5 inches in length and on the concave side of each is a notch called the hilum. Here the large blood vessels enter and leave the organ and the tube (ureter) which takes away the urine has its origin. The blood enters the kidneys and when it has reached the fine capillaries the cells of the gland remove the impurities which pass into the ureters as urine. b. The ureters are small tubes which carry the urine from the kidneys to the bladder. There is one ureter for each kidney. c. The bladder is a hollow, muscular organ lying low in the body just behind the pelvic bone. A ureter enters each side of the organ and as the kidneys secrete the urine it passes on to the bladder, where it is stored, having to be emptied only at intervals. d. The urethra is the tube through which the urine is discharged from the bladder. 53. Nervous system.—The nervous system is the most complex system of the body and may be thought of as two systems, as the functions of one differ from the other. The cerebrospinal system is that part made up of the brain and spinal cord and the nerves given off by these organs, namely, 43 cranial and spinal nerves. The other system is called the sympathetic nervous system and con- sists of two rows of central ganglia (masses of nerve cells) lying along the front of the spinal column, the ganglia being united with each other by strands of nerve fibers and connected by means of sympathetic nerves with various parts of the body. The sympathetic system has largely to do with the movement of involuntary muscles and the activities of glands. a. Brain.—The brain lies well protected in the skull. The organ consists of a large cerebrum and a much smaller cerebellum. The 25 TM 8-220 53 MEDICAL DEPARTMENT cerebrum is the seat of the mind. When it is removed all power of moving voluntary muscles is gone. Without it all sensations of light, taste, smell, touch, and heat are lost. The cerebrum decides what we shall do. It sends out the messages to the muscles when we wish to move and is that part of the brain that thinks and feels. Without a cerebrum an animal can live but all of its intelligence is gone. It still breathes but is only a machine. b. Cerebellum.—The cerebellum causes all the muscles to keep the proper amount of contraction {tonus) and it assists in governing the muscles in standing and walking. c. Spinal cord.—The spinal cord is a continuation of the nervous tissue extending from the brain down through the spinal canal. Figure 5.—Diagrammatic illustration of lateral aspect of the brain. 26 TM 8-220 SOLDIER S HANDBOOK 53-56 The spinal cord widens out on its upper end where it is attached to the brain to form the medulla oblongata. The medulla is a very important part of the brain as it contains the nerve centers govern- ing the action of the heart and respiration. The spinal cord itself is a large bundle of nerve fibers which carry nervous impulses from the various parts of the body to the brain as well as impulses in the opposite direction. 54. Glands and their products.—The fact that certain groups of tissue cells supply certain secretions to the body has been pointed out under the description of the alimentary tract. Some of these same glands also secrete substances which are absorbed directly into the blood stream. The pancreas, for example, not only secretes pan- creatic juice but it secretes a substance directly into the blood which has to do with carbohydrate metabolism. a. . The endocrine glands is a term applied to these glands and the active substances contained in their secretions are called hormones. These hormones influence such functions as growth, reproduction, and metabolism. b. The thyroid gland, in the neck, one of the largest glands whose secretion is entirely an internal one, was one of the first to be studied from this view. Overactivity of this gland causes nervousness, loss of weight, rapid heart, and other symptoms, while an insufficient amount of secretion, in children, causes mental dullness, retardation of growth of the long bones, coarse hair, etc. c. The following glands secrete one or more hormones: Adrenals, ovaries, glands in the lining of the stomach and duodenum, testicles, pancreas, thyroid, parathyroid, and pituitary. It is also believed that certain other glands secrete hormones but it has never been definitely proved. 55. Special senses.—The special senses are feeling, tasting, smell- ing, hearing, and seeing. These senses are due to the peculiar devel- opment of the ends of sensory nerves in various parts of the body. The sense of feeling is more or less generally distributed over the body surface. However, in some places as the finger tips, the nerve endings are very close together and feeling is more acute. The sen- sory nerves of taste are all located in the mouth and those of smell in the nose. The other two special senses have rather complicated end organs which aid in the reception of either light or sound waves. 56. Eye.—The eye may be likened to a small camera which is con- stantly photographing objects and sending the picture to the brain. a. The eyes are well protected from injury by being placed in a hollow or socket in the front of the skull. On the exposed side they 27 TM 8-220 56 MEDICAL DEPARTMENT are protected by the eyelids, eyebrows, and eyelashes. The exposed surface of the eye and the inner surface of the lid are kept moist by the secretion t)f the tear glands. b. The eyeball is generally spherical in shape being made up of two hollow segments of unequal size. The larger, posterior segment comprises about five-sixths of the eyeball and the anterior, one-sixth. These segments form two chambers, the larger containing a gela- tinous material, the vitreous humor, and the smaller, the aqueous humor. Figure 6.—Cross section of eye. c. The eye has three coats, a thick outer protective one which is continuous with the clear cornea in front, but otherwise is thick and white; a middle coat which contains blood vessels, a small muscle, and in front the iris; and an inner coat which contains the end organs of sight of the optic nerve. This inner coat is called the retina. d. The lens is placed right behind the pupil, being held in place by the ciliary muscle. e. If the eye is compared with a camera it will be seen that rays of light, entering the front of the eye through the pupil, pass through the lens and are registered on the retina, which corresponds to the film. Now in taking pictures with a camera the operator has to regu- late his light by means of a stop or diaphragm. This is done in the 28 TM 8-220 SOLDIER S HANDBOOK 56-57 eye by the iris which produces a small aperture in bright light and a larger one in dull light. In a camera the lens is moved away from or toward the film in- order that the light rays from the object to be photographed will fall on the film. This focus is changed depending upon the distance of the object from the camera. In the eye the focus is not changed by shortening or lengthening the box, but by contraction and relaxation of the ciliary muscle the lens is made thicker or thinner as required. 57. Vision .—a. The first phase in vision, insofar as the eye is concerned, is the formation on the retina of an image of a luminous object. The image is formed by the refractive actions of the cornea, aqueous humor, crystalline lens, and vitreous body. These structures are colorless and transparent. Their refractive indices are greater than that of air. The cornea and aqueous humor form a concavo-con- vex lens. The crystalline lens is bi-con vex, the curvatures of its sur- faces different and changeable. The amount of light admitted to the eye is controlled by the action of the lids and of the iris. The eyes are directed toward an object being viewed by movement of the head and of the eyeballs themselves. The extrinsic muscles of the eye act to keep the principal axes of the two eyes parallel, convergent, or divergent as required. The combined effect of the refractive structures of the eye may be considered as that of a bi-convex lens, the posterior focal plane of which lies in the retina. Images of external objects are formed on the retina stimulating the sensory cells thereof. The sensation is conveyed to the visual tracts of the brain where perception takes place. Although the image formed on the retina is inverted this gives rise to no confusion as we have learned by experience to make proper interpretation of the sensation. 6. The production of a clear, distinct image on the retina is de- pendent, in the normal eye, upon the distance of the object from the optical center of the refractive system. When this distance is greater than 20 feet all light rays from each of the innumerable luminous points of the object are practically parallel and will be focused properly. As the distance decreases the rays will be di- vergent hence will not be focused. This difficulty is overcome by a change in the focal distance of the refractive system, a change which is produced by alteration of the curvature of the surfaces of the crystalline lens. This power of accommodation, as it is desig- nated, is greatest in early life and decreases steadily with age. At 10 years of age the normal eye can form a distinct image of an object 2% inches from the eye; by the fortieth year this distance has increased to about 8% inches and by the fiftieth year to 15% TM 8-220 57-58 MEDICAL DEPARTMENT inches. Between the fortieth and fiftieth years, therefore, most people find it necessary to use convex lenses for near vision. c. In the normal eye the optical center of the refractive system is 15.5 millimeters from the retina. In many individuals the distance is either greater or less than this. When such is the case a dis- tinct image is not formed on the retina. In the myopic (short sighted) eye the antero-posterior diameter of the eyeball is greater than normal, or the curvature of the cornea, or lens, too great. Lengthening of the eyeball is the more common case. Rays of light are focused before reaching the retina and the retinal image is indistinct as a consequence. Myopia may be congenital or ac- quired; usually it is acquired. The defect may be produced by the increase in tension within the eyeball which results when the eyes are much converged, as for example, in reading with the book too near the eyes, a thing which is often done when the illumina- tion is poor. If the fibrous coat of the eyeball be weak the increased tension tends to produce elongation of the antero-posterior diameter. d. In the hypermetropic (far sighted) eye the focal point of the refractive system is beyond the retina and the retinal image is diffuse. The condition may be due to lessened curvature of the cornea or lens but is generally the result of a diminished antero- posterior diameter of the eye-ball. In most instances the defect is congenital. e. Astigmatism is a common optical defect. In the so-called nor- mal eye the refractive surfaces are sections of true spheres; all the meridians Of the cornea are of equal curvature, the same being true of the anterior and posterior surfaces of the crystalline lens. In this event refraction is equal at all meridians. But if there is variation in the meridional cuivature of any of the surfaces it can be seen refraction will be unequal, producing inequalities of the focal lengths in different planes. This is the case in astigmatism. 58. Ear.—The ear consists of an external, a middle, and an inner ear. a. External ear.—The external ear is ovoid in shape, flattened, wider above than below, and presents several depressions and eminences. This organ collects the sound waves and directs them through the external auditory canal to the middle ear. The external auditory canal is a tube about an inch long, slightly curved and lined with skin containing a few hairs. In the skin of the canal are a few glands which secrete a waxy substance which, together with the hairs, serves to prevent the entrance of foreign particles. The canal ends with the eardrum which separates it from the middle ear. 30 TM 8-220 SOLDIER S HANDBOOK 58-60 h. Middle ear.—The middle ear is a small, irregular bony cavity in the temporal bone. The eardrum separates it from the external ear. A thin bony wall in which are located two small openings separates it from the inner ear. Stretched across the cavity of the middle ear from the eardrum to one of the small openings to the inner ear are three small movable bones called the malleus or hammer, the incus or anvil, and the stapes or stirrup. The Eustachian or auditory tube connects the cavity of the middle ear with the throat. Generally this tube is closed by the tissues of the throat. On swallowing it is opened, allowing air to enter the ear, thereby maintaining an equality of air pressure between the inside and outside of the ear. c. Interned ear.—The internal ear consists of two complicated structures, the spiral-shaped organ of hearing called the cochlea and the semicircular canals. 59. Mechanism of hearing.—ln hearing, the sound waves are collected by the external ear and passed through the ear canal to the eardrum. These impulses are transmitted across the middle ear by the three small bones to the inner ear. Impulses received by the inner ear set in motion a fluid material filling the hearing organ proper, the cochlea. The sensory nerve cells for hearing are lo- cated in the cochlea. These cells are stimulated by the vibration of the fluid, thus giving rise to sensations which are conducted to the brain by the auditory nerve. The semicircular canals are concerned with the sense of equilibrium. 60. Male genital system.—a. The testicle is the reproductive organ of the male; however, the vas deferens, seminal vesicles, prostate gland, and penis are considered as accessory organs of reproduction. b. The testicles are two ovoid glands which lie in a pouch of skin called the scrotum. They are covered with a thin membrane which doubles back on itself to line the scrotum. Before birth the testicles develop in the abdominal cavity and descend into the scrotum, usually, just before birth. The passageway closes up in most cases but some- times remains open or at least weak so that the intestine may descend along it causing a hernia or rupture. c. The testicles have two important functions, the first being the formation of the male cells or spermatozoa and the secretion of a sub- stance necessary for the development of sexual characteristics in the male. d. When the spermatozoa are formed they pass into a long con- voluted tubule on the back of the testicle called the epididymis. This TM 8-320 60 MEDICAL DEPARTMENT tube measures about 20 feet in length but is coiled up so that it takes up but little space. The tube of the epididymis is continued in a more or less direct manner as the vas deferens to a membranous pouch (one on each side) lying between the base of the bladder and the rectum. Figure 7.—Male genital system. These are called the seminal vesicles. The seminal vesicles act as a reservoir for the spermatozoa and discharge them through small ducts into the back part of the urethra. At the same place where these ducts empty the prostate gland empties a secretion which is added to the 32 TM 8-220 SOLDIER S HANDBOOK 60-62 spermatozoa. The prostate gland is shaped somewhat like a chest- nut and surrounds the urethra just as it leaves the bladder. Section II DENTAL Paragraph Mouth 61 Teeth 62 61. Mouth.—a. The mouth may be defined as the cavity at the beginning of the digestive tract. With its contents, it is the organ of chewing, taste, and speech. The mouth cavity is lined by mucous membrane containing many mucous glands which pour their con- tents, saliva, into the mouth. It is divided into two portions—the vestibule, a narrow, slit-like space which lies between the lips and cheeks anteriorly and laterally, and the dental arch posteriorly and medially, and the mouth ccwity proper, the space within the dental arches. The mouth cavity proper is open posteriorly and communi- cates With the phamyx by a constricted aperture, called the isthmus facium. Its roof is formed by the hard and soft palates, while its floor is the mylohyoid and geniohyoid muscles covered by mucous membrane on which rests the tongue. The side walls and front are formed by the alveolar processes and the teeth of the upper and lower jaws. h. Opening into the mouth cavity are the ducts of the three paired salivary glands discharging their secretion, the saliva. Sten- son's duct, from the parotid gland, opens into the vestibule opposite the upper second molar tooth. Wharton's duct, from the svb- maxillary gland, and the ducts of Rivinus, from the sublingual gland, open into the floor of the mouth anteriorly in the sublingual space beneath the tip of the tongue. c. The tongue is a highly muscular organ, covered by mucous membrane, resting on the floor of the mouth cavity proper, and to which it is attached on its under surface by a fold of this membrane called the frenum. On the surface of the tongue are seen several varieties of papillae, which give to the tongue its characteristic rough appearance. The tongue contains the special organs of taste, is an important organ of speech, and aids in the process of chewing and swallowing food. 62. Teeth.—a. The teeth of man make their appearance in two sets or series. The first, having only temporary usage (the last of them disappearing about the twelfth year), is known as the deciduous, temporary, or milk teeth; the second set, having to serve for the 33 TM 8-220 62 MEDICAL DEPARTMENT remaining life period, is known as the permanent teeth. The deciduous teeth number 20 in all, and the permanent teeth number 32 when complete. Both sets of teeth are similarly arranged, in the form of two arches, half of their number (10 for the deciduous, and 16 for the permanent) being arranged in an upper arch and the other half in an opposite lower arch. b. The bones within which the teeth are set are known respectively as the superior maxilla, for the upper jawbone, and the inferior maxilla or mandible for the lower jawbone. An imaginary, vertical, central line dividing the body into right and left, known as the median line, divides the teeth into the same number and kind on both right and left sides. The permanent teeth are named as follows, starting from the median line: Tooth Name Tooth Name lst_ Central incisor. Lateral incisor. Cuspid. First bicuspid. 5th Second bicuspid. First molar. Second molar. Third molar. 2d 6th 3d 7th 4th 8th c. In the Army, for the, purpose of convenience, uniformity, and briefness of records, the teeth are numbered from 1 to 16, right and left, beginning with the upper central incisors. Thus, the upper left central incisor would be designated as LI, the upper left third molar as LB, the lower left central incisor as L 9, the lower left third molar as Ll6, and similarly for the right side. See figure 8. d. Grouped collectively, the incisors and cuspids are referred to as the anterior teeth, and the bicuspids and,molars as the posterior teeth. Certain other terms used in describing the teeth with which one should become familiar are— (l) Labial surface.—That surface of the incisors and cuspids which lies next to the lips. (2) Buccal surface.—That surface of the bicuspids and molars presenting toward the cheeks. (3) Facial surface.—A term used to designate the side of a tooth next to the lips or cheeks and may be applied to either an anterior or a posterior tooth. (4) Lingual surface.—That surface of a tooth toward the tongue. (5) Proximal surface.—That surface which adjoins the next tooth. TM 8-220 SOLDIER’S HANDBOOK 62 (6) Mesial surface.—That proximal surface nearest the median line of the arch, that is, a line drawn between the central incisors. (7) Distal surface.—That proximal surface that is farthest away from the median line. (8) Occlusal surface.—That surface of a bicuspid or molar tooth that makes contact with a tooth of the opposite jaw when the mouth is closed. (9) Incisal surface.—The cutting edge of the incisors and cuspids. e. A tooth is divided into two main parts, the crown and root. The crown is that portion which projects above the gum and is the chewing part of a tooth. The remaining part, or root, is firmly embedded within the bony structure of the jawbone, and so de- signed as to withstand the stresses of chewing. (See figs. 9 and 10.) The end of the root is called the apex and through the opening in it the nerve and blood supply enter the tooth. The incisors, cuspids, and bicuspids (with the exception of the upper first bicuspid which may have two roots) have only one root, while the molar teeth have from two to three roots. At the junction of the crown and root of the tooth is found a constriction in greater or less degree, which is known as the neck or cervix. Occupying the central portion of the crown and root is the pulp cavity, containing the dental pulp. This cavity is divided into two parts—that in the crown, known as the pulp chamber, and that in the root, known as the pulp canal. f. The alveolar process is that portion of the maxilla and mandible formed for the reception and support of the roots of the teeth. When a tooth is removed from its process an opening is left that resembles in outline the shape of the root. This cavity or socket is called an alveolus. The alveolar process is composed of an inner and an outer plate of compact bone. Between these two plates the bone is less compact, being of a spongy or cancellous nature. The inner plate of compact bone approximates the roots of the teeth and is called the peridental lamella. That portion of the alveolar proc- ess which lies in the bifurcation of the roots of multirooted teeth or between the roots of two adjacent teeth is called the septum. Sur- rounding the root and separating it from the bony wall of the socket is a layer of fibrous connective tissue known as the pei'identait mem- brane, which has the important function of binding the tooth to the surrounding bone. Covering the alveolar process and investing the necks of the teeth is a firm tissue called the gingiva, or gum. (See fig. 10.) g. In structure, a tooth is composed of four tissues, the enamel, dentin, cementum, and the dental pulp. 35 TM 8-220 62 MEDICAL DEPARTMENT (1) Enamel.—Enamel is the hard, calcified, glistening substance which covers the crown of a tooth. It is thickest at the biting surfaces of the teeth, where it is most required to resist the stress of mastication, and gradually thins out as it approaches the neck, where it is, in most instances, slightly overlapped by the cementum. The enamel is the hardest tissue of the body and is composed of a series of prismatic rods held together by a cementing substance which, like the rods, is composed chiefly of inorganic salts. UPPER TEETH Right Left LOWER TEETH Right Left Figure 8.—Numerical designation of permanent teeth as used in the United States Army. (2) Dentin.—Dentin is the hard, calcified, yellowish substance that makes up the mass of the tooth, giving to the tooth its general form. The dentin matrix is highly resilient and tough and gives strength to the tooth. Extending throughout the matrix and radiating from the pulp cavity are minute tubules, containing the dentinal fibrils which are protoplasmic extensions from the outermost layers of cells of the dental pulp. In the center of the dentin, extending the whole length of the root and into the crown of the tooth, is the pulp cavity. (3) Cementum.—Cementum is the calcified tissue covering the root portion of the tooth, which closely resembles bone in structure. It is arranged in concentric layers around the tooth root varying in thick- ness according to the position on the root, being thinnest at the neck and thickest at the apex. The cementum gives attachment to the fibres of the peridental membrane holding the tooth firmly in its socket. 36 TM 8-220 SOLDIER’S HANDBOOK 62 (4) Dental pulp.—The dental pulp, often called the nerve on ac- count of its sensitiveness, occupies the central cavity or pulp chamber and canal of a tooth. It is composed of embryonic connective tissue, Figure 9.—Occlusion of the teeth and their position in the jawbones. rich in blood vessels and nerves. Lying along the outer border of the pulp in contact with the dentin wall is a layer of specialized connective cells, the odontoblasts, which have the important function of forming 37 TM 8-220 62 MEDICAL DEPARTMENT dentin. Protoplasmic processes from these cells pass into the dentinal tubules and have the property of transferring sensations of pain to the nerve fibrils within the pulp. Blood vessels and nerves enter the Fiourh 10.—Diagrammatic drawing of tooth and supporting structurea root canal of a tooth through openings in the apex known as the apical foramina. The walls of the blood vessels are extremely thin, render- ing the pulp tissue highly susceptible to inflammation. Section 111 VETERINARY Paragraph General 63 Skeletal system 64 Bones 65 Skeletons of horse and man 66 Bones of skull 67 Vertebral or spinal column 68 Bony thorax 69 38 SOLDIER S HANDBOOK TXL 8-220 3 Paragraph Ribs 70 Sternum 71 Bones of foreleg 72 Os coxae or hip bone 73 Bones of hind leg 74 Joint or articulation 75 Joints of foreleg 76 Joints of hind leg 77 Suspensory ligaments and check ligaments 78 Plantar ligament 79 Ligamentum nuchae 80 Muscular system . 81 Structure and action of muscles 82 Tendon sheaths and bursae 83 Muscles of neck and attachment of foreleg : 84 Muscles of back, loin, and croup 85 Muscles and tendons of lower leg 86 Fatigue of muscles 87 Digestive system ' 88 Mouth 89 Pharynx 90 Esophagus 91 Stomach 92 Small intestine 93 Large intestine 94 Organs of respiration 95 Physiology of respiration 96 Organs of circulation 97 Physiology of circulation 98 Blood 99 Nervous system 100 Skin 101 Hair 102 Parts of foot 103 Bones of pastern and foot 104 Elastic structures of foot 105 Sensitive structures of foot 1 106 Hoof 107 Dissipation of concussion 108 Blood supply 109 Moisture 110 External regions of horse 111 63. General.—The intelligent operation and care of any mechanism is based on a good working knowledge of its general structure and normal functions. The animal body may be considered as a com- plex machine of many parts, with each of these various parts normally functioning in a more or less definite manner. The sci- ence which treats of the form and structure of the animal body is 39 TM 8-220 63-65 MEDICAL DEPARTMENT known as anatomy. The science which treats of the normal func- tioning of the animal body is known as physiology. It is quite essential that the study of animal management include a basic knowledge of the anatomy and physiology of the horse, in order that the student may more intelligently recognize the reasons upon which the fundamental principles of animal management are based. In this text the study of anatomy and physiology will be correlated as much as possible and limited to those parts of greatest essential in- terest. The body of the horse is in general structure quite like the body of man. Their chief differences are in the relative size and relationship of the various parts, and for these reasons the various structures of the horse will in many instances be compared with the similar parts of the human body. The body of the horse, like that of man, is made up of a skeletal system, a muscular system, a di- gestive system, a respiratory system, a circulatory system, a nervous system, a urinary system, a reproductive system, and an outer covering of skin and hair. 64. Skeletal system.—The skeletal system includes the bones and the ligaments which bind bones together to form joints. The skeletal system gives the body form and rigidity and forms cavities for the protection of vital organs. Bones and joints together form a com- plex system of levers and pulleys which, combined with the muscular system, gives the body the power of motion. The relative size and relationship of position of the bones determines the real form or conformation of the horse and his efficiency for any particular work. The trunk or axial skeleton consists of the skull, spinal or vertebral column, ribs, and breast bones. The limbs or appendicular skeleton support the body and furnish the levers of propulsion. 65. Bones.—a. The skeleton of the horse is made up of about 206 bones. In their living state bones are composed of about one part of organic matter and two parts of inorganic matter. The latter, which is mineral matter, is largely lime salts. The bones, as you see them in the mounted skeleton, have been freed of organic matter and are white and brittle, but living bone is about twice as strong as a green oak stick of the same size. Bones, according to their shape, are classified as long, short, flat, and irregular. (1) Long bones are found in the limbs, where they support the body weight and act as the levers of propulsion. (2) Short bones occur chiefly in the knee and hock, where they function in the dissipation of concussion. (3) Flat bones, such as the ribs, scapula, and some of the bones of the skull, help to inclose cavities containing vital organs. 40 TM 8-220 SOLDIER S HANDBOOK 65-67 (4) Irregular bones are such bones as the vertebrae and some bones of the skull. b. All bones are covered with a thin, tough membrane called periosteum except at points of articulation where they are covered with cartilage. (1) The periosteum is closely attached to the bone. It covers and protects the bone and influences the growth of the bone to a certain extent. This latter function is of particular interest, for we know that injury to this membrane often results in an abnormal bone growth called an exostosis, occurring at the point of injury. Bone growths, such as splints, spavins, and ringbones, are the frequent result of some form of injury to the periosteum. The bone is in part nourished by blood vessels in the periosteum and there are many nerve endings in this membrane. (2) The articular or joint surfaces of bones are covered with a dense, very smooth, bluish-colored substance called cartilage. The cartilage diminishes the effects of concussion and provides a smooth joint surface offering a minimum of frictional resistance to move- ment. 66. Skeletons of horse and man.—See figure 11. The same let- ters and figures indicate corresponding parts in each skeleton. 67. Bones of skull.—There are 34 bones in the skull and it is divided into two parts, the cranium and the face. a. The bones of the cranium are all flat or irregular bones and surround the cranial cavity which contains the brain. This cavity is relatively small considering the size of the animal. The bones join each other in immovable joints. The bone forming what is known as the poll has an articulating surface where the head is jointed to the vertebral or spinal column. Together with the bones of the face, the cranial bones form the orbital and nasal cavities. b. The bones of the face form the framework of the mouth and nasal cavities and include the more important bones of the upper and lower jaws, known as the maxillae and mandible respectively. (1) Each maxilla has six irregular cavities for the reception of the cheek or molar teeth. From the maxillae forward the face be- comes narrower and terminates in the premaxilla, which contains cavities for the six upper incisor teeth. Inclosed in each maxilla is a cavity known as the maxillary sinus, which opens into the nasal passages. This sinus contains the roots of the three back molar teeth and at times becomes infected, due to diseased teeth. (2) The mandible, or lower jaw, is hinged to the cranium on either side by a freely movable joint in front of and below the base of the 41 Plot;UK 11 -Skeletons of horse and man. Hand bones of man. Finger bones of man. Foot bones of man. Toe bones of man. S. Shoulder Joint. E. Elbow joint. IT. Knee joint of horse, wrist Joint of man. H. Hip Joint. K. Stifle Joint of horse, knee Joint of man. A. Hock joint of horse, ankle joint of man. I. Skull. 2. Mandible or Jaw. 3. Atlas. 4. Axis. 5—9. Cervical vertebrae. 10—27. Thoracic vertebrae. 28—33. Lumbar vertebrae. 34—38. Sacral vertebrae. 39—56. Coccygeal vertebrae. 57. Ribs. 58. Scapula or shoulder blade. 59. Humerus. 60. Ulna. 61. Radius. 62. Small metacarpal or splint bone. ) 63. Large metacarpal or cannon bone. j 64. First phalanx (long pastern bone). 1 65. Second phalanx (short pastern bone). 66. Third phalanx (coffin bone). 74. First phalanx (long pastern bone). 75. Second phalanx (short pastern bone). 76. Third phalanx (coffin bone). 72. Small metatarsal or splint bone. 73. Large metatarsal or cannon bone. 67. Os coxae or hip bone. 68. Femur. 69. Patella (kneecap of man). 70. Tibia. 71. Fibula. 42 TM 8-220 SOLDIER’S HANDBOOK 67-68 ear. At its front extremity it has cavities for the six lower incisors. Back of the incisors is a space between the incisors and the six lower molars in each side of the mandible known as the interdental space. Injuries to periosteum or possible fracture of the mandible may occur in the interdental space due to rough usage of the bit. The space between the branches of the lower jaw is occupied by the tongue and important salivary and lymph glands. 68. Vertebral or spinal column.—The vertebral or spinal column may be regarded as the basis of the skeleton from which all other parts originate. It is composed of irregularly shaped bones bound together with ligaments and cartilage and forms a column of bones from the base of the skull to the tip of the tail. Through the length of this column is an elongated cavity called the spinal canal that contains the spinal cord, which is the main trunk-line of nerves coming from the brain lying in the cranial cavity. Through this more or less flexible column of bones the powerful impetus of pro- pulsion originating in the hind legs is transmitted to the forequarters of the animal and indirectly it bears the weight of the rider and his equipment. The bones of the vertebral column are divided into five regions as follows: a. The cervical, or neck, region contains seven cervical vertebrae. The first of these, the atlas, is jointed to the cranium by a hinge-like joint permitting only extension and flexion of the head on the heck. The next cervical vertebra is known as the axis and is so jointed to the atlas that it permits of rotation of the head and atlas on the remainder of the neck. The remaining five cervical vertebrae have no special names. The column of bones in this region is arranged, when viewed from the side, in an S-shaped curve. Lengthening and shortening of the neck is brought about by lessening or increasing this curvature. The cervical region is the most flexible part of the vertebral column and from the viewpoint of the student of equita- tion the possible movements of the head and neck are of great importance. h. The thoracic region contains 18 thoracic vertebrae. These ver- tebrae form in part the upper wall of the chest cavity. Each verte- bra has on either side an articulating surface for jointing to its corresponding pair of ribs. Each vertebra has on its upper surface a spine or process of bone called the spinous process. These processes vary in length. They increase rapidly in length from the first to the fourth and fifth, which are the longest, and form the summit of the withers, and then decrease in length. Movement in this part of the vertebral column is somewhat limited. 43 TM 8-220 68-72 MEDICAL DEPARTMENT c. The lumbar region contains six lumbar vertebrae, sometimes five, especially in the Arab horse. This part of the column forms the framework or the loin. Movement in this part of the vertebral column is much greater than in the thoracic portion. d. The sacral region contains five sacral vertebrae. These five bones are fused or grown together and may be considered as one bone, the sacrum, the highest point of which forms the summit of the croup. The sacrum is jointed very securely to the hip bones on either side and through these joints the propulsive impulses from the hind legs are transmitted to the vertebral column. e. The coccygeal region contains from 16 to 21 coccygeal vertebrae which form the bony column of the tail. The spinal canal is prac- tically absent in this part of the vertebral column. The vertebral formula of the horse is C7TIBL6SSCyIS-21. The vertebral formula of man is C7TI2LSS6Cy4. 69. Bony thorax (chest).—The bony thorax is a large cavity formed by the thoracic vertebrae above, the ribs on the sides, and the sternum (breastbone) forming the floor. This cavity contains the heart, lungs, large blood vessels and nerves, and part of the trachea and oesophagus. Depth of this cavity with moderate width is desirable. 70. Bibs.—The horse has 18 pairs of ribs, all of which are jointed to the thoracic vertebrae at their upper ends. The lower ends of the first eight pairs, called true or sternal ribs, are jointed by means of cartilage to the sternum or breastbone. The last ten pairs, called asternal or false ribs, are at their lower ends continued by extensions of cartilage which are bound to each other by elastic tissue. The shape and length of the ribs determine the contour of the chest. The ribs form the direct skeletal support of the saddle. 71. Sternum.—The sternum, or breastbone, is a canoe-shaped bone consisting of seven or eight bony segments connected by intervening cartilage. The sternum forms the floor of the thorax and the front end of the bone forms the bony prominence in the midline of the breast. 72. Bones of foreleg.—The bones of the foreleg named from above downward are the scapula, humerus, radius, and uVna, carpal bones, three metacarpal bones, -first phalanx, second phalanx, third phalanx, and the proximal and distal (navicular) sesamoid bones. a. The scapula, or shoulder blade, is a triangular flat bone in the region of the shoulder and lies on the side of the thorax. Along its upper border, or the base of the triangle, is attached a thin, flat, and 44 TM 8-220 SOLDIER'S HANDBOOK 72 flexible cartilagenous extension. When the leg is extended to the front the edge of this cartilage may slip under the front of the bar of the saddle without injury to the shoulder blade. The direction of this bone is sloping downward and forward. If the direction of this bone approaches vertical the shoulder is said to be straight or upright, which is not favorable for length and freedom of the for- ward movement of the foreleg. The scapula is attached to the thorax only by muscles, there being no bony union with the sternum, ribs, or spinal column. In man the scapula is jointed to the sternum through the clavicle or collarbone, a bone that is entirely absent in the skeleton of the horse. The lower end of the scapula is jointed to the humerus. b. The humerus is the bone of the arm and extends downward and backward from the shoulder joint to the elbow. The humerus is surrounded with heavy muscles and is attached by muscles to the wall of the thorax. Because of its muscular protection and position, this bone is not often injured. In man the humerus or arm bone is much freer of the body and has a much greater range of movement in the shoulder joint. c. The radius is the bone of the forearm and with the ulna and humerus forms the elbow joint. The ulna is a short bone which is fused to the upper part of the radius and also projects above the end of the radius to form the point of the elbow. In man the ulna is comparatively longer and extends, on the little finger side, with the radius to the wrist joint. The long axis of the radius should be vertical. d. The carpal bones, or knee bones, correspond to the wrist bones of man. There are seven or eight carpal bones arranged in two rows. The top row articulates with the lower end of the radius and most of the movement of the knee joint is confined to this articulation. The top and bottom rows articulate with each other and the bottom row also with the upper ends of the metacarpal bones. A great deal of concussion transmitted up the bony column from below is absorbed and dissipated by the carpal bones. e. The horse has three metacarpal bones. The large middle meta- carpal bone (cannon bone) extends from the knee to the fetlock and is sometimes known as the third metacarpal. Because of the great strength of this bone it is seldom fractured although it is one of the most exposed bones of the skeleton. In his early evolutionary state the horse was a fivetoed animal, but during his development to his present form he has lost the two inner and two outer toes and only the two splint bones or small metacarpals persist as vestigial remains of 45 TM 8-220 72-73 MEDICAL DEPARTMENT the original second and fourth metacarpals. These small metacarpals are located on the internal and external posterior borders of the large metacarpal. Their upper ends articulate with the lower row of car- pal bones. As they are only about three-fourths as long as the large metacarpal, they have no direct support at their lower end but where they are in contact with the large metacarpal they are closely bound to it by the strong interosseous ligament. Strains of this ligament result in the condition known as splints. After a horse is about 7 years of age this ligament begins to ossify and, in old animals, the splint bones may be firmly fused to the cannon bone. The long axis of the cannon bone should be vertical. /. The -first phalanx, or long pastern bone, corresponds to the first bone of the long finger of man. g. The second, phalanx, or short pastern bone, corresponds to the second bone of the long finger of man. h. The third phalanx, or coffin bone, corresponds to the bone in the tip of the finger and is completely inclosed in the hoof which is analagous with the fingernail of man. The general shape of the coffin bone is very similar to the shape of the hoof. The three phalanges have their long axis in prolongation of each other and their direction is downward and forward so that the inclosed angle with horizontal in the foreleg is about 50°. If the phalangeal column of bones approach the vertical, the horse is said to have upright or stumpy pasterns, and in such a case greater concussion is imparted directly to the bony column. Upright pasterns are often associated with a straight or upright shoulder. When the slope of the region is greater than average an undue amount of strain is thrown on the flexor tendons and suspensory ligament. i. The sesamoids are two pyramidal-shaped bones that form a part of the fetlock joint and articulate with the posterior part of the lower end of the cannon bone. They lie imbedded in ligaments and cartilage and form a bearing surface over which the flexor tendons lie. j. The distal sesamoid, or navicular bone, is situated back of the coffin bone and articulates with the lower end of the second phalanx. The deep flexor tendon plays over its lower surface. This point is the seat of navicular disease. 73. Os coxae or hip bone.—The os coxae, or hip bone, is a paired bone and each unites with its fellow of the opposite side at the low- est point to form the floor of the pelvic cavity. Each hip bone is firmly jointed to the sacrum. This girdle of bone is called the pelvic girdle and incloses the pelvic cavity. Each hip bone bears on its side a cavity where the femur, or first bone of the hind leg, is jointed 46 SOLDIER’S HANDBOOK TM 8-220 73-74 to it. The outer front angle of the hip bone forms the point of the hip, or haunch, which is often injured. The inner front angle, to- gether with the sacrum, forms the point or summit of the croup. The back angle of the hip bone forms the point of the buttock. A long and flat (approaching horizontal) pelvis is most suitable for speed and freedom of movement of the hind legs. 74. Bones of hind leg.—The bones of the hind leg named from above downward are the femur, 'patella, tibia and fibula, six or seven tarsal bones or bones of the hock, large metatarsal (cannon bone), two small metatarsals or splint bones, first phalanx, second phalanx, third phalanx, and the proximal and distal (navicular) sesamoid bones. a. The femur, or bone of the thigh, corresponds to the thigh bone of man. At its upper end this bone articulates with the hip bone in the hip joint and extends downward, forward, and slightly outward to the stifle joint. Viewed from the side, the inclosed angle between the long axis of this bone and horizontal is about 80°. b. The patella is a small bone lying on the front of the stifle joint and articulating with the lower end of the femur. It corresponds to the kneecap of man. c. The tibia is the second long bone of the hind leg and lies in the region known as the leg or gaskin. It extends from the stifle joint downward and backward to the hock joint, forming an inclosed angle with horizontal of about 65° to 70°. A position approaching vertical is more favorable for speed of movement than one of con- siderable slope. This bone along its inner surface has but a thin protective covering of skin and other tissue, and because of its ex- posed position is the most frequently fractured bone in the horse’s skeleton. This bone corresponds to the shin bone of man. The f.bida in the horse is a small rudimentary bone about two-thirds as long as the tibia and is attached to the upper and outer surface of the tibia. In man this bone, as well as the tibia, extends from the knee to the ankle. d. The hock or tarsas of the horse, like the ankle of man, contains six or seven tarsal bones arranged in a manner similar to the carpal bones of the knee. The largest of these extends upward from the back of the joint and forms the bony prominence known as the point of the hock, and serves as a point of attachment of the powerful tendon of Achilles. e. The metatarsal bones correspond to the metacarpal bones of the foreleg. The hind cannon extends downward and slightly forward 47 TM 8-220 74-75 MEDICAL DEPARTMENT at an angle of about 87°. The hind cannon is about one-sixth longer than the fore cannon, and is also more nearly round. /. The phalanges and sesamaids of the hind leg are very similar to those of the foreleg, except that the phalangeal axis is inclined to be slightly more upright. 75. Joint or articulation.—a. Classification.—Joints are classi- fied according to structure and mobility into three types. (1) Immovable, in which the opposed surfaces of bone are directly united by connective tissue or fused bone, permitting no movement, such as between the bones of the cranium. (2) Slightly movable, where a pad of cartilage, adherent to both bones, is interposed between the bones and a slight amount of move- ment is possible due to the elasticity of the cartilage. Many of the joints between the vertebrae are of this character. (3) Freely movable, when a joint cavity exists between the opposed surfaces. The joints of the legs are examples of this type. b. Structure.—The freely movable joints are the truest examples of joints. The ends of the bones entering into a freely movable joint are held in opposition to each other by strong bands of tissue called ligaments, which pass from one bone to the other. Ligaments pos- sess but a slight degree of elasticity and have a limited blood supply, which accounts for the fact that they heal very slowly and often im- perfectly following an injury. In freely movable joints the ends of the bones are covered with smooth cartilage, which absorbs concus- sion and provides a smoother bearing for the ends of the bones. In freely movable joints the entire joint is inclosed in a fibrous sac, called the joint capsule, which assists the ligaments in holding the bones in position. Its inner surface is lined with a thin secreting membrane called the synovial membrane, which secretes a fluid called synovia or “joint water.” Synovia is a clear and slightly yellowish fluid of much the appearance and consistency of the white of a watery egg. This fluid serves to lubricate the joint in the same way that oil lubri- cates a bearing. Normally the amount secreted is limited to only the actual amount necessary to prevent friction in the joint. In joints that are inflamed as a result of undue concussion or from other causes, the amount secreted is increased and results in a distention of the joint capsule. Where the capsule is not closely bound to the joint by the ligaments, the distended capsule will pouch out under the skin as a soft swelling. A bog spavin is an example, as are also certain windgalls. Wounds over a joint are always likely to be dangerous for they may have opened the joint cavity. When the joint cavity is opened the synovia flows from the wound and the synovial membrane 48 SOLDIER S HANDBOOK TNL 8-220 75-78 is stimulated by the loss of the synovia to secrete more. This synovia pouring over the wound surface retards healing and the joint cavity becomes readily infected. An open joint is usually very painful and in a great many instances results in the permanent disability of the animal, even with the best possible care. The hock joint is most frequently opened by accidental injury. 76. Joints of foreleg.—The joints of the foreleg named in order from above downward are the shoulder, formed by the scapula and humerus; the elbow, formed by the humerus, radius and ulna; the knee, formed by the radius, carpal bones, and the three metacarpal bones; the fetlock, formed by the cannon bone or large metacarpal, two sesamoid bones, and the first phalanx or long pastern bone; the pastern, formed by the first and second phalanges (long and short pastern bones); and the coffin, formed by the second and third phalanges (short pastern and coffin bones) and the navicular bone. 77. Joints of hind leg.—The joints of the hind leg named in order from above downward are the hip, formed by the hip bone and femur; the stifle, formed by the femur, patella, and tibia; and the hock, formed by the tibia, the tarsal or hock bones, and the three metatarsal bones. The remaining joints of the hind legs are named and formed the same as the corresponding joints of the foreleg. 78. Suspensory ligaments and check ligaments.—ln addition to the ligaments which form a part of the joints, there are certain other important body ligaments. a. The suspensory ligament of the foreleg is a very strong, flat ligament arising from the back of the knee and upper end of the cannon bone and passing down the back of the leg, lying in the groove between the splint bones. A short distance above the fetlock the ligament divides into two diverging rounded branches, each branch attaching to the upper and outer part of its corresponding sesamoid bone and then passing downward and forward around the front of the long pastern bone to join its fellow in a point of union with the extensor tendon which attaches to the front of the coffin bone. From the lower part of the sesamoids, bands of ligament pass downward and attach to the back of the long and short pastern bones. From its nature of attachment, it is readily seen that the suspensory liga- ment is a remarkable sling-like or truss apparatus by which the fet- lock is supported, concussion diminished, and the phalangeal axis mechanically held in its sloping position. h. The check ligament is a short, strong ligament arising on the back of the upper end of the suspensory ligament, just below the 49 TM 8-220 78-82 MEDICAL DEPARTMENT knee, and passing downward and backward for a short distance to where it attaches to the deep -flexor tendon, which passes down the back of the leg to a point of attachment on the under surface of the coffin bone. When the muscle above is relaxed, it is easily seen that the check ligament by its action really functionally converts the part of the tendon below the check ligament into a ligament which assists the general action of the suspensory ligament. c. The suspensory ligament is considerably more , elastic than are the binding ligaments of joints and by its supporting springlike action it absorbs a great deal of concussion. This ligament is most frequently injured in horses that do a great deal of their work at the gallop. The suspensory ligament in the hind leg is very similar to that of the foreleg, but the check ligament is much less perfectly developed. 79. Plantar ligament.—The plantar ligament is a strong band of ligamentous tissue on the back of the hock bones. It extends from the point of the hock to the upper end of the cannon bone and, by its strong attachments to the small hock bones, braces the hock against the strong pull of the tendon of Achilles. It is of particular im- portance because it is sometimes injured, resulting in the unsoundness known as curb. 80. Ligamentum nuchae.—The ligamentum nuchae, or ligament of the neck, is a fan-shaped ligament of very elastic tissue ex- tending from the poll and upper surfaces of the cervical vertebrae backward to attach to the longest spines of the thoracic vertebrae (withers). It assists the muscles of the neck in maintaining the head and neck in position. It is of particular interest because the withers or poll is sometimes injured, resulting in the serious conditions of fistulous withers and poll evil. 81. Muscular system.—See paragraph 22. 82. Structure and action of muscles.—a. All voluntary muscles are composed of a contractile portion called the body or belly of the muscle and a noncontractile continuation called the tendon which is a modified continuation of one end of the body or contractile por- tion of the muscle. The contractile portion of the muscle is made up of many elongated muscle cells lying side by side lengthwise of the muscle, which when stimulated becomes shorter and thicker. The tendon of a muscle is in structure quite similar to that of a ligament and its function is to transmit the power of the muscle to some definite point of movement. The contractile portion has a large blood supply, but the blood supply of the denser tendons is rather limited. 50 TM 8-220 SOLDIER S HANDBOOK 82-84 b. The body of most muscles is attached to some bone and the point of attachment is called the origin, while the tendon may pass one or more joints and attach (insertion) to some other bone. c. For almost every muscle or group of muscles having a certain general action, there is another muscle or group of muscles whose action is the exact opposite. The most important examples are the extensor and flexor muscles of the legs. A muscle is an extensor when its action is to extend a joint and bring the bones into aline- ment. A muscle is a flexor when its action is to bend the joint. Some muscles, if their points of origin and insertion are separated by two or more joints, may act as a flexor of one joint and an extensor of another joint. Except to establish fixation and rigidity of a part, such opposed muscles do not act simultaneously in opposition to each other, but act successively. There are hundreds of muscles in the body and their actions are very complex, but in this text we will consider only the general action of the important muscle groups. 83. Tendon sheaths and bursae.—Many muscles, especially those of the legs, have long tendons which pass one or more joints and undergo changes of direction or pass over bony prominences before reaching their point of insertion. To avoid undue friction at these points and to allow the muscle to act most efficiently, nature has supplied tendon sheaths and tendon hursae at various points of fric- tion along the course of the tendon. A tendon sheath is a synovail sac through which a tendon passes. The inside of the sac secretes synovia and lubricates the tendon. A tendon hursae is a synovial sac which is interposed between the tendon and the surface over which it passes in change of direction. It serves the same purpose as a tendon sheath but differs from it in that the tendon is not surrounded by the synovial sac. These tendon sheaths and tendon bursae are found chiefly near joints. The synovial membrane and synovia secreted are the same as those found in joints. Due to chronic ir- ritation from hard work or as a result of injury, the amount of sy- novia secreted may be greatly increased and result in a distension of the sac characterized externally by a circumscribed puffy swell- ing. Such swellings are often seen above the fetlocks where they are called wind puffs or windgalls. While they seldom cause distinct lameness, they are evidence of a so-called “second-handed” condition and indicate that the horse probably is a little stiffened and shortened in his gaits. 84. Muscles of neck and attachment of foreleg.—a. We have learned from the study of the skeleton that the foreleg of the horse 51 TM 8-220 84-86 MEDICAL DEPARTMENT has no bony connection with the remainder of the skeleton. The foreleg is attached to the body by a very complex system of muscles which extend from the leg along the side of the neck to the poll, upward to the withers, backward along the sides of the chest, and back and under the chest to meet at the sternum. The fore part of the horse is really suspended between two uprights, the forelegs, and by this elastic muscular sling a very efficient shock-absorbing mecha- nism is provided. As the forelegs bear from 9 to 20 percent more of the body weight than do the hind legs, it is easy to understand the importance of this muscular attachment, especially in the riding horse. h. The long muscles that extend from the region of the shoulder to the sides of the neck and to the head are of special interest to the student of equitation, for the manner of the movement of the horse is profoundly influenced by their action. With the shoulders fixed these muscles by their action cause movement of the head and neck and, when the head and neck is fixed by opposing muscular action, these muscles act to advance the shoulder. With the head and neck extended, these muscles are most favorably placed for maximum extension of the shoulder and foreleg with a low and ex- tended action. A high head carriage with shortening of the neck is most favorable for maximum elevation of the shoulder and fore- leg, resulting in a higher and shortened stride. Much of the early training of the remount is directly aimed at gaining suppleness and control of the action of this group of muscles. 85. Muscles of back, loin, and croup.—The triangular space between the ribs, the transverse processes of the lumbar vertebrae, and the spines of the thoracic and lumbar vertebrae is filled with large muscles. The principal one of this group is the largest and longest muscle of the body, longissimus dorsi, extending from the posterior part of the loin along the back and down between the shoulder and thorax to the last cervical vertebrae. These muscles, one on each side, are used extensively when the horse elevates its hindquarters in kicking or when rearing. Acting singly, the muscles flex the vertebral column laterally. In the thoracic region, this muscular pad bears the weight of the saddle when the horse is rid- den and distributes the weight evenly to the supporting ribs. The croup and thighs are made up of groups of powerful muscles which are the chief sources of propelling power. 86. Muscles and tendons of lower leg.—a. The extensor mus- cles of the foreleg attach mainly to the humerus and radius and lie on the front of the forearm. 52 TM 8-220 SOLDIER’S HANDBOOK 86 (1) The common digital extensor originates on the lower end of the humerus and upper part of the radius. At the upper part of the knee the muscle continues as a tendon along the front of the knee, cannon, and pastern regions to its point of insertion on the upper end of the coffin bone. In the pastern region two branches of the suspensory ligament unite with the tendon. This muscle acts as extensor of all joints below the elbow but flexes the latter. This tendon is seldom injured. (2) The extensor of the knee is a strong muscle attached to the humerus and lying on the front of the forearm, having a short heavy tendon which passes over the knee and attaches to the upper end of the cannon bone. It extends the knee joint and flexes the elbow. The tendon passes through a tendon sheath extending from the middle of the knee to about 4 inches above the knee. This region is often bruised in jumping horses, resulting in a synovial distention of the sheath commonly called “jumping knee.” While unsightly, it seldom causes lameness. h. The flexor muscles of the foreleg lie on the back of the forearpa and like the extensors originate on the humerus, ulna, and radius. (1) The superficial digital flexor originates on the lower end of the humerus and its fleshy portion extends to the lower part of the forearm and from that point continues as a flattened tendon which passes down the back of the leg and below the fetlock divides into two branches which are inserted on either side of the upper end of the short pastern bone. This muscle flexes the knee, fetlock, and pastern. The tendon lies just under the skin on the back of the leg and just back of the deep flexor tendon. (2) The deep digital flexor originates with the superficial digital flexor. The body of the muscle lies on the back of the forearm and from just above the knee continues as the deep flexor tendon and passes down the back of the leg in front of the superficial flexor tendon, passes between the branches of the latter, and continues to its point of insertion on the under surface of the coffin bone. This muscle is the most powerful flexor of the foreleg. In the upper part of the cannon region, this tendon is joined by the check ligament (see par, 78). WTiere the tendon passes over the back of the sesamoid bones at the fetlock joint, it is inclosed in a tendon sheath. This sheath frequently becomes distended with synovia forming windgalls or wind puffs. This tendon also passes over a bursa where it glides over the navicular bone near the coffin joint, and injury to this bursa results in the condition known as nxwicular disease. TM 8-220 86-88 MEDICAL DEPARTMENT In the cannon region the two tendons described above appear to the eye as one large rounded tendon, but if the foot is raised and the structure examined with the fingers the separate tendons can be readily distinguished. These two muscles and their tendinous extensions, in addition to bringing about movements of the leg, act also as shock absorbing mechanisms. The strains to which they are subjected seldom injure the bodies or bellies of the muscles, but the tendons are not uncommonly injured by strain, particularly in the cannon region, and the resulting inflamed condition is known as tendinitis. Either or both tedons may be affected, the deep flexor most frequently. c. The general arrangement and action of the extensor and flexor tendons of the hind leg from the hock joint downward are almost identical with those of the foreleg. Tendinitis in the hind legs is uncommon because of the lesser amount of weight borne and con- cussion absorbed. Distention of the tendon sheath at and just above the fetlock often occurs, but the navicular bursa is rarely diseased. The navicular bursa of the hind leg, as in the foreleg, is sometimes opened by a nail’s penetrating from the under surface of the foot. 87. Fatigue of muscles.—-a. Fatigue of the muscles follows con- tinued work. This is due principally to the consumption of substances from which energy is derived and results in exhaustion. As soon as the accumulated waste products are removed by the blood and lymph, and a fresh supply of nutrition is brought to the muscles, a feeling of fitness again prevails. Hand-rubbing the legs of a horse is bene- ficial, because the blood and lymph vessels are stimulated to increased activity in the removal of waste products and cause the blood to cir- culate more freely. Fatigue may also be overcome, in part,, by pro- viding a feed of easily digested carbohydrates, which furnishes a maximum of energy. h. A green horse, that is, one not accustomed to steady work, fatigues much more easily than a hardened horse. This is due to the muscles of the former being softer and possibly carrying an excess of fat. It should be remembered that there is a limit to continued muscular effort, and that harmful fatigue can be avoided only by working the horse at a moderate rate in order to keep the proper balance between the products of muscular activity and the ability of the blood to remove its waste material. An animal should never be worked until exhausted, if for no reason other than that it is not economical. 88. Digestive system.—The digestive system is really a muscular tube passing through the body and having two external openings, the mouth and the anus. This tube has a total length of about 100 feet, looped on itself many times, dilated at intervals along its course, and 54 TM 8-220 SOLDIER’S HANDBOOK 88-89 provided with several accessory organs. The entire tube is lined with mucous membrane. Mucous membrane is a modified form of skin, and this close relationship between the lining of the digestive tube and the covering of the body explains why digestive disturbances are often reflected in skin disturbances. The digestive organs are the mouth, pharynx, esophagus, stomach, small intestine, large intestine, and rectum. (See fig. 12.) Figure 12.—Schematic diagram of digestive system (horse) (not drawn to constant scale). 89. Mouth.—The mouth extends from the lips to the pharynx. It is bound on the sides by the checks, above by the hard palate, and below by the tongue. Separating the mouth from the pharynx is the soft palate, a fleshy curtain suspended from the back part of the hard palate, which permits the passage of food and water from the mouth to the pharynx but prevents its passage in the opposite direction. The lips pick up loose feed and it is passed into the mouth by the action of the tongue. When the horse is grazing the feed is grasped with the incisor teeth. It is masticated or ground between the molar or cheek teeth and mixed with the saliva. The saliva is secreted into the mouth by the salivary glands, the largest of which is the parotid lying below the ear and back of the jaw. The horse is by nature a slow eater and requires from 15 to 20 minutes to eat a pound of hay and from 5 to 10 minutes to eat a pound of grain. Hay, when properly masticated, absorbs approximately four times its weight of saliva, and oats a little more than its weight. The saliva moistens and lubricates the mass for swallowing, and as a digestive juice acts on the starches and sugars. The ball of masticated feed, when ready for swallowing, is forced past the soft palate into the pharynx by the base of the tongue. Drinking is performed in the horse by drawing the tongue backward in the mouth, and thus using it as the piston of a suction pump. A horse 55 TM 8-220 89-92 MEDICAL DEPARTMENT usually swallows slightly less than one-half pint at each gulp, and the ears are drawn forward at each swallow and drop back during the interval between swallows. 90. Pharynx.—The pharynx is a short and somewhat funnel- shaped muscular tube between the mouth and esophagus and is also in part an air passage between the nasal cavities and the larynx. The muscular action of the pharynx forces the food into the esoph- agus. Food or water after entering the pharynx cannot return to the mouth because of the trap-like action of the soft palate and for the same reason a horse cannot breathe through the mouth. Food or water returned from the pharynx passes out through the nostrils. 91. Esophagus.—The esophagus is a muscular tube extending from the pharynx down the left side of the neck and through the thoracic cavity and diaphragm to the stomach. The swallow of food or water is forced down the esophagus to the stomach by a progres- sive wave of constriction of the circular muscles of the organ. In the horse this wave of constriction cannot move in the reverse direc- tion and vomiting is not possible. The return of food or water through the nostrils is almost a certain indication that the horse is choked and the esophagus is blocked by a mass of food. 92. Stomach.—The stomach is a U-shaped muscular sack which lies in the front part of the abdominal cavity and close to the dia- phragm. The esophageal and intestinal openings are close together and for this reason water passes rather quickly through the stomach and small intestine to the first of the large intestines, the caecum, sometimes known as the water gut. Considering the size of the animal and the amount of food consumed, the stomach of the horse is relatively very small. The horse in his natural state was a slow but more or less constant eater and did not require a stomach of great storage capacity. The maximum -capacity of the stomach is 3 to 4 gallons but it functions most efficiently when it does not contain over 2i/2 gallons. These facts have a decided influence on our methods of feeding. The small size of the stomach makes it imperative that food be given in relatively small amounts and at frequent intervals. Over- loading of the stomach not only lowers its efficiency as a digestive organ but, by pressure against the diaphragm, makes breathing more difficult. The food on entering the stomach is arranged in layers, the end next to the small intestine filling first. The digestive process begins immediately upon receipt of food but no food leaves the stomach until it has been filled to about two-thirds of its capacity. While the animal continues to eat, the partially digested food passes out into the small intestine in a continuous stream. As a result two 56 TM 8-220 SOLDIER’S HANDBOOK 92-84 to three times the capacity of the stomach may pass out during a bulky meal. The emptying process slows up only when feeding stops. The stomach never is completely empty except after complete withholding of food for lor 2 days. The contents of the stomach are squeezed and pressed by the muscular activity of the organ but its contents are never churned. The digestive juice secreted by the walls of the stomach is called gastric juice, an acid fluid containing the active digestive enzyme called pepsin which acts on the protein in the food. Some digested food is absorbed by the stomach but as a whole stomach digestion is partial preparatory digestion for more complete digestion in the intestines. The consumption of any con- siderable quantity of water during the period of stomach digestion tends to disarrange the layering of the food in the stomach and causes as much as one-half of the stomach contents to be washed into the small intestine. For this reason the horse should be watered first arid fed afterward, unless he is allowed free access to water during his meal. As the food tends to leave the stomach in the order of its re- ceipt, it is advisable to feed some hay before feeding grain so that the grain, being held longer in the stomach, undergoes more complete digestion. 93. Small intestine.—The small intestine is a tube about 70 feet in length, extending from the stomach to the caecum. The small intestine is about 2 inches in diameter and just after leaving the stomach is arranged in a distinct U-shaped curve which in the horse seems to prevent food returning to the stomach after it has once entered the intestine and also tends to close the opening into the intestine when the stomach is over-distended with food. The small intestine lies in folds and coils near the left flank and is suspended from the region of the loin by an extensive fan-shaped membrane called the mesentery. The partially digested food in the small in- testine is always quite fluid in character and seems to pass rather rapidly through this part of the digestive tract. Digestion is con- tinued in the small intestine by the action of the bile and pancreatic juice which are secreted by the liver and pancreas, respectively. Some digested food is absorbed in the small intestine. 94. Large intestine.—The large intestine is divided into the caecwm, large colon, small colon, rectvmi, and arms. The caecum is a large, elongated sack extending from high in the right flank downward and forward to the region of the dia- phragm. The openings from the small intestine and to the large colon are close together in the upper end of the organ. This organ is sometimes known as the “water gut” for the reason that water 57 TM 8-220 94-95 MEDICAL DEPARTMENT passes rather quickly to the caecum and because its contents are always liquid. Digestion is continued in the caecum and some food is absorbed. b. The large colon is about 12 feet in length and has a'diameter of 10 to 12 inches. It extends from the caecum to the small colon. This organ is usually distended with food; the greater part of digestion of food by the digestive juices and bacterial action take place in this part of the digestive tract and the greater part of absorption of digested food occurs. c. The small colon is about 10 feet in length and 4 inches in diameter and extends from the large colon to the rectum. The con- tents of the small colon are solid and here the balls of dung are formed. d. The rectum is that part of the digestive tract about 12 inches in length extending from the small colon through the pelvic cavity to the emus, which is the terminal part of the digestive tract. 95. Organs of respiration.—The organs of respiration comprise the nasal cavity, pharynx, larynx, trachea, bronchi, and lumgs. The lungs are the essential organs of respiration; all of the other parts simply act as passages for the air to and from them. a. The nasal cavity is bounded by the facial bones and begins at the nostrils, which are held open by cartilages. It is divided into halves by the cartilaginous nasal septum. Each half is partially filled with the thin turbinated bones, which are covered with a very vescular mucous coat. This coat serves to warm the inspired air. b. The pharynx, as described before, is common to both the respira- tory and digestive tracts. c. The larynx is a short tube-like organ situated between the pharynx and the trachea. It regulates the amount of air passing to and from the lungs and helps to prevent the aspiration of foreign bodies. It is the seat of that common disease of the horse known as “roaring”, which is a paralysis of the muscles controlling the vocal cords. d. The trachea is a long tube connecting the larynx with the lungs and is located in the lower median border of the neck. It is composed of a series of cartilaginous rings held together by elastic fibrous material. e. The bronchi are the branches of the trachea which connect the trachea with the lungs. They, in turn, branch into minute tubes, which penetrate every part of the lung tissue. f. The limgs are two in number and nearly fill the thoracic cavity. The lung tissue is pinkish in color and will float in water. The 58 TM 8-220 SOLDIER’S HANDBOOK 05-97 lung is made up of innumerable air cells having thin elastic walls which contain capillaries of the pulmonary circulation. This elas- ticity of the lung tissue permits the organ to contract and expand in the act of respiration. Heaves is caused by a breaking down of the walls of some of the air cells, with attendant loss of elasticity in that part of the lung. 96. Physiology of respiration.—Respiration is the act of breath- ing and is the most vital function of animals. It consists of an ex- change of the oxygen in the air for the carbon dioxide in the blood and an interchange of these gases between the blood and the body tissues. The former is external respiration and the latter is internal respira- tion. External respiration consists of two movements, inspiration and expiration. Inspiration is brought about by a contraction of the diaphragm and an outward rotation of the ribs. Expiration is effected by relaxation of these muscles and contraction of rib and abdominal muscles. The abdominal muscles are used extensively in labored breathing. Since the diaphragm plays such an important part in the respiration movement, it follows that the distention of the digestive tract with bulky food materially interferes with normal breathing, especially when the animal is subjected to fast gaits. The lungs of the average horse contain, wlien freely distended, 1y2 cubic feet of air. The normal horse at rest breathes from Bto 16 times per minute, and inhales at each respiration approximately 250 cubic inches of air, A horse, while walking, nearly trebles the number of normal respira- tions, but the normal rate is regained in a very few minutes after the horse stops. If the animal breathes 10 times a minute, during repose, the whole lung is ventilated about once a minute. The amount of air required by the horse depends upon the extent of muscular work being performed. The following table shows the mean amount of expired air obtained from horses at various gaits: Oait Ouhic feet evtHrei per hour Repose 74.17 Walk 183.55 Trot 287. 87 Canter 391. 00 Gallop 849.10 97. Organs of circulation.—The organs concerned with the cir- culation of blood and lymph are the heart, arteries, veins, capillaries, lymph vessels, and lymph glands. a. The heart, the central organ of the system, is situated in the left half of the thorax, between the lungs and opposite the third to sixth ribs. In the ordinary-sized horse, it weighs from 7to 8 pounds. It is inclosed in a sero-fibrous sac called the pericardium. The heart 59 TM 8—220 97-99 MEDICAL DEPARTMENT is divided into four cavities, separated by muscular walls and valves. The action of the heart is to receive the blood and to pump it out to the lungs and body tissues. b. The arteries have rather thick elastic walls and carry the blood from the heart to the tissues of the body. c. The veins have much thinner walls and, in many cases, are equipped with valves to prevent the blood from flowing back. They carry the blood from the tissues to the heart. The veins of the legs afford an excellent example of valves in veins. d. The capillaries are microscopic in size and function as connecting tubes between the arteries and veins. It is through the capillaries that the interchange of oxygen and food between the blood and tissues takes place. e. The lymphatics consist of numerous well-defined groups of lymph glands and connecting vessels which are closely related to the arteries. The vessels all unite eventually to form one large duct, which is par- allel to the aorta (main artery from the heart) and empties into one of the veins. The lymph glands are located at strategic places along the main vessels and act as filters for the lymph. They assume consid- erable importance in some diseases; strangles is one disease affecting these organs. The lymph assists in carrying food from the digestive tract to the body and transporting waste back to the blood stream. 98. Physiology of circulation.—The heart movements are con- trolled by an intricate group of nerves. The heart beat is the com- bined cycle of contraction and relaxation of the organ. In the normal horse at rest, the heart beats from 36 to 40 times per minute. The pulse rate is determined by counting the rate of pulsations in some artery that is easily palpitated; for example, the one at the angle of the lower jaw. The pressure and rate of flow in the veins is very slow when com- pared with that in the arteries. It is aided by the respiratory move- ments and muscular contractions. From these facts it is seen that good circulation is made possible by exercise. While the left side of the heart carries on the body circulation the right side pumps impure blood to the lungs to be purified before it returns to the left side of the heart for return to the body tissues. This latter is known as the pul- monary circulation. 99. Blood.—The blood is a red alkaline fluid, composed of blood plasma and red and white corpuscles. It clots almost immediately when exposed to the air. The total amount is about one-fourteenth the weight of the body. The white corpuscles are active agents in combat- ing disease germs in the body. The red corpuscles originate in the red bone marrow, liver, and spleen. They carry oxygen from the 60 TM 8-220 SOLDIER’S HANDBOOK 99-101 lungs to the tissues, convey waste away from the tissues, distribute heat, assist in regulating the temperature, and neutralize or destroy bacterial invaders. 100. Nervous system.—The nervous system is made up of the brain, spinal cord, ganglia, and nerves, and is the communication system of the body. a. The brain and spinal cord are the most important parts of the nervous system and are known as the central nervous system. The brain lies in the cranial cavity of the skull. Compared with the size of the animal the brain of the horse is relatively, small consider- ing the relative brain size of other animals. Relative size of brain to size of body cannot be considered as an absolute indication of the degree of reasoning intelligence; however, there is a distinct corre- lation. The horse has been considered as occupying about a mid- way position in the scale of intelligence of the domesticated animals. The spinal cord continues from the brain back through the spinal canal of the vertebral column. The central nervous system might be likened to the switchboard of a telephone system, for it is the directing center of the system which receives and dispatches nerve messages. b. The ganglia are secondary nerve centers located chiefly along the spinal cord and might be likened to a subexchange in a tele- phone system. They receive and dispatch nerve impulses which do not of necessity have to reach the brain. Together with their com- municating nerves, they control the involuntary muscles, vital or- gans, and reflex actions. c. The nerves are bands of white tissue emanating from the cen- tral nervous system and ganglia and extending to all parts of the body. In general they follow closely the course of the arteries. There are two kinds of nerves, those that convey sensation to the central system, and those that carry back the command impulses of the central nervotis system. The nerves may be compared to the wire lines of the telephone system and the large nerves, like the tele- phone cable, contain many separate lines. 101. Skin.—a. The skin is the covering tissue that acts as a pro- tection to the surface of the body. Wherever the chance of injury is the greatest, the skin is the thickest; in those parts where sensi- bility is most required, it is the thinnest. The skin of the back, quarters, and limbs are examples of the first type. An especially heavy protective covering is found on the back. In some horses, this covering is as much as one-quarter of an inch in thickness. The face, muzzle, and those parts not exposed to violence, for example, 61 TM 8-220 101 MEDICAL DEPARTMENT inside the forearm and thighs, have very thin skin. In spite of this thinness, its strength is remarkable. It is highly sensitive, because it is highly endowed with sensory nerve endings. Accessory organs of feeling are the tactile hairs on the muzzle and the eyelashes. The skin is easily irritated and the horse is endowed with the power of shaking the skin to relieve himself from slight irritations, such as flies. This is accomplished by the aid of the skin muscle {panniculiis camosus), which is a thin muscular layer lying directly underneath the skin and attached to it. In health, the skin feels pliable and elastic. The skin of the horse is black except on those parts of the body covered by white hairs where it is white or pinkish in color. b. The skin is divided into two layers: (1) The epidermis, or outer portion, is non vascular and contains the openings for the sweat and sebaceous glands and hair follicles. (a) The sebaceous glands are well distributed over the whole sur- face of the body and secrete an oily fluid. The oily fluid thus pro- duced serves as a protective secretion against the disintegrating in- fluence of water on the skin; to keep the skin supple; to give gloss to well-groomed skin; to prevent penetration of rain; and to save, to some extent, undue loss of heat. (b) The involuntary muscle fibers are attached to the hair roots which cause the hair to stand up when the horse is cold. (2) The dermis, or inner portion, is a vascular structure and is closely adherent to the underlying fat and skin muscles. It contains: (a) The nerve endings which give to the skin the sense of touch. (b) The hair follicles which grow the necessary hairs. (c) The sweat glands which discharge sweat directly on the sur- face of the skin. Sweat is a watery, salty, alkaline fluid of character- istic horse-like odor. It serves to keep the skin moist, remove waste, and help regulate the body temperature by evaporation. It is not found to occur over the general surface of the body in any hairy animal other than the horse. The secretion of sweat is continuous. Certain parts of the skin sweat more readily than others. It begins first at the base of the ears, then the neck; the side of chest and back follow. No sweating takes place on the legs. There are two kinds of sweating, namely, insensible, which evaporates as fast as it is formed, and sensible, which is the visible fluid that collects on the skin when the secretion is rapid. The evaporation of sweat from the surface of the skin is a most important source of loss of body heat. Through sweating there is also a loss of protein substance and of mineral matter. Horses that have sweated freely show this, when dry, by a TM 8-220 SOLDIER S HANDBOOK 101-104 grayish covering on the hairs, resembling fine sand. The loss thus produced accounts for the general reduction of vitality in some horses. For this, clipping is the only preventive. Sweating usually results from work or exercise but may appear as a result of nervous- ness or excitement. After hard work, horses that have been thor- oughly groomed and dried sometimes break out in what is known as a second sweat. This usually indicates extreme fatigue or nervous- ness and that the horse has not been thoroughly cooled out. Patchy sweating, or sweating continuously in a certain localized area, is some- times observed. The cause is not definitely known. 102. Hair.—Hair covers most of the skin, exceptions being the anal region, genitals, insides of thighs and deep inside of the ear. Even in these regions a few short hairs appear. Hair forms the clothing of the body and its growth is determined by the surrounding temperature. The permanent hair of the body is the hair of the mane and tail, eyelashes, long tactile hairs around the muzzle, and the long hair on the back of the fetlock. The permanent hair is not shed. The general body coat of hair is temporary and is shed twice yearly, spring and fall. The time of shedding is governed by weather conditions or temperature in which the horse is kept. The vitality of the horse seems to be somewhat lowered incident to shed- ding the coat. This particularly is true during the spring shedding and at this time the skin is much more susceptible to eruptions, irri- tations, and infections. Mixed sparsely with the general body coat of hair, there will be found a few longer and more rapidly growing hairs that are known as “cat hairs.” These hairs are most readily observed when appearing in the growth of the coat following clipping. 103. Parts of foot.—The horse’s foot is composed of four parts: a. The bones. b. Certain elastic structures of cartilage, or gristle. c. A layer of highly sensitive flesh or quick, the corium, which covers this bony and elastic framework. d. The box, or case of horn, called the hoof, which incloses and protects the sensitive parts. 104. Bones of pastern and foot.—The bones of the pastern region and foot form a column extending downward from the fetlock joint into the hoof and are named as follows: the long pastern bone, the short pastern bone, the coffin bone, and the navicular bone. a. The long pastern bone extends from the fetlock joint above to the pastern joint below. Its upper end joins, or articulates, with the lower end of the cannon bone, forming the fetlock joint. Its 63 TM 8-220 104-105 MEDICAL DEPARTMENT lower end articulates with the upper end of the short pastern bone, forming the pastern joint. h. The short pastern hone follows the direction of the long pastern bone downward and forward and lies between the pastern and coffin joints, its lower end being within the hoof. c. The coffin hone is of irregular shape, is situated within the hoof, and is similar to the hoof in shape. (1) The surface of the front and sides is known as the wall surface. It has a number of small openings for the passage of blood vessels and nerves and is roughened to give attachment to the sensitive laminae which cover it. On each side of this surface is a groove running for- ward to an opening, through which an artery and a nerve enter the bone and a vein leaves it. (2) At the top of this surface, in front, is a projection called the extensor process, to which is attached the extensor tendon of the foot. On each side of the coffin bone is an extension to the rear called the wing. The lateral cartilages are attached to the outer and upper borders of the wings and the ends of the navicular bone are attached to the inner surface. (3) The lower surface of the coffin bone, called the sole surface, is concave, half-moon shaped and smooth, except at the back part, which is roughened for the attachment of the deep flexor tendon of the foot. It is called the tendinous surface. The upper surface, called the artic- ular surface, articulates with the short pastern bone and navicular bone and with them forms the coffin joint. d. The navicular hone is of irregular shape. It is situated behind and below the short pastern bone and behind the coffin bone, forming a joint with both. The extremities of the bone are attached to the wings of the coffin bone. The lower surface is covered with cartilage, which forms a smooth surface for the movement of the deep flexor tendon, which bends the joint. Because of its shape the bone is frequently called the shuttle bone. 105. Elastic structures of foot.—All the structures of the foot, except the bones, are more or less elastic or springy, and yield when pressure is applied, but certain parts have a very high degree of elastic- ity, their special use being to overcome the effects of concussion or jar when the foot strikes the ground, and to prevent injury. These parts are the lateral cartilages and the plantar cushion. a. The lateral cartilages are two large elastic plates of cartilage, one attached to the top of each wing of the coffin bone. They extend backward and upward so far that their borders may be felt under the skin above the coronet at the heels. 64 TM 8-220 SOLDIER S HANDBOOK 105-107 h. The 'plantar cushion is a very elastic wedge-shaped pad, which fills up the space between the lateral cartilages on the sides, the frog below, and the deep flexor tendon of the foot above. The point, or front part, of the plantar cushion extends forward to the ridge, which separates the sole surface from the tendinous surface of the coffin bone, and lies just below the lower end of the deep flexor tendon. The base, or back part, is covered by the skin above the heels. If the frog pomes in contact with the ground when the foot is planted, the plantar cushion acts as a buffer and prevents jar. 106. Sensitive structures of foot.—Over the bones and elastic parts of the foot is found a complete covering of very sensitive flesh called the corium. From each part of this layer of flesh some por- tion of the hoof is secreted or grown. The sensitive parts are the coronary band, the perioplic ring, the sensitive laminae, the sensitive sole, and the sensitive frog. a. The coronary band is a thick band of tough flesh, nearly an inch wide, extending entirely around the top of the hoof from one bulb to the other, and lying in a groove called the coronary groove on the inner surface of the wall at its upper border. The surface of the coronary band is covered with small hair-like projections, called villi, from which is grown the horny wall of the hoof. b. The perioplic ring is a narrow band of flesh running around just above the coronary band and separated from it by a faint groove in the wall. From the fine villi on the surface of this ring the deli- cate fibers grow which form the periople or varnish-like horn covering of the hoof which assists in the prevention of evaporation of moisture from the wall. c. The sensitive laminae, or fleshy leaves, cover and are firmly at- tached to the wall surface of the coffin bone and to the lower part of the outer surface of the lateral cartilages. From these delicate leaves of flesh grow the homy laminae, or inside lining of the horny wall. d. The sensitive sole covers the sole surface of the coffin bone, is covered with villi, and grows the horny sole. e. The sensitive frog covers the lower surface of the plantar cushion and from its villi the horny frog is secreted. 107. Hoof.—The hoof is the outer homy covering of the foot. It is divided into three parts, the wall, sole, and frog. In the healthy foot these parts are firmly united. a. The wall, except the bar, extends from the edge of the hair to the ground and is divided into the toe, quarters, and buttress. 65 TM 8-220 107 MEDICAL DEPARTMENT (1) The toe is the front part of the wall. It is steeper in the hind foot than in the fore. (2) The quarter extends backward on each side from the toe to the buttress. (3) The buttress is the back part of the heel and may be defined as the angle formed by the union of the wall and bar. (4) The bar is that part of the wall which extends inward and forward from the buttress to within about an inch of the point of the frog. The hoof is thus made stronger by the ends of the wall extending inward to form the bars. The bars are weight carriers, and they also act directly on the wall to produce expansion when weight is placed on the frog, (5) The outer surface of the wall is covered by a thin varnish- like coat of fine horn, called periople. The inner surface is covered with from 500 to 600 laminae. These are thin plates of horn run- ning downward and forward. Between them are fissures into which dovetail the sensitive laminae. The horny laminae and the sensitive laminae are firmly united. This union binds the wall of the hoof to the coffin bone and its cartilages, suspends the weight of the horse from the wall as in a sling, and thus prevents the bones from de- scending on the sole. (6) On the upper border of the wall is the coronary groove, in which lies the coronary band. The lower border is known as the bearing surface. It is the part that comes in contact with the ground in the unshod foot and to which the shoe is fitted in the shod foot. b. The homy sole is a thick plate of horn, somewhat half-moon shaped. (1) The upper surface is arched upward and is in union with the sensitive sole from which the horny sole grows. The lower sur- face is hollowed and is covered with scales or crusts of dead horn, which gradually loosen and fall off. (2) The outer border of the sole is joined to the inner part of the lower border of the wall by a ring of soft horn called the white line. This line shows where the nail should be started in shoeing. (3) The inner border is V-shaped and is in union with the bars, except where the sole joins the point of the frog. The sole protects the sensitive parts above. c. The frog is a wedge-shaped mass filling the V-shaped space between the bars and sole and extending downward more or less be- low the bars. (1) The lower surface has two prominent ridges, separated be- hind by a cavity called the cleft, and joining in front at the point 66 TM 8-220 SOLDIER’S HANDBOOK 107-110 of the frog. These ridges terminate behind in the bulbs of the frog. Between the sides of the frog and the bars are two cavities called the commissures. (2) The upper surface of the frog is the exact reverse of the lower. It has in the middle a ridge of horn called the frog stay, which assists in forming a firm union between the horny and sensitive frog. (3) The function of the frog is to assist the plantar cushion in breaking the jar or concussion, to prevent slipping, and to produce expansion and contraction upon which the normal blood circulation in the foot depends. 108. Dissipation of concussion.—The concussion borne by the foot is lessened by a combination of functions of its varied structures. When the weight of the horse is transmitted down the bony column of the leg, the following things take place: Except possibly at the walk, the weight, or at least a great portion of the weight, is first received by the frog. The frog spreads and moves the bars outward, carrying the heels and the posterior part of the quarters outward. Simultaneously, the frog transmits the jar to the plantar cushion, which spreads and carries the lateral cartilages outward. The frog and plantar cushion, by virtue of their elasticity, receive the major portion of the jar. At the same time the weight is initially borne by the wall and the bars. The end of the bony column is hung in a sling in the wall and bars by the dovetailing of the sensitive laminae into the homy laminae. As the weight comes downward, these leaves ‘give way slightly and allow the coffin bone to approach the ground; this in turn causes the sole to be somewhat lowered. The arrangement of the deep flexor tendon over to the navicular bone affords a means by which a portion of the shock is absorbed. The spreading movement of the elastic structures is known as expans-ion. When the weight is removed, these structures return to their normal positions. This is known as contraction. 109. Blood supply.—The sensitive structures, especially the corium, are highly vascular and filled with a network of veins. The arterial circulation is sufficient unto itself, but the venous circula- tion receives a mechanical aid from the movements of the foot. When contraction takes place, the plexuses fill with blood; later, during expansion, the blood is forced out of the veins. These move- ments of the foot materially aid in the circulation. 110. Moisture.—The horn is made up of a network of tubules that are cemented together. The moisture is contained primarily in these tubules. It is derived internally from the blood supply and externally from moist standings and the soil. The natural hard- 67 TM 8-220 110 MEDICAL DEPARTMENT 1. Lips, upper and lower. 2. Nostril. 8. Face. From muzzle to a line connecting inner corners of eyes. Bounded on sides by lines from outer corners of eyes to corresponding nostril. 4. Eye. Includes eyelids. 5. Forehead. From upper border of face to poll. Bounded on sides by line from outer corner of eye to base of ear. 6. Ears. 7. Poll. Prominence between the ears. 8. Throat. 9. Crest. Upi>er border of neck bearing the name. 10. Neck. 11. Withers. 12. Shoulder. 13. Arm. 14. Breast. A single region bounded by the neck, region of the arm, and below by horizontal line at level of elbow joint, 15. Elbow. Corresponds to ulna. 16. Forearm. 17. Knee. Corresponds to knee joint. 18. Cannon. 19. Fetlock or fetlock joint. 20. Pastern. 21. Coronet. Corresponds to coronary band. 22. Hoof. 23. Back. 24. Costal region. 25. Loin. 20. Point of hip. 27. Plank. 28. Abdomen or belly. 29. Sheath. 30. Croup. 31. Thigh. 32. Stifle. Corresponds to stifle joint. 33. Tail. 34. Buttocks. 35. Leg. 30. Hock. 37. Chestnut. (Also on foreleg above knee.) 38. Muzzle. Includes lips, nostrils, and nose, or space between the nostrils. FigUuk 13. External regions of horse. 68 TM 8-220 SOLDIER S HANDBOOK 110-111 ness of the horn and the periople on the wall serve to prevent undue evaporation. The wall is about one-fourth water, the sole one-third, and the frog one-half water. 111. External regions of horse.—ln order to insure a uniformity of phraseology for various official papers, and for other purposes of description, a standard nomenclature of the external regions of the horse has been developed which is generally used by horsemen throughout the world. These regions are shown in figure 13. (Tor a more complete description see AR 40-2250.) 69 TM 8—220 112 MEDICAL DEPARTMENT Chapter 3 MINOR SURGERY AND MEDICAL AID Section I. Operating room and surgical technique 112-123 11. Bandaging and dressing 124—129 111. Splints and their application 130-138 IV. Emergency medical treatment - 139-152 V, Emergency dental treatment - 153-162 VI. Emergency veterinary treatment 163-180 VII. X-ray service 181-186 Paragraphs Section I OPERATING ROOM AND SURGICAL TECHNIQUE Paragraph Operating room 112 Lighting 113 Heating and ventilation 114 Equipment 115 Cleanliness 116 Adjoining rooms 117 Surgical technique 118 Surgical dressings 119 Sutures and ligatures 120 Instruments 121 Operating personnel 122 Preparation for operation 123 112. Operating room.—a. By operating room is usually meant not only the room or rooms where operations are actually performed, but all the other rooms connected and associated with them, all of which constitute the operating suite. This section of a hospital is a most important place, and upon its equipment and care depends to a considerable extent the success or failure of an operation. Surgeons may, however, be required by necessity to perform operations under conditions far from satisfactory in combat. However, whenever possible, operations of a major character should be performed in hospitals where the patient can be safeguarded by all possible aseptic conditions. b. The administration of the operating room is one of the duties of the chief of the surgical service. He issues the necessary instructions to nurses and attendants regarding procedures and technique. TM 8-220 SOLDIER S HANDBOOK 112-115 c. The operating suite of a modern hospital should be in a location as free from miscellaneous hospital traffic and noises as possible. It consists of the operating room or rooms and various accessory com- partments arranged in a convenient order. There are usually at least two operating rooms so that one is always ready for use while the other is being cleaned or repaired, the main room being used for clean surgery and the other one for the dirty or pus cases. In an emergency both may be used simultaneously. d. The actual size of an operating room should be determined by the number and character of operations to be performed and the space available; it should be large enough to prevent crowding, yet not so large that it is difficult to clean, ventilate, or heat. 113. Lighting.—When natural light is used, a northern exposure is preferable because there is less variation in the intensity of the light from that direction. However, if large north windows are used in a cold climate, one must consider the danger of placing the oper- ating table too close to the window. Little dependence is now placed on natural light, since artificial light is much more dependable and easily controlled. Overhead adjustable top lights are now made with the rays focused from a number of reflectors to reduce shadows on the field of operation to a minimum. These are even more effec- tive when the new spot-beam portable light is used in conjunction with them. Emergency lights are also available to work with batteries should the electric current fail. 114. Heating and ventilation.—The temperature of the operat- ing room is kept at about 80° F. during operations and the ventilating system should be capable of maintaining this temperature during the coldest weather likely to occur in the locality. Many of the modern hospitals are equipped with an air-conditioning unit. Direct or natural ventilation is used chiefly in small hospitals, and must be as nearly perfect as possible. Fresh, clean, warm, moist air should be constantly provided and drafts avoided. 115. Equipment.—a. An operating table with all accessories, ad- justable as to height and the various standard positions, is desirable, but this type of table is expensive, and quite as good work may be performed on one of a simple design, provided proper forethought is given the type of operation and the required position of the patient. On the table there should be a soft pad about iy2 inches thick cov- ered with rubber sheeting and over all a linen sheet. In addition to the operating table but few pieces are necessary. There should be two or three tables with glass or polished metal tops, preferably metal, for surgical dressings and instruments to be used during the 71 TM 8-220 115 MEDICAL DEPARTMENT operation; one single and one double hand basin stand; an irrigating stand; two enamel buckets and a set of glass shelves for solutions, ligatures, drains, pins, etc. All the operating room equipment should be of simple, sturdy, easily cleaned design and should be painted with a durable white enamel. b. Each table in the operating room holds certain specified articles placed in a definite way so that no time is lost in hunting for the desired article. (1) On the large table are kept special instruments, reserve instru- ments, reserve sutures, and linen. At the far end is laid out the preparation equipment for sterilization of the operative field. (2) There is a basin stand near the foot of the operating table within easy reach of the instrument nurse containing sterile water for dipping the suture materials or for soaking tape sponges. (3) The instrument tray or table which extends over the operating table holds instruments arranged in regular order. This table rou- tinely holds knives, various scissors, plain and toothed thumb forceps, curved and straight hemostats, Allis forceps, Kocher forceps, gauze sponges, stick sponges, various retractors, probes, and grooved di- rectors. (4) A stand with a hand basin for sterile water is behind the sur- geon for rinsing his gloves during the operation if necessary. (5) Conveniently located, either in the scrub room or in the oper- ating room near the entrance from the scrub room, are placed basins for solutions to sterilize the previously scrubbed hands of the sur- geon and assistants. (6) A table is provided near the entrance from the scrub room to hold sterile gloves and gowns. (7) The anesthetist’s table for general anesthesia, in addition to the articles necessary for the administration of the anesthetic and an extra supply of the anesthetic, should have the following equipment on it and immediately available for use in an emergency: (a) Wooden mouth gag. (b) Tongue forceps. (c) A curved needle threaded with silk, sterilized, and in a sterile package. (d) Sterile hypodermic syringes with the following drugs in sterile solution in appropriate containers: Caffeine sodium benzoate. Atropine sulfate. Epinephrine hydrochloride (adrenalin). (e) Tracheotomy set. SOLDIER’S HANDBOOK TM 8-220 (/) Gauze strips. (g) Forceps (to hold gauze sponge). (h) Watch or small clock. {i) Pus basin. (j) Blood-pressure apparatus. {k) Stethoscope. (I) Anesthetist’s chart. This equipment should be within easy reach and it should be un- necessary to ask for any of these important articles during anesthesia, as delay in meeting an emergency may result in disaster. Some cases require washing out of stomach during or upon completion of opera- tion. It is essential, therefore, that a stomach tube and Levine tube be available in the operating room. 115-117 116. Cleanliness.—-The walls and floor of the operating room are usually built of waterproof material with a smooth surface and so constructed that sharp, dirt-collecting angles are avoided. The floor should be washed daily with soap and warm water and all surfaces that might collect dust wiped with a damp cloth, the glass-topped tables, that are usually draped sterile, being wiped with a cloth dam- pened with alcohol. Once a week the walls are thoroughly scrubbed with soap and water, special care being taken to scrub and clean all corners and crevices. Blood or other stains that may get on the floor during an operation should be removed as quickly as possible, and, if a second operation is to be performed immediately, the floor, if necessary, should be cleansed by hand. 117. Adjoining- rooms.—The rooms, other than those used for operating, that comprise the operating suite are usually the anes- thetizing room, the wash or scrub-up room, the sterilizing room, the instrument room, the surgical dressings room, the storeroom, and the utility room. a. The anesthetizing room is suitably equipped for the administra- tion of anesthetics. i. In the wash or scrub-up room there should be at least two lava- tories, with foot or knee control for the hot and cold water, a shower bath and toilet, and clothes lockers for the use of the-surgeon and his assistants when they change into operating suits. It is well also to have in this room a basin stand for the solutions used to disinfect the hands after the preliminary scrubbing, in order that the surgeon and his assistants can receive their operating gowns and proceed without delay. c. The sterilizing room is provided wuth all equipment necessary to sterilize properly instruments, utensils, dressings, water, etc. De- 73 TM 8-230 117-118 MEDICAL DEPARTMENT spite the fact that this equipment is sturdily constructed, constant care must be taken that it is always in working condition and the printed directions furnished by the manufacturers exactly observed. Operation of this equipment will not be intrusted to an inexperienced or careless person, thereby endangering the lives .of patients. d. An instrument room, while not a necessity, is advantageous. However, as a rule, unless the clinic is large, suitably designed glass cabinets placed in the surgical-dressings room will suffice. e. The surgical-dressings room should be constructed similarly to the operating room. In this room are made, prepared, and stored, after sterilization, the various surgical dressings and packages of linen, such as gowns, sheets, towels, etc., used in operations. Here cleanliness is of paramount importance. Ample locker and shelf space should be provided, and also a large smooth-topped work table. /. There should be a storeroom solely for the storage of operating room supplies. Much valuable time may be lost unless such a room is provided and kept fully stocked for emergencies. g. The utility room, in which all cleaning equipment used in the operating suite is stored, should have in it a large, deep sink with running hot and cold water, in which the linen used during operations may be soaked and the greater part of blood stains removed before sending to the laundry. The utility room is an integral part of the operating room equipment, and as such must be scrupulously cared for. 118. Surgical technique.—a. Before an operation, it is necessary to make sterile and to keep sterile the patient’s skin, the hands and clothing of the surgeon and his assistants, and all instruments and materials that come in contact with the wound or are handled by the surgeon and his assistants. b. During the operation the surgeon and his assistants must not touch anything that is not sterile. A great responsibility rests upon the operating room personnel, because the most perfect surgery may be a complete failure if there is the smallest break in the aseptic technique for which they are responsible. c. By aseptic surgery is meant that mode of surgical practice in which everything used at the time of operation and at subsequent dressings, as well as the wound, is free from pathogenic bacteria and is sterile, or surgically clean. To maintain that condition requires constant vigilance before, during, and after an operation, and no failure of technique, however trivial, must be allowed to pass uncorrected. 74 SOLDIER S HANDBOOK TM 8-220 118 d. Infection is the word used to describe the condition which exists when infectious organisms gain access to the tissues of the body in such numbers that their presence is manifested by characteristic symptoms, such as inflammation, suppuration, putrefaction, etc. e. Inflammation is the first objective or outward symptom of in- fection and is characterized by local pain, heat, redness, swelling, and disordered function. The general or subjective symptoms of inflammation vary greatly, depending upon the amount and location of the tissues involved, the physical condition of the patient, and the disease-producing power of the infecting organism. Fever is the most constant subjective symptom of inflammation, but it may be so slight that it escapes notice or it may be so severe that recovery of the patient seems doubtful. Aseptic treatment and careful observa- tion of wounds is imperative, in order to prevent infection, and if infection does occur it may be recognized promptly and appropriately treated. /. Suppuration is the result of inflammation and is due to the liquefying action of pyogenic (pus-producing) organisms on the exudates of tissues damaged by inflammation and also upon the tissues themselves, forming pus. g. When a wound has become so infected that the inflammation does not subside and pus forms, it is termed a “septic” wound. Fre- quently, as a result of the passage of bacteria from a septic wound into the blood stream or of the absorption of the toxins (poisons) elaborated by the bacteria, grave general symptoms are caused and sepsis or septicemia (blood poisoning) is said to be present. h. The word putrefaction refers to that condition when inflam- mation has so far progressed that the tissues have been devitalized and a foul or putrid odor arises from the wound. The putrid odor is due to the action of putrefactive bacteria. i. The micro-organisms producing pus are know as pyogenic bac- teria. The various varieties of the staphylococcus and streptococcus are the causative agents in the majority of surgical infections. Other organisms are, however, occasionally demonstrable. The staphylo- coccus is the most common cause of infection. It rarely causes alarming constitutional symptoms, and as a rule such an infectious process remains quite localized. The streptococcus is more virulent and tends to invade the Avhole system. Infection of wounds by one type of organism is quite rare; two or more varieties usually are present and the coincident symptoms are dependent upon the pre- dominating bacterium, either because of its virulence or numbers. 75 TM 8-220 118 MEDICAL DEPARTMENT It is well to note that the encapsulated spores of the Bacillus an- • thracis are the most difficult of all germs to kill, and any process which will render them harmless (and they must be dead to be harm- less) may be relied upon to accomplish the same result as regards the other bacteria. The prevention of infection is the best treatment known for this condition. Infection is prevented through the em- ployment of measures that destroy infectious bacteria and their spores, or inhibits or stops their growth. These measures make up that process in surgical technique known as sterilization. j. Sterilization is the process of rendering anything sterile by destroying infectious organisms and their spores, and is accomplished by mechanical, thermal, and chemical methods. Sterilizing agents are substances which destroy or remove or prevent the growth of infectious organisms. (1) The methods used in mechanical sterilization, while not de- pendable, are important preliminary steps to more complete methods of sterilization. The most important of the mechanical methods of sterilization are scrubbing and irrigation. (a) A thorough scrubbing with hot water, soap, and brush is frequently of great importance, as it removes dirt which may harbor harmful bacteria from the walls and floors of operating and treat- ment rooms, from instruments and utensils, the hands of the surgeon and those assisting at operations and dressings, and the skin of the patient. Instruments and utensils should always be cleaned and scrubbed immediately after use, as that removes most of any bacteria present and makes subsequent sterilization more easily effective. (h) The irrigation of wounds with sterile water or other aqueous solutions to float off or dislodge by force dirt and bacteria, or to bring solutions in contact with parts of a wound which are not other- wise accessible, has a distinct place in surgical practice. Irrigation is a splendid mechanical cleanser and, in many cases, will remove infectious organisms when other methods fail. (2) Thermal sterilization, or sterilization by heat is the most efficient agent of sterilization, and, when properly used, is almost certain in its germicidal action. Moist heat is used as a sterilizing agent in two forms—boiling water, and live steam under normal and increased pressure. (a) Boiling water is the simplest method of sterilization, and is used chiefly for sterilizing instruments (except those with lenses), metal utensils, enamelware, and other objects which are not injured by heat and moisture. These articles should be boiled for 20 minutes in water containing about 1 percent (3 teaspoonfuls to the quart) 76 TM 8-220 SOLDIER’S HANDBOOK 118 of sodium carbonate, which is added to prevent rusting, to raise the boiling point of the water, and to dissolve any organic matter that may be present. In emergencies surgical dressings may be boiled, but it is far more satisfactory to have them dry at the time of oper- ation. Glassware is boiled 20 minutes in water without sodium carbonate. (h) Live steam is air-free steam and for sterilization purposes is used under normal or increased pressure. Steam under increased pressure is termed superheated steam and is the best method of sterilization. Steam at normal pressure is but little used at the present time. (c) An autoclave is a sterilizer in which steam under pressure (superheated steam) is used. A vacuum first is created to insure penetration of the steam, and when the proper reading of negative pressure (vacuum) is registered in the gage, superheated steam is admitted to the chamber and the articles therein subjected to a steam pressure of 20 pounds for three-quarters of an hour. At the end of this time all organisms will have been killed and the dressings or other articles rendered safe to use, but they are wet. A second vacuum then is induced and maintained until they are dry. One such sterilization ordinarily is sufficient to preclude the possibility of infection, but if there exists the slightest doubt as to the asepsis of the sterilized material the process may be repeated two or three times, despite the fact that anthrax spores are killed by live steam in 12 minutes. This method of repeated sterilization, either by steam or boiling, is termed fractional sterilization. (d) The method of sterilization in which dry heat is used includes the use of the actual cautery, a flame, or hot air. Hot air is fairly satisfactory and it will kill anthrax spores in about 3 hours at 140° C. The cautery is a positive germicide, but causes extensive destruction of the tissues. Sterilization by a flame is rarely, if ever, used in surgery, but may be used for rapid sterilization of platinum loops, needles, and other small instruments. (3) Chemical sterilization will kill bacteria and spores, but in order to do this promptly they must be used in such strong solu- tions that the tissues to which they are applied may likewise be destroyed. Such a result is usually undesirable and the use of chemicals as sterilizing agents is confined chiefly to the sterilization of instruments which boiling or steam would ruin, or in weak solu- tion as an adjunct to the mechanical method of sterilization. Chemi- cal solutions of appropriate strength are used in the sterilization of instruments, materials, and utensils, the skin of the patient, the oper- 77 TM 8-220 118 MEDICAL DEPARTMENT ator’s hands, and the walls and floors of rooms. When used in con- tact with the tissues the aid is to secure complete sterilization without causing damage to the tissues, but no such ideal aniseptic has yet been found. The following are some chemicals used in sterilization: (a) Alcohol, 70 percent, is commonly used to disinfect the hands of operators, for disinfecting cutting and sharp instruments, for cleansing and drying the skin of the operating field before the application of iodine, and as a solvent or diluent for various antiseptics. {h) lodine, in strengths varying from 3y2 t° 7 percent, is a re- liable germicide and is used for sterilizing wounds and in prepara- tion of the skin. In the presence of water the iodine is precipitated and it will not penetrate if the skin or tissues are wet. When used for skin sterilization it is usually preceded by an application of benzine or ether to remove the sebaceous matter and dry the skin. After the iodine has dried it is customary to remove the excess with alcohol to prevent the burning or blistering of the skin. (c) Bichloride of mercury is now seldom used in contact with the body although some operators use it in preparation of their hands. In weak solutions it has a powerful germicidal action on superficial bacteria, but is of little value as a germicide in deep wounds because it combines with the proteins in the tissues to form an insoluble albuminate of mercury which markedly hinders its action and pene- trative power. A 1-500 solution in alcohol is useful in sterilizing rubber goods. As mercury has corrosive action on metals it should never be used to sterilize instruments. (d) Phenol (carbolic acid) in saturated solution is used for steri- lization of cutting instruments which would be injured by boiling. They are submerged in the solution for 15 minutes, washed in sterile water, and placed in alcohol until needed. It is also used for steri- lization of tissues, such as the stump of the appendix, where deep penetration is not required, and as a local cauterizing agent. Phenol dressings should not be used because of the danger of subsequent gangrene. (e) Dakin’s solution is a solution of sodium hypochlorite of strength between 0.45 and 0.5 percent. In contact with the tissues it gives off nascent chlorine, which destroys bacteria and dissolves the necrotic tissue in which they grow. It is rapidly decomposed by light and heat and should be titrated daily to insure the proper strength. When used according to the Carrel technique in a properly prepared wound, it is of great value. 78 TM 8-220 SOLDIER S HANDBOOK 118 (/) The chloramine group of disinfectants also act by liberation of chlorine. They are more stable than Dakin’s solution and give off their chlorine more slowly, but they lack the important solvent action on the necrotic tissue. {ff) Potassium permanganate is an excellent deodorizer and, in addition, is a good disinfectant for the hands in saturated solution. (A) Boric acid is a very mild antiseptic and generally is used in saturated solution (4 percent) for the irrigation of infected wounds or the sterilization of instruments which h6at in any form would destroy. (i) Formaldehyde is a germicide and is Used as a gas or in solu- tion. It is very irritating to the tissues and seldom is applied in a dressing; in weak solution (4 percent) it is a satisfactory sterilizing solution for instruments. Formaldehyde solution is a satisfactory method of sterilizing instruments which heat would injure, as catheters, cystoscopes, and similar articles. Mercury oxycyanide so- lution 1-1,000 is also used for catheters, cystoscopes, etc. (j) Various substances that color or dye the skin, such as picric acid, mercurochrome, gentian violate, merthiolate, and acriflavine are also used as disinfectants. k. The sterilization of equipment is accomplished as follows: (1) Large packs are sterilized for 60 minutes under 20 pounds pressure with 20 to 30 minutes vacuum allowed for drying. Small packs are sterilized for 30 minutes under 20 pounds pressure with 15 to 20 minutes vacuum allowed for drying. Enamelware and glass- ware are sterilized for 20 minutes under 30 pounds pressure with no vacuum. Rubber goods are sterilized for 15 minutes at 20 pounds pressure and 15 minutes vacuum. Solutions in flasks are sterilized separately for 15 minutes at 20 pounds pressure. Pressure, at con- clusion of sterilization period, is allowed to decrease gradually. No vacuum is used on solutions. Sharp instruments are sterilized in cresol 1 hour and boiled for 1 minute. Sharp instruments can be sterilized by placing in cresol for 30 minutes, rinsed in plain sterile water, and placed in 70 percent alcohol for 30 minutes. Other in- struments are placed in trays and boiled for 20 minutes, A 1-per- cent solution of sodium carbonate (3 teaspoonfuls to the quart) raises the boiling point about s°, prevents rust, and removes grease and other organic matter. Gloves are cleaned, inspected for holes, dried, then powdered well and evenly on both sides with talc. The cuffs are turned back 2 inches. Each pair is placed in a muslin envelope of 4 thicknesses with a small powder bag. This is wrapped 79 TM 8-220 118-119 MEDICAL DEPARTMENT in a muslin cover and sterilized for 15 minutes under 20 pounds pressure. (2) Both chemical and bacteriological controls are used to insure proper sterilization, and laboratory cultures of all packages are frequently taken. (3) Basins are boiled in a special sterilizer for 30 minutes. (4) The suture materials which are dispensed in tubes have been rendered sterile by the manufacturer. The tubes themselves are sterilized in two ways. If the tubes are marked “boilable” they are sterilized by boiling with instruments for 20 minutes. If they are not marked “boilable”, they are stored in 5 percent phenol or cresol solution and then placed in 70 percent alcohol for 20 minutes just prior to operation. (5) Suture materials such as silk and linen not dispensed in tubes are sterilized in the autoclave under 20 pounds pressure for 15 minutes or boiled with instruments. Horsehair, silkworm gut, silver wire, etc., are sterilized by boiling for 20 minutes prior to operation. 119. Surgical dressings,—a. Surgical dressings commonly are made from gauze, cotton, flannel, rubber, linen, etc., by the operating room force. The gauze and cotton should be of good quality and capable of rapidly absorbing fluids. b. It sometimes happens that the gauze, as received from the man- ufacturers, is sized (coated with a starch preparation which makes it unfit for surgical use) and such gauze must be boiled in a 1 per- cent solution of sodium carbonate in order to remove the sizing. c. Sponges are used for many purposes and are made of gauze, either rolled in a ball or flat. The flat sponges are of various sizes, 2 by 2, 4 by 4, and 4 by 8 inches, and are usually of from 6 to 8 thicknesses of gauze. All raw edges are turned in. Sponges are wrapped in double muslin wrappers for sterilization. d. Packs, or taped sponges, are used for. surrounding the field within the abdomen. They are made of 6or 8 layers of gauze, with all the raw edges turned in and sewed. To avoid. leaving them in the abdomen, a tape is sewed to one corner, and to this a metal ring is secured. The common sizes of packs are 4 by 18, 8 by 18, and 12 by 12 inches. For sterilization they are placed in double muslin covers, each package containing a definite number and so labeled. During the operation the nurse or attendant in charge of them must know the exact location at all times of every pack that has been issued. 80 TM 8-220 SOLDIER S HANDBOOK 119-120 e. Pads are 8 by 10 and 12 by 16 inches and are of absorbent cotton wrapped in an outer covering of gauze. They are used in wound dressings for absorbing fluids and to protect the tissues from pressure. /. Sheets and towels are folded in a certain manner and wrapped, a definite number in each package, in double muslin covers for sterilization. g. Caps and masks are worn to prevent infection by dandruff or secretions from the mouth and nose. They are inclosed in muslin wrappers, sterilized, and placed in the surgeon’s dressing room. h. Operating suits are worn in place of their outer clothing by surgeons and attendants during operations. They may be used as they come from the laundry. i. Operating gowns are of standard type in the Army and are worn by all persons present at an operation. When putting on a sterile gown one should avoid touching the ungloved hand to its outside. j. In preparation for emergencies a hospital should have on hand a considerable quantity of sterile goods. They may be placed in metal drums or in packages, each containing a standard outfit for an op- eration. These should be sterilized once a week if not used. 120. Sutures and ligatures.—a. There are two principal kinds of sutures and ligatures, absorbable and nonabsorbable. The prin- cipal varieties of absorbable sutures are plain gut, chromic gut, and kangaroo tendon. Gut sutures are made from the submucous coat of the intestine of the sheep; they are used in the deep tissues such as peritoneum, muscle, and fascia. The plain gut is supposed to last from Bto 10 days in the tissue. Chromic gut sutures are prepared to last 10 and 20 days in the tissue, but the rate of absorption is variable. Sutures come in various sizes from 000 to 3. They are usually issued in plain glass tubes which may be sterilized by boiling or submerging in a special suture sterilizing solution such as potas- sium-mercuric-iodide solution 1-8,000 in 95 percent alcohol. Kanga- roo tendon is much stronger and heavier than the gut and lasts about 30 days in the tissue. b. The atraumatic intestinal suture is attached to the needle in such a manner that the perforation made by the needle is not enlarged or traumatized by the entrance of the suture itself. These sutures are made in both plain and chromic from size 0000 to 2 and may be used for all membranes where minimized suture trauma is desirable. c. Nonabsorbable sutures are made of silk, linen, silkworm gut, horsehair, dermol, silver wire, and other materials. 81 TM 8-220 121-122 MEDICAL DEPARTMENT 121. Instruments.—a. Most surgical instruments are made of special steel, and are nickel-plated or of stainless steel. They are kept in a special cabinet when not in use. b. After an operation all metal instruments should be washed care- fully in cold water with a brush to remove all blood and other foreign matter, then boiled. They should be then dried and carefully examined for dirt in the crevices and breaks in the plating and sharp- ened if necessary. They are then wiped with warm liquid petrola- tum or typewriter oil to prevent rusting and placed in the instrument cabinet. c. The instruments required for an operation vary greatly according to the nature of the operation and the ideas of the surgeon. The fol- lowing is suggested as a basic outfit for ordinary operations (others may be added as desired) : 2 scalpels; 3 scissors (1 curved Mayo, 1 straight Mayo, and 1 blunt for suture scissors) ; 2 plain thumb for- ceps; 2 rat-toothed thumb forceps; 12 small (Kelly Rankin) straight hemostats; 12 curved Kelly hemostats; 8 Allis intestinal forceps; 12 Ochsner straight forceps, 6%-inch; 6 large Ochsner straight forceps. 6 mosquito forceps; 12 towel clips; 2 large retractors; 2 Army type retractors; 1 grooved director; 1 silver probe; 12 sponge holders; 3 curved hysterectomy forceps; 3 needle holders; needle kit containing all types of needles (straight intestinal, straight skin, curved cutting, curved intestinal, Mayo needles) ; plain and chromic gut; assorted glass syringes and hypodermic needles; 3 medicine glasses; skin clips and forceps or dermol for the skin; 12 laparotomy rings; and 2 tumblers. 122. Operating personnel.—®. In the Army this consists of the operating surgeon and the medical officers who assist him, the operat- ing room nurse, the anesthetist, and two or more enlisted men. b. The operating surgeon is in general charge. He is responsible for the patient’s life and for the successful outcome of the operation. He is held accountable for all mistakes and accidents, no matter whose fault it may be, that may cause an unfavorable outcome. c. To the operating room nurse is delegated the authority necessary for the routine administration of the operating suite. This in- volves numerous details such as the care and accounting for all property, cleanliness, sterilization, preparation for operations, and supervision and instruction of enlisted men. d. (1) The anesthetist is usually a nurse who has had special training in this branch. She is responsible to the operating surgeon for the general condition of the patient during the administration of an anesthetic. 82 TM 8-220 SOLDIER S HANDBOOK 122-123 (2) Since local and spinal anesthesia have become so popular, many surgeons prefer to be their own anesthetists. The operating room nurse, in case no regular anesthetist is assigned, sits at the patient’s head during the operation and keeps a record at frequent intervals of the blood pressure, pulse, and respirations. e. The enlisted men are detailed to the operating room for the purpose of instruction and training. The principal characteristics of a good operating room attendant are dependability, faithfulness in the most minute details of his work, an even temper which will enable him to work quickly and accurately in emergencies, intelli- gence to understand the reason for everything he does, and a devotion to the welfare of the patient. 123. Preparation for operation.—a. Each one of the operating room personnel removes his outer clothes, puts on his operating clothes,, and then proceeds to the scrub-up room. Here the hands and forearms are scrubbed for 15 minutes with hot water and green soap and rinsed and soaked in 70 percent alcohol. This washing should be done in a methodical way so that each side of the fingers and every part of the hands and forearms are scrubbed thoroughly. It is essential that persons engaged in surgical work keep their nails short and clean. After scrubbing and rinsing in alcohol, the sur- geon enters the operating room where he is handed a hand towel with which he dries only his hands, leaving his forearms untouched by the towel. He then puts on a sterile gpwn and sterile rubber gloves. When fully prepared as above, and while waiting for the start of the operation, the surgeon and his assistants must hold their hands, covered with a sterile towel, above their waist. h. The field of operation is shaved before the patient enters the operation room, although sometimes this is done in the operating room. If a general or spinal anesthetic is used, the skin prepara- tion is done after the patient is anesthetized. With local or block anesthesia, the field is prepared before the injection of the anesthetic is given. c. If a spinal anesthetic is used, special material and apparatus are necessary which should be laid out on a table. The spinal kit consists of the following articles: one 5-cc. hypodermic syringe; one 2-cc. hypodermic syringe; two spinal needles; one hypodermic nee- dle; one mixing needle; one ampule saw; one sacral sheet; sponges, etc.; 100, 120, 150 milligrams of novocaine crystals or other drug as desired by the operating surgeon. After the spinal injection the table is tilted according to instructions from the anesthetist. 83 TM 8-220 123 MEDICAL DEPARTMENT d. There are many ways of preparing the skin. A simple and very satisfactory one is to scrub the skin with a gauze “prep” sponge wet with ether to remove grease and moisture, and then paint the skin thoroughly with 3.5 percent iodine and allow to dry. After the iodine is completely dry paint the skin with a second coat, beginning in the middle of the field and progressing outward to the edges of the previous coat and remove with alcohol on sponges. Drape with sterile towels and sheets, so that only the prepared skin is exposed. Other common disinfectants used in the Army for skin preparation are merthiolate, mercurochrome, Scott’s solution, etc. e. Following is a summary of the routine preparations for an operation: (1) The operating room nurse, the anesthetist, and the surgeon are notified as to the time and nature of the operation. (2) The attendant in charge of the instruments selects those needed and puts them in the sterilizer with the necessary utensils. (3) The cutting instruments are placed in a sterilizing solution. (4) All hands assist in placing the furniture and equipment in proper order, and all glass-topped tables, Mayo tables, overhead lights, and portable lights are wiped with a towel wet with alcohol. (5) The attendant in charge of sterile supplies selects the packages of sterile goods and places them on the proper tables. (6) The nursed or attendants proceed to scrub up and put on sterile gowns and gloves. (7) Nurses or attendants drape, with sterile sheets, the table for gowns and gloves, the instrument table, the surgical dressing table, the basin stands, and spinal anesthetic table. (8) The trays of sterile instruments are brought in from the sterilizer and are arranged in proper order on the instrument table and draped with a sterile towel until needed. (9) The basin and utensil set is opened and the contents placed in their proper places. (10) The sterile packages are opened and an attendant places their contents in the proper place on the surgical dressing table. (11) Nurse or attendant sorts and arranges the extra instruments on a table and prepares the sutures and ligatures. (Sutures are no longer placed in a damp towel, but in a dry one, as it has been dis- covered that continued soaking causes them to lose their tensile strength and greatly increases the danger of contamination. They are dipped in warm water for a few seconds immediately before handing them to the operator.) (12) If spinal anesthesia is to be used, the spinal kit is opened. 84 TM 8-220 SOLDIER’S HANDBOOK 123-127 (13) All tables and stands containing sterile articles are draped with sterile towels or sheets until they are needed. (14) The patient is wheeled into the operating room. (15) By this time the surgeons and assistants are dressed and scrubbed and ready to put on sterile gowns and gloves. (16) The patient’s skin is then prepared by the assistant in the manner previously described. (17) The patient is then draped with towels and laparotomy sheets by the assistant and nurse or attendant. (18) The instrument table is rolled into place as well as the basin stands. (19) The surgeon and his assistants assume their proper places. (20) The nurse or attendant hands the surgeon the scalpel; the incision is made, after which the skin knife is discarded, and the operation proceeds. Section II BANDAGING AND DRESSING General 124 Uses 125 Acknowledgment 126 Rules for bandaging 127 Application of bandages and their uses 128 Dressings 129 Paragraph 124. General.—Bandaging is an art which develops only after extensive practice. The coach-and-pupil method is a very good method for beginners. Each pair alternate as the coach and pupil. 125. Uses.—a. To retain dressings, in keeping medications to affected parts. b. To give support to dependent parts of the body as the arms, scrotum, etc. c. To apply pressure in control of hemorrhage, to assist in ab- sorption of fluids and as tourniquets. d. To keep foreign matter out of wounds. e. To absorb wound secretions, as pus, etc. f. For immobilization in combination with splints. 126. Acknowledgment.—The illustrations and most of the text in this section are taken from the Handbook of the Hospital Corps, U. S. Navy, and the courtesy of the Bureau of Medicine and Surgery in permitting the use of that handbook is acknowledged. 127. Rules for bandaging.—a. In applying a roller bandage, the roll should be held in the right hand so that the loose end is on 85 TM 8-220 127- MEDICAL DEPARTMENT the bottom; the outside surface of the loose or initial end is next applied to and held on the part by the left hand; and the roll is then passed around the part by the right hand which controls the tension and application of the bandage. Two or three of the initial turns of a roller bandage should overlie each other in order to secure the bandage and keep it in place. In applying the turns of the bandage, it is often necessary to transfer, the roll from one hand to the other. h. Bandages should be applied evenly, firmly, and not too tightly. Excessive pressure may cause interference with the circulation and may lead to disastrous consequences. In bandaging an extremity, it is therefore advisable to leave the fingers or toes exposed in order that the circulation of these parts may be readily observed. It is likewise safer to apply a large number of turns of a bandage rather than to depend upon a few too firmly applied turns to secure a splint or dressing. c. In applying a wet bandage, or one that may become wet in holding a wet dressing in place, it is necessary to allow for shrinkage. The turns of a bandage should completely cover the skin, as any uncovered areas of skin may become pinched between the turns with resulting discomfort. d. Bandages should be applied in such a manner that skin sur- faces are not brought in contact, as perspiration will cause excoria- tion and maceration of the skin. e. In bandaging an extremity, it is advisable to include the whole member (arm and hand, leg and foot), except the fingers and toes, in order that uniform pressure may be maintained throughout. It is also desirable in bandaging a limb that the part be placed in the position it will occupy when the dressing is finally completed, as variations in flexion or extension of the part will cause changes in the pressure of certain parts of the bandage. /. The initial turns of a bandage of an extremity (including spica bandages of the hip and shoulder) always should be applied securely, and when possible, around the part of the limb that has the smallest circumference. Thus in bandaging the arm or hand, the initial turns m illy are applied around the wrist, and in bandaging the leg or ft the initial turns are applied immediately above the ankle. (~ The final turns of a completed bandage usually are secured in the same manner as are the initial turns, by the employment of two or more overlying circular turns. As both edges of the final circular turn are necessarily exposed, they should be folded under to present a neat, cuff-like appearance. The terminal end of the 86 TM 8-220 SOLDIER S HANDBOOK 127-128 completed bandage is turned under and secured to the final turns by either a safetypin or adhesive tape. When these are not avail- able, the end of the bandage may be split lengthwise for several inches, and the two resulting tails secured around the part by tying. h. When the turns of a bandage cross each other, as in the figure- of-eight, the spiral reverse, and the spica, the line of crossing should be straight, and if practicable, should be in the center line of the part bandaged, but the line of crossings should not be over a bony prominence. The exposed portions of the turns should be of approxi- mately the same width. i. In removing a bandage, it may be cut, preferably with bandage scissors.. In doing so the operator should be careful to avoid inter- ference with the underlying dressing and the affected area. j. If the bandage is removed without cutting, its folds should be gathered up in first one hand and then the other as the bandage is unwound. This procedure will facilitate removal and the rewinding of the bandage, if that be desirable. 128. Application of bandages and their uses.—a. Circular bandage.—After anchoring the initial turns of the bandage, a series of circular turns is made around the part. Each turn should overlie accurately the turn beneath it, neither ascending nor descending. This bandage is used for retention of dressings to a limited portion of an extremity, the neck, or the head; compression to control venous hemorrhage and to prqmote venous stasis. b. Spiral bandage.—After anchoring the initial turns, each turn is applied in a spiral direction in such a manner as to overlie one-third of the preceding turn. As usually applied to an extremity, the upper edge of each turn of an ascending spiral is tighter than the lower edge with resulting inequality of pressure. For this reason, many surgeons object to its use on an extremity. This bandage is used for retention of dressings of the arm, chest, and abdomen (fig. 14). c. Oblique bandage.—A series of oblique turns is applied around a part in such manner as to have an uncovered area between turns. The width of the uncovered area should be uniform throughout. This bandage is used for retention of thick dressings or of temporary dress- ings which require frequent removal. d. Recurrent bandage.—ln applying this bandage, the roller, after securing the primary turns, is carried completely over a part to a point opposite its origin, and then reflected and brought back to the starting point where it is secured by one or more circular turns (fig. 15). In the recurrent bandage of the hand, the bandage is 87 TM 8-220 128 MEDICAL DEPARTMENT secured at the wrist, carried over the back of the hand, around the tips of the fingers, across the palm to the wrist. Held at this point by the disengaged hand of the operator, the bandage is carried across the palm around the tips of the fingers, across the back of the hand to the wrist, where it is held by the thumb of the operator’s disengaged hand. Each turn overlies one-third of the pre- ceding turn. The original turn over the fingers may cover the middle and ring fingers, with each succeeding turn applied alternately over the other fingers first to one side and then to the other of the middle finger; or the original turn over the fingers may be applied over the first finger Figure 14. Spiral band- age. (Owen.) Figure 15. Recurrent bandage of stump. (Wharton.) or over the little finger, each subsequent turn covering a portion of the remaining exposed fingers. The reflected portion of the bandage at the wrist is then secured by a number of circular turns. It is cus- tomary to complete such a bandage with a figure-of-eight bandage enclosing the entire hand. e. Figure-of-eight bandage.—This is undoubtedly the most useful bandage and, with its various modifications, probably is employed more frequently than any other type. The enlisted man should perfect himself in the application of this bandage, as, with a few exceptions, the majority of bandages are applied on the principle of the figure-of- eight. Its name is derived from the fact that the turns are applied so as to form a figure 8. Although it is employed commonly in band- ages of the joints (elbow, knee, and ankle), it frequently is applied 88 TM 8-220 SOLDIER S HANDBOOK 128 in bandaging the neck and axilla, head and neck, and head and jaw. If properly applied, it may be used very successfully in bandaging the extremities. (1) Hand and wrist.—After anchoring the bandage with two cir- cular turns about the wrist, the bandage is carried across the back of the hand to the base of the fingers, then into the palm, across the palm to the back of the hand, and across the back of the hand to the starting point at the wrist, where one circular turn is made. This general course is followed with several similar turns, each one overlying about one-third of the preceding turn on the back of the hand. After a sufficient number of turns has been made, the bandage is terminated with a circular turn around the wrist. This bandage is used for re- tention of dressings on the back of the hand or in the palm (fig. 16). Figure 16.—Figure-of-eight bandage. (Wharton, modified.) (2) Forearm.—This bandage may be the continuation hf the figure- of-eight of the wrist and hand, or may be started with primary circular turns of the wrist. The bandage is carried obliquely upward across the back of the forearm and around the arm in its natural course, where it forms the upper loop of the figure-of-eight. The bandage then is carried in an oblique direction downward across the back of the arm, where it crosses the upward turn of the bandage. Then it is carried around the lower end of the forearm to complete the lower loop of the figure-of-eight. The same process is repeated several times until the elbow is reached, each turn overlapping the upper one-half or three-quarters of the preceding turn. The bandage is terminated finally with two or more circular turns at the elbow. The final cir- 89 TM 8-220 128 MEDICAL DEPARTMENT cular turn, with both upper and lower edges of the bandage folded under, should be applied firmly and should present a neat, cuff-like appearance at the upper end-of the completed bandage (fig. 16). Dur - ing the application of this bandage, there is always considerable slack in one edge of the bandage where it is carried around the arm. As the bandaging proceeds, however, these loose edges are covered by t he ascending turns of the bandage. It is used for retention of dressings and covering of splints. (3) Elboio.—With the elbow in the desired position, the initial end is secured by circular turns around the forearm just below the elbow. The bandage then is carried upward over the flexure of the elbow in an oblique direction and passed around the arm just above the elbow, where a circular turn is made, and then is carried obliquely downward across the flexure and passed around the forearm. This procedure is repeated, with each turn overlying the preceding turn, the turns on the forearm ascending and those on the arm descending until the entire joint is covered. The final turn is a circular one around the elbow joint itself. This bandage may be started with a circular turn around the joint followed by figure-of-eight turns covering the upper part of the forearm and the lower part of the arm. It is used for retention of dressings around the elbow joint. /. Spiral reverse bandage of the arm.—This bandage is in reality a modification of the figure-of-eight, in that only the lower loop or one-half of the figure-of-eight is completed. After anchoring the Figure 17.—Spiral reverse. (Bliason.) primary turns, the bandage is carried obliquely upward on the back of the arm. When this turn reaches the center line of the arm, the thumb of the disengaged (usually the left) hand is placed upon the body of the bandage to hold it securely in place upon the arm. The 90 TM 8-220 SOLDIER S HANDBOOK 128 operator then unrolls about 5 or 6 inches of bandage which is held slack and is folded upon itself by changing the position of the hand holding the roller from supination to pronation. The bandage then is carried obliquely downward across the arm to a point opposite that from which the ascending turn started. It then is tightened slightly to conform to the part accurately, then is carried around the limb and the procedure is repeated. It is necessary to retain the thumb upon the point of reverse until the succeeding turn reaches that point. As in the figure-of-eight, each turn should overlie at least one-third of the preceding turn and the reverses should be in-a straight line (fig. 17). g. Complete bandage of the hand.—After securing the initial turns around the wrist, a recurrent bandage of the hand is applied. The bandage then is carried obliquely across the back of the hand to the tip of the index finger. A circular turn is made around the ends of the fingers. The fingers and hand then are covered by a figure-of-eight or spiral reverse bandage which finally is completed by two or more circular turns around the wrist. This bandage may or may not be applied to include the thumb. It is used for retention of dressings of the hand (fig. 18). h. Demigauntlet bandage.—Using a 1-inch bandage, secure the initial turns at the wrist and carry the bandage across the back of the hand to the base of the thumb, around the thumb, across the back of F'gukk 18.—Complete band age of hand. (Wharton.) FHiintK 19.—I of hand. (Wharton.) FuJUite 20.—Gauntlet band- age of hand. (Wharton.) the hand to the wrist, where a circular turn is made. The same pro- cedure is repeated successively for each finger and the bandage finally terminated with a circular turn around the wrist. It is used for reten- tion of dressings on back of hand (fig. 19). /. Gauntlet bandage.—The demigauntlet bandage may be extended to include the entire thumb and fingers with either simple spiral turns or spiral reverse turns of each digit (fig. 20). 91 TM 8-220 128 MEDICAL DEPARTMENT j. Spica handage of right -shoulder {ascending).—After securing the initial end by two circular turns around the arm opposite the axillary fold, the bandage is carried diagonally across the arm and front of the chest to the axilla of the opposite side, then around the back of the chest, across the arm, and across the upward turn to the point of origin. After carrying the bandage around the arm, this pro- cedure is repeated, each turn overlying about two-thirds of the preced- ing turn until the entire shoulder is covered. The turn should cross in a straight line extending up the center line of the arm over the point of the shoulder. Likewise the turns across the chest and back should overlap each other uniformly, and the turns in the opposite axilla should overlap each other exactly. The bandage may be secured by either a pin or adhesive tape. It is used for retention of dressings of shoulder and axilla and of shoulder cap (fig. 21). Figure 23.—Spica, and spica loops of the shoulder. (Eliasou.) Figure 22.—Ascending and descending spica. (Eliason.) k. Bandages of the lower extremity,—The bandages described in the preceding paragraphs may be applied to the corresponding parts of the lower extremity. However, descriptions of a few of the special bandages of the lower extremity are as follows: (1) Spiea hand age of the groin {ascending).—After securing the initial turns around the upper part of the thigh just below the groin, the bandage is carried obliquely upward across the lower abdomen to the iliam crest of the opposite side, transversely across the back, then downward obliquely across the front of the thigh, across the upward turn of the bandage, and around the thigh to the point of origin, thus completing a figure-of-eight. This is repeated several times until the entire groin is covered, each turn overlying about two- thirds of the preceding turn. The same care in regard to the line of crossings of the turns and to the uniform overlapping of the bandage on the abdomen should be observed as is noted in the descrip- tion of the spica bandage of the shoulder. It is used for retention of dressings in region of the groin (fig. 22). 92 TM 8-220 SOLDIER'S HANDBOOK 128 (2) Spica 'bandage of the foot.—The initial end is seem i by two circular turns arm nd the leg just above the ankle. The bandage then is carried across the dorsum of the foot to the base of the toes where a circular turn is made around the foot. After two or three spiral reverse turns are made, the bandage is carried across the dorsum of the foot, backward alongside of the heel, around the heel, forward along the other side of the heel across the preceding upward turn on the dorsum of the foot, and around the foot to the starting point of the turn. This process is repeated, the turns gradually ascending on both the foot and the heel, the crossings of bandage being in the midline of the dorsum of the foot. The bandage finally is carried upward around the ankle and secured by two or more circular turns at its original starting point. It is possible to apply this bandage without the use of the spiral reverse turns by employing the figure-of- eight throughout. It is used for retention of dressings on the foot and support for sprained ankle (fig. 23). Figure 20.—Spica of the foot; first step and completed. (Eliason.) (3) Bandage of foot, not covering the heel.—After securing the initial end by two circular turns around the leg just above the ankle, the bandage is carried obliquely across the dorsum of the foot to the base of the toes where a circular turn is made around the foot. The bandage is carried up the foot by a few spiral reverse turns crossing in the center line, and then applied as a figure-of-eight around the ankle and instep. The bandage may be terminated just above the ankle or be extended up the leg as far as may be necessary. It is frequently practicable to apply this bandage without employing the spiral reverse turns, the figures-of-eight being applied following the circular turns at the base of the toes. It is used for retention of dressings of foot. This bandage usually is employed in application of bandages covering the entire leg. I. Special bandages.—(l) Velpeau bandage.—The fingers of the affected side are placed upon the opposite shoulder, a pad placed in 93 TM 8-220 128 MEDICAL DEPARTMENT the axilla, and the skin surfaces separated by sheet wadding. Place the initial end of the bandage on the shoulder blade of the sound side, carry the bandage across the outer portion of the affected shoulder, downward over the outer and posterior surface of the flexed arm, behind the point of the elbow, obliquely across the back of the forearm and chest to the opposite axilla, and around to the point of origin. After repeating this turn once, the bandage is carried from the point of origin across the back and side of chest, in front of the flexed elbow and transversely across the front of the chest. Then it is carried around the other side of the chest, diago- nally across the back to the affected shoulder. The first turn then is repeated, followed by a second circular turn around the chest and PiGWitE 24.—Velpeau bandage; start (Eliason). posterior view (Kliason), and completed (Wharton). flexed arm. Each vertical turn over the shoulder overlaps two- thirds of the preceding turn, ascending from the outer part of the shoulder to the neck and from the upper posterior surface of the arm inward toward the point of the elbow. Each transverse turn also overlies one-third of the preceding turn. These transverse turns are continued until the last turn covers the wrist. The bandage is finally secured with pins, both where it ends and at various points where the turns of the bandage cross each other. (The initial turns of this bandage may be secured by circular turns around the chest under the arm of the affected side.) It is used for fixation of arm in treatment of fractured clavicle and fixation of humerus after reduc- tion of dislocated shoulder joint (fig. 24). (2) Barton hand age.—With the initial end of the bandage applied to the head just behind the right mastoid process, the bandage is carried under the bony prominence at the back of the head, upward 94 TM 8-220 SOLDIER’S HANDBOOK 128 and forward back of the left ear, obliquely across the top of the head, downward in front of the right ear, under the chin, upward in front of left ear, obliquely across the top of the head, crossing the first turn in the midline of the head, thence backward and downward to the point of origin behind the right mastoid. Then it is carried around the back of the head under the left ear, around the front of the chin, under the right ear to the point of origin. This procedure is repeated several times, each turn exactly overlying the preceding turn. The bandage is secured with a pin or strip of adhesive tape, and either a pin or adhesive may be applied at the crossing on top of the head. It. is used for fracture of lower jaw and retention of dressings of chin (fig. 25). FiGTJiti; 25.—Barton bandage. (Wharton.) (3) Recurrent bandage of head.—The initial turns are applied around the head, passing around the nape of the neck, above each ear and around the forehead. When the bandage has reached the center of the forehead on the third turn, its free margin is held by a finger of the left hand and the bandage is reversed and carried over the top of the head in the center line to the nape of the neck. With an assistant holding the bandage at the latter point, it is re- flected forward over the top of the head covering the right half of the preceding turn. When it reaches the forehead in the midline, it again is reflected over the top of the head, overlying the left half of the first turn. At the nape of the neck in the center line, it is again reflected and carried forward overlying the outer half of the second turn. This process is repeated until the entire head is covered, the turns alternating to the right and left of the center line. The band- age finally is completed by several circular turns overlying the origi- nal turns and fixing the ends of antero-posterior turns at the nape of the neck and on the forehead, where pins should be applied to pro- vide additional security. Uses: Retention of dressings of wounds of 95 TM 8-220 128 MEDICAL DEPARTMENT the scalp, of fractures and operative wounds of the skull (fig. 26). This bandage may be applied with the turns over the head in a transverse direction extending from ear to ear. (4) Grossed bandage of one eye.—The initial extremity is secured by a circular turn around the head below the bony prominence at the back, above both ears and across the forehead. The bandage then is carried from the back of the head, below the ear, obliquely across the outer part of the cheek to the base of the nose at its junction with the forehead, over the opposite side of the head and downward behind the mastoid process, A circular turn then is carried around the head, overlying exactly the original turns. A Figure 27.—Crossed bandage (figure-of- eight) of one eye and of both eyes. (Eliason.) Figuke 26.—Recurrent turns. (Eliason.) second turn under the ear and across the face and head then is ap- plied, overlapping the upper two-thirds of the preceding turn. These alternating turns are repeated until the eye (and if more comfortable, the ear on the same side) is completely covered. The bandage is completed with a final circular turn around the head. It is used for retention of dressings of the eye (fig. 27). (5) Grossed bandage of both eyes.—The initial turns are applied as for one eye and the bandage carried forward below the right ear, diagonally upward across the cheek to the base of the nose and over the opposite side of the head above the left ear, and down- ward behind the left mastoid process. Then a circular turn is ap- plied. When the roller reaches the back of the head below the bony prominence, it is carried obliquely forward and slightly upward over the right ear across the forehead and downward over the left eye, the lower margin of the bandage crossing the previous turn at the junction of the nose with the forehead. The bandage then is carried across the left cheek below the left ear and backward to the nape of the neck. Then a circular turn is made, followed by a repe- tition of the previous turns across the eyes, each circular turn 96 TM 8-220 SOLDIER’S HANDBOOK 128 accurately covering its predecessor and each oblique turn overlying the upper one-half of the preceding turn until both eyes are com- pletely covered. The ears may or may not be included in the bandage, which is completed by two circular turns around the head. Pins are placed at the interesections of the bandage (fig. 27). (6) Sayre’s dressing.—This consists of two strips of adhesive plaster 3 inches wide and 2 yards long. Two circular turns of a flannel bandage 4 inches wide are applied to the arm of the affected side just below the axillary fold. The end of one adhesive strip is looped around the arm (overlying the flannel bandage) and pinned, with the loop sufficiently large not to constrict the arm. With the Figure 28.—Sayre's dressing for fracture of the clavicle, showing application of first and second strips. (Wharton.) arm drawn upward and backward, the strip of plaster is carried across the back and around the opposite side of the chest. It may end here or be carried completely around the chest. The hand of the injured side now is placed as near as possible to the shoulder of the sound side, the skin surfaces being separated by sheet wadding. The end of the second strip is applied over the scapula of the affected side (some surgeons start this strip at the top of the posterior sur- face of the arm of the affected side; others apply the initial end of this strip on the shoulder of the sound side) and is carried downward on the posterior surface of the arm of the affected side, under the point of the elbow, diagonally across the chest on the posterior sur- face of the forearm and hand over the sound shoulder down the back where it joins the first strip of plaster. A small hole is cut in this strip to receive the point of the elbow, which must be protected by a layer of cotton or sheet wadding. Then the entire dressing is covered with a Velpeau bandage. It is used for treatment of frac- tures of the clavicle (fig. 28). (7) T-bondage.—This bandage consists of a horizontal bandage to which is attached, about its middle, a vertical bandage of approxi- 97 TM 8-320 128 MEDICAL DEPARTMENT mately one-half the length of the horizontal bandage. The hori- zontal portion is employed to secure the bandage to the body, the vertical portion being used to retain dressings. This bandage is very useful in retaining dressings about the perineum and anal region. When used for this purpose, the horizontal band is applied around the abdomen above the iliac crests in such manner that the vertical portion is placed exactly in the midline of the back directly over the spine. The vertical portion then is brought forward between the thighs and secured to the horizontal portion in front of the abdomen, The vertical portion may be split longitudinally to form two strips of equal width. (8) Double T-bandage.—This differs from the T-bandage in hav- ing two vertical strips instead of only one. The horizontal portion may be of any desired width. It frequently is used for the retention of dressings of the chest, breast, and abdomen. When so employed, the two vertical strips are carried over the shoulders from the back to the front and secured by pins to the horiztonal portion. (9) Tailed bandage.—(a) The four-tailed bandage is made readily by splitting a strip of muslin or other material of the desired width, lengthwise, within a few inches of the center of the strip. This pro- vides a bandage with a body and four tails. (b) The many-tailed bandage is prepared in a similar manner, by splitting the muslin or other material into several strips, having a sufficiently large area in the center for the retention of dressings, etc. The number of tails on each side should be the same. (10) Plaster of paris bandage.—These bandages are prepared by impregnating the meshes of crinoline with plaster of paris of the extra calcined, dental variety. A strip of crinoline about 3 or 4 inches wide and usually 4 or 5 yards long, is placed on a table. Plaster of paris then is dusted upon the strip and evenly rubbed into the meshes of the fabric. A very satisfactory method of pre- paring this bandage is by constructing a wooden box 12 inches long, 6 inches wide, and 3 inches deep, and at each end, just above the bottom of the box, cutting a slit 5 inches long and % to % inch wide. The end of the bandage is drawn into the box through one slit across the bottom of the box and out of the box through the other slit. A sufficient quantity of the plaster of paris to cover the bandage with a layer of powder 1 inch deep is placed in the box. As the bandage is drawn through, plaster of paris is rubbed into the meshes with the hand or preferably with a smooth piece of wood approximately 4 inches in length. The bandage may be loosely rolled into a cylinder as it emerges from the box. If the bandages 98 SOLDIER’S HANDBOOK TM 8-220 128 are not to be used within a few hours, they should be wrapped in paper to prevent absorption of moisture. (a) Application.—The part-to be encased in plaster of paris should be covered with a suitable bandage of soft material, preferably flannel. The bony prominences should be well protected with cotton. Care should be taken to remove all creases in the dressing and bandage. Two rolls of the plaster of paris bandage are placed in warm water. When bubbles cease to arise from the bandage one roll is removed from the water, the excess water being expressed by grasping the roll at its two ends and exerting pressure with the hands. This method pre- vents the loss of a considerable amount of plaster through the ends of the roll. Note.—As soon as a bandage is removed from the water replace it with another bandage. The bandage should be applied rapidly and evenly to the limb. No special form of bandage is necessary as it is sufficient that the part be properly covered. The second bandage is applied as soon as the first has been completed. During the application of the bandage it should be rubbed with the hands in order to provide a smooth, even surface. It also is desirable to rub some loose plaster into the dressing. When the final roller has been applied, the surface of the completed dressing should be rubbed evenly with liquid plaster prepared by addition of water to dry plaster until it has the consistency of thick cream. In many cases, such as compound fractures, it is frequently necessary to provide access to certain areas of the encased limb. After the bandage has partially set, a “window” or trap may be cut in the bandage over the desired area. Kemoval of a plaster of paris bandage may be ac- complished with the aid of a plaster saw. If none is available, the plaster may be softened ith a small amount of peroxide of hydrogen, hydrochloric acid, or vinegar, and then may be cut with a knife. (b) Uses.—This bandage is used for fixation of fractures; ambulant treatment of fractures; fixation and treatment of injuries and diseases of joints. (11) Starched bandage.—This bandage may be obtained already prepared or it may be prepared in the following manner: Starch is mixed with cold water until a thin, creamy mixture results. This is heated to form a clear mucilaginous liquid. The part should be cov- ered with a flannel bandage over which a gauze bandage is applied. The starch then is rubbed evenly into the meshes of the material. A second gauze bandage is applied and again treated with the starch mixture. This may be repeated until the desired thickness of the bandage is obtained. Bandages impregnated with starch may be 99 TNL 8-220 128 MEDICAL DEPARTMENT moistened and applied wet to a part. This type of bandage is oc- casionally useful in the treatment of sprains of the thumb or fingers. (12) Triangular bandage.—This bandage, also known as the hand- kerchief bandage, is used for the temporary or permanent dressing of wounds, fractures, dislocations, etc., and for slings. It is very valu- able in first-aid work as it is quickly and easily applied, stays on well, and can be improvised from any kind of cloth, as a piece of a shirt, an old sheet, a large handkerchief such as the Navy uniform neckerchief, etc. Unbleached muslin is generally used in making triangular band- ages, although linen, woolen, silk, etc,, will answer the purpose. In making them, a square of material about 3 by 3 feet or slightly more is folded diagonally to make one bandage or may be cut along the fold to make two bandages. The long side of the triangle is called the “base”, the point opposite the base is called the “apex”, and the points at each end of the base are called the “ends” or “extremities.” These bandages may be used either as a triangle or as a cravat, the latter being made from the triangle by bringing the apex to the base and folding it upon itself a sufficient number of times to obtain the width desired (fig. 29). The names of these bandages indicate the part of the body to which the base is applied, the location of the apex, and the shape. For example, in the fronto-occipital triangle the base of a triangular bandage is applied to the forehead and the apex is carried to the occiput, and in the mento-vertico-occipital cravat the middle of the base is placed under the chin and the ends carried over the vertex of the skull to the occiput. A few of the more commonly used tri- angular bandages are as follows: (a) Fronto-occipital triangle.—Place the middle of the base of the triangle on the forehead so that the edge is just above the eyebrows and bring the apex backward over the head, allowing it to drop over the occiput. Bring the ends of the triangle around to the back of the head, above the ears, cross them over the apex at the occiput, and carry them around to the forehead and there tie them in a square knot. Finally turn up the apex toward the top of the head and pin with a safety pin or turn up the apex and tuck it in behind the crossed part of the bandage. It is used to retain dressings on the forehead or scalp (fig. 30). (h) Triangle of chest or back.—Drop the apex of the triangle over the shoulder on the injured side and bring the bandage down over the chest (.or back) to the level desired and so that the middle of the base is directly below the shoulder. Carry the ends around the body and tie in a square knot on the back. Finally, bring the apex down on the back (or chest) and tie it in a square knot to one of the ends. 100 TM 8-220 128 SOLDIER S HANDBOOK It is used to retain dressings on burns or wounds of the chest or back (fig. 31). (c) Brachio-eerviral triangle, or arm sling.—The arm to be put in the sling should first be bent at the elbow so that the little finger is about a baud’s breadth above the level of the elbow. Drop one end of the triangle over the shoulder on the uninjured side and let the bandage hang down over the chest with the base toward the Figure 29.—Folding cravat from triangle. hand and the apex toward the elbow. Slip the bandage between the body and the arm, carry the lower end up over the shoulder on the injured side, and tie the two ends together at either side of the neck, using a square knot. Draw the apex of the bandage toward the elbow until it is snug, bring it around the elbow to the front, and after folding back a little, fasten it to the front of the bandage with a safetypin. The lower end of the bandage may be passed between the arm and the body and under instead of over the injured 101 TM 8-230 128 MEDICAL DEPAKTMEJNIT Fiudre 30.—Erouto-oecipital triangle. 102 SOLDIER'S HANDBOOK TM 8-220 128 Figueb 31.—Triangle of chest or back. 103 TM 8-220 128 MEDICAL DEPARTMENT Pigvub 82.—Brachio-cervical triangle or arm sling showing lower end passing between arm and body. 104 TM 8-320 SOLDIER'S HANDBOOK 128 Fkjijhm. —Trijmnkl of hand TM 8-330 128 MEDICAL DEPARTMENT shoulder before tying to the other end. The ends of the fingers should extend slightly beyond the base of the triangle (fig. 32). (d) Triangle of hand.—Place the middle of the base of the triangle well up on the palmar surface of the wrist, carry the apex around the ends of the fingers and over the dorsum of the hand to the wrist or forearm, fold each half of the part at the sides of the hand back toward the opposite side of the wrist, cross the ends around the wrist, and tie in a square knot. It is used to retain dressings of consider- able size on the hand (fig. 33). (e) Triangle of foot.—Place the middle of the base of the triangle on the ankle well above the heel, carry the apex around the ends of the toes and over the dorsum of the foot to the ankle, fold each half of the part at the sides of the foot back toward the opposite side of the ankle, cross the ends around the ankle, and tie in a square knot. It is used to retain dressings of considerable size on the foot (fig. 34). Figure 34.—Triangle, of foot. (/) Gluteo-femoral triangle.—To apply this bandage requires two bandages, one a triangle, the other a cravat. First fasten the cravat around the waist. Place the base of the triangle in the gluteo-fem- oral fold and carry the ends around the thigh to the front where they are tied with a square knot. The apex is then carried upward and passed under the cravat around the waist, turned down and fastened to the triangle with a safetypin. It is used to retain dressings on the buttock or hip (fig. 35). (13) Cravats.—(a) Mento-vertico-occipital cravat.—After making a triangle into a cravat of the proper width, place the middle of the cravat under the chin, carry the ends upward in front of each ear to the vertex of the skull, crossing them there, and continuing down- ward to the occiput where they are tied in a square knot. Uses: To retain dressings on the chin, cheeks, and scalp, and as a temporary dressing to secure fixation of the parts in fracture or dislocation of the jaw (fig. 36). 106 TM 8-320 SOLDIER'S HANDBOOK 128 Figure 35.-—Gluteo-femoral triangle.'. Pi«juke 3(5.—Monto-vert ico-occipit;i I or; i vat. Figure 37.—Bis-axlilary cravat. Figure 38,—Cravat of head or ear. 107 TM 8-220 128-129 MEDICAL DEPARTMENT (b) Bis-a.xilla.ry cravat.—After making a triangle into a cravat of the proper width, place the middle of the cravat in the axilla, carry the ends upward to the top of the shoulder, crossing them there and continuing across the back and chest, respectively, to the opposite axilla, where they are tied in a square knot. It is used to retain dressings in the axilla or on the shoulder (fig. 37). (c) Cravat of head, or ear.—After making a triangle into a cravat of the proper width, place the middle of the cravat over the point de- sired. carry the ends to the opposite side of the head, cross them, and bring them back to the starting point and tie with a square knot. Use: To apply pressure to control serious hemorrhage from wounds (fig. 38). 129. Dressing’s.—a. Types..—A dressing consists of everything used to cover or dress n wound. The pad put directly over the wound is called a “compress.” In ordinary emergency treatment, a wound dressing consists of a compress with bandage to hold it on. A dressing may be either dry or wet, asceptic or antiseptic. (1) An asceptic dressing is one which is sterile, that is, with no bacteria on it. (2) An antiseptic dressing is one which, in addition to being sterile, contains some substance for killing bacteria. (3) A wet dressing generally is an antiseptic dressing and is used in wounds where infective inflammation is going on. Wet antiseptic dressings generally are made up of a layer of sterile gauze saturated with the antiseptic solution. A layer of sterile cotton is then applied, with some impervious material such as oiled silk put over the dressing to retain the moisture, and a bandage over all. The dressing must be kept wet with the antiseptic solution, either by frequent changing or by having perforated rubber tubes between the gauze and cotton through which the dressing can be periodically moistened with the antiseptic solution. (4) A d-ry dressing is used to cover a recent wound which is consid- ered to be free from infection. b. Purpose.—The purpose of a wound dressing is to stop hemorrhage, to prevent introduction of bacteria, and to prevent further injury to the wound. c. Types in first-aid packet.—The Army supplies two first-aid pack- ets. one small and one large, which are hermetically sealed tin cans con- taining dry sterile dressings. (See figs. 39 to 42, inch). All these dressings consist of a sterile gauze compress with bandages attached. d. Preparation of wov/nd fo?' dressing.—(l) General..—Any piece of cloth, such as gauze, cotton, linen, muslin, or a handkerchief, pro- vided it is rendered sterile, is suitable for a compress in case of emer- 108 TJVt 8-220 SOLDIER’S HANDBOOK 129 Figure 39.—First-aid packet, U. S. Army. Figure 40,—Application of dressing, first-aid packet, smalL 109 TM 8-220 129 MEDICAL DEPARTMENT gency. The most vital point about material used as a compress of a wound is that, before it is applied to a wound, it should be rendered sterile. The part of the dressing which is to come in contact with the wound must not be touched with any part of the body or anything else except sterile instruments before its application to the wound. In an emergency, material to be used in a wound dressing may be sterilized by boiling it for 10 minutes. Fu;cuk 41.—First-aid drossinj;. lar^e. FiOuicw 42.—First-aid dressing, larjro, open. (2) Procedures.—When a patient can be brought under the care of a medical officer in the near future, the procedure necessary in the first-aid treatment in the case of ordinary wounds is to stop the hem- orrhage, treat the shock, and apply a sterile dressing to the wound. If a medical officer is not available, the wound must be further treated as described below. 110 TM 8-220 SOLDIER S HANDBOOK 129 (a) In treating a freshly made wound, the following procedure is recommended: 1. Cleanse the hands as thoroughly as possible by a thorough scrubbing with soap and hot water, followed, if possible, by immersion in hot 1-2,000 bichloride of mercury solu- tion and then 70 percent alcohol. 2. Sterilize all instruments to be used in removing foreign bodies such as dirt, glass, splinters, or for shoving the skin about the wounds. Figure 4.'5.—Type of wet dressing. 3. If there is bleeding, arrest the hemorrhage. Jf. If there is grease in or about the wound, remove it with tur- pentine or gasoline. 6. Remove all foreign particles with sterile forceps. 6. Apply tincture of iodine to all parts of wound and the skin about the wound for a distance of about one-half inch beyond the wound edges. After the skin has been well dried, the wound edges are brought together and a dry dressing applied. 7. There is no substance which should be used by the first-aid man to wash a wound; more dirt is washed in than out, and ordinary water is dangerous since it is not sterile. Strong antiseptics, such as bichloride of mercury or phenol, will destroy the cells of the body which dispose of 111 TM 8-220 129-130 MEDICAL DEPARTMENT the pus bacteria before they kill the latter. Peroxide of hydrogen is not strong enough to kill alt bacteria and in large or deep wounds it washes some of these bacteria to uninfected parts which then become infected. Tinc- ture of iodine is the only substance to be used in an ordi- nary fresh wound by the first-aid man, aside from ben- zine and gasoline to cut grease, if 'present. (b) The manner in which a wound showing evidence of infective inflammation is treated is as follows: 1. Elevate the part. 2. Put it at rest. 3. Remove foreign bodies, if present. Jf,. Remove sufficient sutures, if present, to obtain good drainage. 5. Insert drain. 6. Apply a wet antiseptic dressing (fig. 43). 7. Treat the constitutional symptoms. Section 111 SPLINTS AND THEIR APPLICATION General —; . 130 Army hinged half-ring thigh and leg splint 131 Thomas arm splint 1 132 Cabot posterior splint 133 Wire ladder splint 134 Aeroplane or abduction splint 135 Clavicular or T-splint 136 Wooden splints 137 Other splints : 138 Paragraph 130. General.—a. Splints are devices used for the fixation of broken bones. They are used in the emergency treatment, as well as in the final treatment, of a fracture. It is most important to fix a broken bone as soon as possible after injury. In fractures of large bones, especially of the thigh bone (femur), the injured person within a short time often enters into a state of shock or collapse which may cause death. Fixation of the fractured part with adequate splints as soon as the injured person is seen prevents the development of more shock, or if shock has not already set in, it may not occur. It should be remembered that in addition to splinting the fracture, the patient should be covered with blankets and given hot drinks, if possible, to aid in the prevention or decrease of shock. b. Fixing the fragments of a broken bone prevents the rough and jagged edges of the bone ends from injuring and tearing nearby 112 TM 8-220 SOLDIER’S HANDBOOK 130-131 blood vessels and nerves, thus serious bleeding and paralysis is avoided. In simple fractures (one in which the bone has not punc- tured the skin) proper application of a splint will prevent penetra- tion of the skin by fragments of bone and introduction of infection into deeper tissues. If the fracture is compound (one in which the skin has been punctured by a fragment of bone) splinting will pre- vent the bone from sliding in and out of the wound and the intro- duction of more infection. In addition, proper splinting greatly relieves the pain associated with the fracture. The patient is made much more comfortable and the amount of shock is reduced. c. Thus, proper splinting of a fracture prevents the occurrence of, or increase of, the following: (1) Shock. (2) Local tissue damage (to nerves and blood vessels), (3) Infection. d. Always remember that every fracture of a long bone should be splinted where they lie. Figure 44.—Army hinged half-ring thigh and leg splint. 131. Army hinged half-ring thigh and leg splint.—a. The Army leg splint is the most valuable of all splints when the saving of life is considered. It is used in nearly ail fractures of the femur and can be used in fractures of the leg as far down as the ankle. The mortality rate for compound fractures of the femur was re- duced from 50 percent to 15 percent in one army during the World War due to proper splinting of this bone. TM 8-220 131 MEDICAL DEPARTMENT h. For the purposes of training, application of the Army leg splint is done in 10 steps with a team of four men consisting of the following: No. 1. Operator. Nov 2. First assistant. No. 3. Second assistant. No. 4. Patient. Note.—The procedure here described appears in the pamphlet The Demonstra- tion and Application of the Army Leg Splint (1940, Revised), published by the Medical field Service School, Carlisle Barracks, Pennsylvania. c. The equipment required for each team is as follows: (1) One litter, standard wooden pole or aluminum. (2) One Army leg splint, half-ring, hinged. (3) Two footrest and splint supports. (4) One traction strap. (5) Two rolls of muslin bandage, 5 inches by 5 yards, and one gauze bandage. (6) Three blankets. (7) Six safetypins. (8) One first-aid packet. d. The 10 steps are as follows: (1) Dress litter. (2) Extension. (3) Dress wound. (4) Apply splint. (5) Support leg. (6) Traction strap. (7) Footrest. (8) Foot splint support. (9) Fix splint. (10) Cover patient. e. The procedure is as follows: (1) Step No. 1, dress litter.—The litter is “dressed” by Nos. 2 and 3. A litter is said to be dressed when blankets have been arranged upon it as follows: Place the first blanket on the litter lengthwise so that one edge corresponds to the outside pole of the litter and its upper edge is even with the head of the canvas. Then fold it back upon itself once, leaving the folded edge even with the inside pole of the litter. Place the second blanket folded lengthwise on the first so that one edge corresponds to the inside pole of the litter, and its upper edge is even with the head of the canvas. Then fold it back upon itself once in the same manner as the first. The free edges 114 TM 8—220 SOLDIER £ HANDBOOK 131 of each of these blankets hang over opposite sides of the litter. The No. 4 man now lies on the litter and acts as patient. The third blanket is placed under the patient’s head until the tenth step. (2) Step No. 2, extension.—The No. 2 man of the team stands at the foot of the litter facing the patient. Grasping the heel of the shoe with his right hand and the toe with his left, keeping the arm straight, he exerts a steady pull to produce the necessary traction. The litter sling may be placed across the patient’s chest, under the arms, and attached to the litter stirrup to provide countertraction. Traction should be continued until the traction strap has been fixed. Figuub 45.—Adjustable traction splint strap. (3) /Step No. 3, dress wound.—While extension is continued by No. 2, the No. 1 and No. 3 men dress the wound designated by the instructor. (4) Step No. 4, apply splint.—The splint is applied by rolling it from the outside inward, the short rod to the inner side of the leg and the half ring well up under the buttock. The splint must be horizontal. It is held in place by buckling the upper strap. 115 TM 8-220 131 MEDICAL DEPARTMENT (5) /Step No. 5, support leg.—The leg is supported on the splint by arranging the muslin bandages in the following manner: (a) The first bandage is placed across the upper part of the splint under the thigh. The ends of the bandages are then reversed by cross- ing them under the splint and tying above and to the side. (b) The second bandage is applied above the ankle in the same manner as the first. (c) The third bandage is placed just above the knee. The ends are drawn downward between the two side rods of the splint and knee, are folded upward, then around the leg, and are tied on the upper outer surface. Note.—The positions of the bandages may vary, depending on the location of the fracture. A fourth muslin bandage may be placed under the calf of the leg for additional support. (See fig. 44.) (6) Step No. 6, traction strap.—The traction strap is applied to the foot by the No. 1 man. The loop of the strap is first placed behind the heel and under the foot, and the short buckling strap is brought over the top of the instep and buckled on the inside of the foot. The long strap is then brought over and under the end of the splint, is folded back upon itself, and is inserted through the metal ring. Traction is then maintained by pulling on the free end of the strap. The free end is now secured by tying with the ordinary cinch knot. (7) Step No. 7, footrest.—The footrest is attached to the splint with the lower hooks downward and inside the splint rods. The footrest is pushed against the shoe to prevent foot drop. Spread the footrest, if necessary, for a more secure fit. Secure with bandage to prevent lateral movement of the foot. (8) Step No. 8, foot splint support.—The Army leg splint is applied with the splint support fastened to the side rods of the splint in such position that it will rest on the litter end about 1y2 inches from the end of the canvas. The splint support will normally rest not on the can- vas of the litter but upon the blankets of the dressed litter. (Sec fig 46 (4).) (9) Step No. 9, fix splint.—(a) Take a roll of the bias muslin band- age and stretch it to its greatest length. (h) Tie one end of the bandage to the litter stirrup on the side of the fracture, placing the knot near the pole. Note.—The knot is placed on the stirrup near the pole and the bandage wound around the bevel of the handle near the edge of the canvas to keep the bandage from slipping and becoming loose. (c) Keeping a constant tension on the bandage, carry it to the bevel of the handle close to the canvas and wind it around the handle twice. (Fig. 46 ®.) 116 TM 8-220 SOLDIER’S HANDBOOK 131 Figukb 46,—Use of bandage for fixation of Army hinged half-ring leg splint for transportation. TM 8-220 131 MEDICAL DEPARTMENT {d) Carry the bandage to the near side of the rod of the leg splint, keeping it at a 90° angle (perpendicular) to the splint. Wind the bandage around the side rod twice and carry it back and around the same handle. Then press the splint firmly down on the litter and continue the constant pull on the bandage so that all the slack in the bandage going from the litter to the splint and from the splint back to the litter will be taken up. (Fig. 46®.) Note.—The bandage is kept under constant tension as it is applied in order to overcome the elasticity. The small amount of elasticity remaining is con- sidered beneficial. In an emergency, wire, rope, or other material can be used for fastening the splint to the handles of the litter. (e) Then carry the bandage across the litter to the bevel of the opposite handle* and wind it around twice. (/) Next secure the side rod of the splint on that side in the same manner as was done on the near side, ending by tying the bandage to the stirrup. (Fig. 46®.) Note.—When the muslin bandage is properly applied and tied, the splinted leg and end of the litter can be lifted clear of the ground without loosening the muslin bandage. The position of the splint rest on the blanket and canvas remains unaffected and the bandage is still taut when the end of the litter is again lowered to the ground. (Fig. 46®.) (10) Step No. 10, cover patient.—Fold the third blanket once lengthwise and place it over patient, the upper edge under the chin. Next, fold the free edges of the first two blankets over the third and hold them in place with safetypins. Inclose the feet of the patient by folding the lower ends of the blankets. (Fig. 46®.) This gives four thicknesses of blanket over and four under the pa- tient, thus assisting in the prevention of shock. (11) Alternate step No. 6.—ln the absence of the traction strap, the following may be substituted for step No. 6: {a) An ankle hitch (fig. 45®) is applied by the No. 1 man, assisted by No. 3. Note.—A piece of muslin bandage about 1 yard long is held in the left hand, one-third falling to the left. Pick up the long end with the right hand and form a loop. Drop the long end over the loop as if to tie a single knot, hut do not bring it through the loop. The hitch is now ready to apply to the foot. Hold the hitch as shown in figure 45®, place it around the ankle, and apply the Spanish windlass. (b) To apply the Spanish windlass, cross the two free ends of the bandage under the instep of the shoe; pass one free end over and one free end under the end of the splint. Bring the two ends together and securely tie to the notch at the end of the splint. Now 118 TM 8-220 SOLDIER S HANDBOOK 131 insert a 6-inch stick or nail between the two ends of the bandage just above the tie. Fix the stick or nail between the two rods of the splint. /. In actual practice three persons to apply the splint will often not be available, and in emergencies or on the battlefield variations of the preceding will, of course, be necessary. However, if possible, two men should apply the splint, as it is important that one main- tain a pull on the injured leg until traction is started within the splint. Figure 47.—Skin traction with zinc oxide adhesive and spreader. g. (1) Instead of using a traction strap or ankle hitch, skin trac- tion may be applied, using adhesive tape. This is done when it is necessary to transport the patient for a long distance and also for final hospital treatment when it is necessary to maintain traction for long periods. Before the adhesive tape is applied, the leg is shaved and cleansed with ether. A long strip of 3-inch adhesive tape is then prepared by folding one end back on itself so that two nonsticky surfaces are obtained. This doubled portion is made long enough to extend from 1 or 2 inches above the ankle to the end of the splint A second strip is made in the same way and both are cut to the desired length. The straps thus formed are then heated over a flame and one is applied to each side of the leg extending up to thigh slightly below the line of fracture. In fractures of the lower leg the straps are placed below the knee and extend up to within about an inch of the fracture line. The ends of straps are then tied to 119 TM. 8-220 131-132 MEDICAL DEPARTMENT the end of the splint, or to a spreader which in turn is attached to the end of the splint, and a Spanish windlass applied. Two narrow strips, 1%-inch, are then spiraled about the leg and a snug gauze or bias muslin bandage is applied about the leg to increase adhesion of the straps. (2) An improved type of skin traction, using an acmesive solution and flannel bandage straps may be used if such is available. A satisfactory solution is Ace Adherent, which is painted on each side of the leg and on which the flannel bandage straps are applied. They are applied in the same manner as the adhesive tape straps, except that the leg is not shaved. 132. Thomas arm splint.—a. The Thomas arm splint is used in fractures of the arm from the shoulder down to and including the upper third of the forearm. As with the Army leg splint, it may be applied in steps for purposes of training and the following is from a pamphlet, Demonstration and Application of the Army Arm Splint (1939), published by the Medical Field Service School, Carlisle Barracks, Pennsylvania. h. A three-man team is necessary: No. 1. Operator. No. 2. Assistant. No. 3. Patient. c. The equipment required for each team is as follows: (1) Two rolls of 2-inch adhesive plaster. (2) One Thomas arm splint with full ring. (3) Three wooden tongue blades. (4) Three rolls 2-inch roller gauze bandage. (5) Three 1-yard strips of 2-inch muslin bandage for each three students. (I. The procedure is as follows: (1) Step No. i, extension.—The operator holds the full ring splint while No. 2, his assistant, inserts his right hand through the full ring. Then the No. 2 man, with his right hand, grasps the patient’s in- jured arm firmly at the wrist and makes steady extension, placing his left hand in the armpit of the patient. The operator then puts the splint in place on the patient well up under the arm, and the end of the splint well up against the thigh of the No. 2 man. The No. 2 man then removes his left hand from under the armpit and grasps the wrist of the patient with his left hand, assisting the right hand. (2) Step No. 2, dress wound.—This is done by the operator or No. 1 man. It should be done neatly and quickly. TM 8-220 SOLDIER’S HANDBOOK 132 (3) Step No. 3, applying adhesive strips.—Use two strips, one over the arm and one under the arm, starting about 2 inches above the elbow, down the entire length of the forearm, and about 8 inches over the hand. The two strips should be the same length. Figuisk 4S.—Thomas splint, arm-hinged, for right or left arm (4) Step No. 4, anchor adhesive with 'bandages Support the adhesive strips by applying bandage. Start the bandage at the wrist and use a spiral reverse all the way up the forearm to the elbow. This anchors the adhesive strips to the arm. Do not make bandage too tight because it will affect seriously the circulation of the blood. (5) Step No. 5. completing fixation and traction.—Tie the ends of adhesive together and over the end of the splint. Then with the use 121 TM 8-220 132-133 MEDICAL DEPARTMENT of a short object, such as a stick or wooden tongue depressor, make a Spanish windlass, pulling the arm until proper extension is secured. (6) Step No. 6, support arm.—Using the muslin triangular band- age, make a narrow cravat, bringing it up between the rods of the Army arm splint and over the side of the rods. Then reverse the two ends and bring them around the outside of the rods, tying on the out- side of the splint. One to three of these supports may be used, one at the wrist, one just below the elbow, and one on the upper arm. The splint may then be secured to the patient’s thigh to insure greater immobility of the injured limb while he is being transported. (7) A hitch around the wrist should never be used and it should be remembered that the adhesive straps for traction extend up to a level slightly below the fracture and not above it. Fiuukk 49.—Cabot posterior splint. 133, Cabot posterior splint.—a. The Cabot posterior splint is used for fixation of the leg without traction. It is used for fractures of the patella (kneecap), for sprains and other injuries in the region of the knee, for fractures of the ankle, for fractures in the lower leg when only one bone is broken (tibia or fibula), and for injuries to soft parts of the leg or foot which require fixation for transportation. h. The splint is a frame of rolled steel rod which is bent at a right angle at one end so as to form a support for the foot, and it is long enough to extend up to the middle third of the thigh. A supporting 122 TM 8-220 SOLDIER S HANDBOOK 133-135 hammock is then made by wrapping bias muslin or gauze bandage around the lateral bars of the splint. Additional gauze and cotton padding is added as necessary to prevent pressure on the leg. The splint is then applied to the back of the leg and secured with a bandage which passes around both the leg and the splint. Figure 50.—Wire ladder splint. 134. Wire ladder splint.—a. The wire ladder splint is used for fractures and injuries of the foot and ankle, and to maintain a fixed position of the shoulder, elbow, or wrist when a position other than extension is desired. It is occasionally used for side splinting, in combination with a Cabot posterior splint. h. It is made up of sheets of malleable wire in the shape of a ladder and may be molded into any desired shape and then cut into desired lengths. The splints are padded for comfort and applied with bias muslin or gauze bandage. 135. Aeroplane or abduction splint.—a. This splint is used for fractures of the upper end of the humerus, for fractures of the scapula (shoulder blade), for nerve injuries which cause a paralysis of the shoulder and upper arm, and for bursitis of the shoulder. It is not used in dislocations of the shoulder. b. It is a frame of rolled steel rod which is bent at a right angle to fit under the armpit, so that the lower portion lies along the side of the chest and abdomen down to the hip. The upper portion forms a shelf 123 TM 8—220 135-137 MEDICAL DEPARTMENT for the arm to rest upon. This is also bent at a right angle so that the elbow is flexed when the arm is resting upon it. Canvas or similar material is sewed around the frame to form a supporting hammock and the entire splint is held in place with three straps. Sufficient gauze and cotton pads are added for comfort. The arm is secured by wrap- ping bandage around both the arm and the splint. Figure 51.—Aeroplane or abduction splint. 136. Clavicular or T-splint.—This splint is used for fractures of the clavicle (collar bone), and resembles the letter T as its name implies. The cross bar of the Tis placed behind the shoulders with the longitudinal bar extending downward along the spinal column. Straps from the ends of the cross bar are passed around the shoulders so as to pull the shoulders upward, outward, and backward. A strap passing around the abdomen is attached to the lower end of the splint to allow for a snug fit. 137. Wooden splints.—Wooden splints are usually made of y2- inch by 4-inch basswood, but boards from discarded fruit crates are also satisfactory. They are mainly used for fractures and other severe injuries of the forearm and hand. The splints are cut into the desired shape and are well padded. Usually two splints are ap- plied, one on the back of the forearm and hand and the other on the inner or palm side. They are held in place with adhesive tape and bandage which should be applied snugly but not too tightly. The forearm can then be suspended in a sling. 124 TM 8-220 SOLDIER’S HANDBOOK ,137 Figukb 52.—T-splint with straps for fractured clavicle. Figure 53.—Splinting of lower forearm fractures. 125 TM 8-220 138-139 MEDICAL DEPARTMENT 138. Other splints.—a. Aluminum splints are more satisfactory than wooden splints but they are not always available. They are used in the same manner as wooden splints and may be molded and cut to any desired size and shape. I). It should be remembered that to obtain adequate fixation of a fracture one does not always need a special splint which has been made for a certain type of fracture. When nothing else is available any handy article may be used. Examples of these are rifles, swords, scabbards, tent pins, wire, umbrellas, canes, mop or broom handles, sticks, small pieces of board, etc. These may not be quite as satis- factory as a finished appliance, but if care is taken in applying them, enough support can be obtained to prevent further injury to the patient. Thus, in fractures of the thigh, if a Thomas splint is not available, a long splint extending from well above the hip to beyond the foot on the outside, and a shorter splint extending from the crotch to beyond the foot on the inside will afford a good support when carefully applied. Section IV EMERGENCY MEDICAL TREATMENT Paragraph First aid ■ 139 Wounds ; : 140 Treatment of wounds_: 141 Miscellaneous wounds 142 Hemorrhage 143 Shock 144 Asphyxia 145 Unconsciousness 140 Injuries due to heat 147 Injuries due to cold 148 Fractures 149 Dislocations and sprains—. 150 Common emergencies 151 Poisons ; 152 139. First aid.—a. First aid is the temporary emergency treat- ment given a case of sudden illness or accident before the services of a medical officer can be obtained. This period of temporary care, if intelligently given, will often save a life. In all cases, first aid, properly administered, will reduce the mental and physical suffering and thereby place the patient in the medical officer’s hands in a better condition to receive further treatment. Very often the only first aid practicable is the prevention of further injury to the patient by well-meaning but poorly informed onlookers. 126 TM 8-220 SOLDIER S HANDBOOK 139-140 b. In rendering first aid there are certain things to be done in all cases of injury or illness. These procedures are—- (1) Send immediately for a medical officer. (2) Keep bystanders far enough away to permit work without hinderance. (3) Do not move the patient until the extent of injury is deter- mined. Keep the patient lying in a comfortable position with the head level with the body. (4) Loosen the patient’s clothing about the head, neck, and abdomen. (5) Examine the patient to determine the nature of the injury or illness, paying particular attention to evidence of hemorrhage, shock, asphyxia, poisonings, fractures, dislocations, burns, and wounds. (6) Proceed with the first-aid treatment at once, treating serious hemorrhage first, asphyxia next, then shock, and other conditions in the order of their seriousness. Remember never to give an uncon- scious person any liquids as they may enter the windpipe and strangle him. Keep the patient warm. c. A soldier giving first aid should do so with evident display of self-assurance and authority born of knowledge, with calmness, and with decision, thereby obtaining the confidence of the patient and of the bystanders. 140. Wounds.—a. A wound is a break in the skin or in the mucous membrane of one of the body cavities. b. The principal kinds of wounds are clean or aseptic wounds, in- fected or septic wounds, and poisoned wounds. (1) An aseptic wound is one in which no germs have gained access, the best example being a wound made by the surgeon’s sterile knife. (2) A septic wound is one in which there has been introduced pus- producing organisms or such organisms as produce tetanus, gas gan- grene, or hydrophobia. (3) A poisoned wound is one in which some nonliving poison, as distinguished from bacteria or microorganisms, has been introduced by the agent causing the wound, as for example the stings of insects or the fangs of snakes. c. Classified as to causative agent or appearance, wounds are— (l) Incised wounds, made by sharp cutting instruments such as knives, razors, and broken glass, the class of wounds commonly known as “cuts.” (2) Lacerated wounds, often irregular and tom. They are caused by contact with angular surfaces, by shell fragments, and machinery. These wounds present ragged edges which do not retract much and TM 8-220 140-141 .MEDICAL DEPARTMENT which, as a rule, consist of masses of torn tissue, frequently with dirt ground into the tissue. (3) Contused wounds, wounds in which the division of tissue is accompanied by more or less severe crushing. Crushed wounds are more serious than they may appear at first, due to the fact that the dead tissues are an excellent media for the growth of bacteria. This may result, in an infection causing the loss of a part or general blood poisoning. (4) Puncture wounds or stab wounds, caused by such penetrating objects as nails, wires, or bullets. They are usually deep and narrow and may be very dangerous if they penetrate deeply enough to seri- ously injure important organs or cause internal hemorrhage. d. Infection, severe bleeding, and shock are the principal dangers from any type of wound. Rapid bleeding requires immediate atten- tion. In most cases bleeding is readily controlled. Infection can occur whenever the skin surface is broken, the size or location of the wound not being related to the possibility of infection. A skin punc- ture with an ordinary pin may cause a serious infection. A wound should never be touched with anything except sterile dressings or in- struments; unclean hands, bandages, or instruments may infect a wound that is relatively clean. 141. Treatment of wounds.—a. Wound in which bleeding is not severe.—(l) In these cases the chief duty is to keep the wound clean and prevent infection. If an antiseptic is available, apply this gently to the wound and to the skin for an inch around the wound. Allow this to dry well, then apply a clean dressing. If neither antiseptics or dressings are at hand, do not apply a substitute but allow the wound to remain open; bleeding will usually stop in a few minutes. (2) Do not touch the wound with the hands, mouth, clothing, or any unclean object. (8) Do not wash the wound with any solutions such as soap or water, as this may carry germs into the wound. (4) Do not massage or squeeze any wound; you may start severe bleeding or injure the tissue. (5) Do not attempt to explore the wound with any object or re- move blood clots. (6) Do not reapply antiseptics such as iodine. Never use iodine in the eye or in any body cavity. b. Wound in which bleeding is severe.—Pressure is the only first- aid method for the control of bleeding. If sterile gauze or bandage material is available, this can be used by direct pressure on the wound and held in place until a dressing is applied or a tourniquet adjusted. 128 TM 8-220 SOLDIER S HANDBOOK 141-142 When direct pressure to a wound is not possible, or when the direct pressure does not control the bleeding, apply pressure with the fingers or with a tourniquet between the wound and the heart. At certain places in the body large arteries lie near bones and may be compressed so as to decrease the flow of blood through them. (See par. 143.) Shock is always present with severe bleeding. Do not give any stimu- lants until the bleeding is controlled. Wounds, especially puncture wounds caused by gun powder or dirty objects, are subject to addi- tional danger from infection by tetanus organisms. Wounds con- taminated by soil or street dirt are frequently infected by the organ- isms of gas gangrene. Serum containing antitoxin is always available against tetanus or gas infection. 142. Miscellaneous wounds.—a. Snake hites.—(1) All snake bites are not poisonous. By inspection of the wound one can sometimes tell if a person was bitten by a poisonous or nonpoison- ous snake. In poisonous snakes the teeth are arranged in two rows, with a fang on each side, outside of the teeth near the point of the jaw. In nonpoisonous snakes there are four rows of teeth without fangs. The venom of poisonous snakes differs in its action. The poisonous constituents of the venom are neurotoxin, a nerve poison; hemorrhagin, which injures the lining of the blood vessels so that an escape of blood occurs into the surrounding tissue; and hemolysin, which destroys red blood cells. Poisonous snakes are classified as viperine and colubrine. The viperine snakes are those whose venom is made up principally of hemorrhagin and to this group belong the rattlesnake, copperhead, water moccasin, and viper. The colubrine snakes are those whose venom is made up principally of neurotoxin, and to this group belong the cobra and coral snake. (2) The symptoms of colubrine poisoning are not marked; there may be severe pain and some tenderness, swelling, and discolora- tion at the site of the bite. In 1 to 2 hours, however, the patient begins to feel tired and drowsy and has some nausea and vomiting. Paralysis generally follows, affecting first the extremities and then becoming generalized, finally affecting respiration and producing death. (3) The symptoms of viperine poisoning are pain at the seat of the bite with excruciating pain, rapid swelling, and discoloration, some nausea and faintness, rapid, feeble pulse, labored breathing, and in fatal cases death follows within 24 to 48 hours. (4) The treatment of snake bite should start immediately. A tourniquet should be placed around the limb and just above the bite to increase bleeding and to reduce the amount of absorption of the 129 TM 8-220 142 MEDICAL DEPARTMENT venom into the general circulation. A necktie, handkerchief, or bandage may be used as a tourniquet and should be tight enough to prevent the flow of blood back through the veins but not tight enough to prevent the flow of blood in the arteries. A cross incision should then be made over each fang mark, and preferably one to connect the two fang punctures, about a quarter to one-half inch deep to insure free bleeding. Suction should then be applied for at least one-half hour, either by glass breast pump or by heating a bottle and applying its mouth tightly over the wound. The cooling bottle will produce considerable suction. The patient should be kept quiet. Antivenom is now available which neutralizes neurotoxin and hemor- rhagin. These are injected hypodermically or intravenously and are very effective, but the application of the tourniquet, free bleeding, and suction are of far greater value if applied immediately. b. Insect bites and stings.— (1) The bites or stings produced by mos- quitoes, fleas, and bees usually require little treatment. The appli- cation of Calomine lotion is soothing and 2 percent phenol may be added to this lotion in cases of extreme irritation. If the sting of the insect is left in the skin, it should be removed by a pair of small forceps. The poison from these insects is chiefly acid, and the local application of some alkali such as baking soda, solution of ammonia, or washing soda affords relief. (2) The bites or stings of the more poisonous spiders, centipedes, tarantulas, or scorpions require prompt treatment. The general treat- ment is similar to snake bites, that is, the application of a tourniquet, cross incision with free bleeding, suction, and treatment of shock if present. Local treatment of the bite with fuming nitric acid or cautery is recommended. c. Bites of rabid animals or those suspected of being rabid.—lt is very important to catch the animal uninjured and place it in quaran- tine. Under no circumstances should it be killed as it is only after a period of observation that one can determine if the animal is rabid. The wound should be cauterized with fuming nitric acid and neutral- ized with sodium hydrate solution 1 percent or sodium bicarbonate solution 10 percent. If fuming nitric acid is not available, sterilize the wound by cautery with a red-hot needle. Do not use silver nitrate or phenol as this will precipitate by coagulation the albumin in the tissues, producing anaerobic conditions necessary for the growth of infective organisms. Apply a dry dressing. d. Human bites.—Human bites are always more or less poisonous from the presence of bacteria constantly found on the teeth and other 130 SOLDIER S HANDBOOK TM 8-220 142-143 parts of the mouth. A human bite is potentially a very serious bite and fatal infection can result. These wounds should be thoroughly disinfected and wet antiseptic dressing applied. 143. Hemorrhage.—a. General.—Hemorrhage or bleeding is the escape of blood from the blood vessel due to a break in the walls. Hemorrhage is spoken of as arterial, venous, or capillary, depending upon -whether the escape of blood is from arteries, veins, or capillaries. h. Arrest.—Nature attempts to arrest hemorrhage by the clotting of blood forming a plug at the point of bleeding. In the average healthy person it takes from 3to 5 minutes for the blood to clot. This clot of blood which arrests the hemorrhage eventually contracts and permanently plugs the break in the vessel wall if allowed to remain undisturbed. We can assist nature in arresting hemorrhage by elevation of the bleeding part, thus decreasing the pressure of the blood at the point of hemorrhage; by keeping the patient at complete rest so that the blood clot at the point of bleeding will not be disturbed; by the application of heat or cold, which tends to cause the blood vessel wall to contract, and by the use of pressure to close the bleeding vessel. In no case give stimulants in hemor- rhage, as they increase the blood pressure and tend to cause the dis- lodgement of the clot at the bleeding point. c. Types.— (1) Capillary hemorrhage.—ln this condition there is a steady oozing of blood from all over the wounded surface. Capillary hemorrhage is treated by the elevation of the part, the application of either very hot or very cold water and the application of uniform pressure by means of a gauze compress and bandage to the part involved. Nosebleed is an example of capillary hemor- rhage. The treatment of nosebleed consists of placing the patient in a sitting position, the removal of any constricting clothing about the neck and the application of cold to the back of the neck which causes a reflex contraction of the blood vessels of the nose. If these measures fail place a roll of paper under the upper lip between it and the gufti and in severe bleeding pack the nostril with some sort of soft material such as cotton, linen, or lint, gently forcing this well back into the nose. (2) Venous hemorrhage.—ln this condition there is a rapid flow of dark blood, a welling up as it were, without any spurting. Venous hemorrhage is treated by the elevation of the part, and the applica- tion of direct pressure over the wound with a sterile compress or bandage. This is usually sufficient. If venous hemorrhage should occur from an extremity, the limb should be bandaged from toes or 131 TM 8-220 143 MEDICAL DEPARTMENT The Arteries The Bones Figuke 54.—American Red Cross tirst-aid chart, showing skeleton, large arteries, and points of digital pressure. 133 TM 8-220 143 MEDICAL DEPARTMENT fingers up to the bleeding point in addition to pressure over the point of hemorrhage. A common location for severe venous hemorrhage is from varicose veins of the legs. (3) Arterial hemorrhage.—ln this condition there is a rapid flow of bright red blood which escapes in spurts. Arterial hemorrhage demands prompt measures, especially if the bleeding is from a large artery. Pressure to control arterial hemorrhage always must be applied at some point between the bleeding point and the heart, preferably, at a point where the bleeding artery may be compressed against bone. Pressure may be applied by means of the finger, by means of compress, or by the application of a tourniquet. A tourni- quet is a constricting band, and there are various kinds. The princi- ple of all tourniquets is a pad over the artery to bring the pressure on the artery and take it off the veins, a band around the limb and over the pad, and some means of tightening the band. The common improvised tourniquet is the so-called Spanish windlass, in which any smooth, hard object, such as a stone, a cork, or a roller bandage is used as a compress; for the band, a handkerchief, a suspender, a waist belt, or a bandage may be used. To tighten the band a stick, bayonet, or scabbard is passed under the band and twisted until the bleeding ceases, and the ends tied to the limb to prevent the band from becoming untwisted. Applying a tourniquet may be a danger- ous procedure and should not be used if bleeding can be stopped by other means. The dangers of a tourniquet are that if applied tightly enough to control arterial hemorrhage it will cause pain and swelling of the limb, and if left on long enough may cause gangrene or death of the part below the constricting band. It should therefore be watched and released at about half-hour intervals. The tourniquet itself should be at least an inch wide, for if it is too narrow, it will cut off the entire blood supply to the injured part and require very frequent removal. If on loosening the tourniquet, bleeding starts again, tighten it up. Never cover a tourniquet with a bandage or splint, as it may be forgotten. Shock is always present with severe hemorrhage and immediately after the arrest of hemorrhage it must be treated. When the bleeding has stopped, and not until then, should stimulants be given. d. Pressure 'points in treatment of arterial hemorrhage.—(l) Bleed- ing from the scalp.-—Apply pressure over the wound with compress and bandage. (2) Bleeding from the lips.—Grasp lips between thumb and fingers on each side of the wound, as the arteries to the lips come from both sides. 134 TM 8-220 SOLDIER’S HANDBOOK 143 (8) Bleeding from other 'parts of the face.—Apply digital pres- sure on the facial artery against the lower jaw midway between the ear and chin where its pulsations can be felt. (4) Bleeding from the neck.—Apply digital pressure with the thumb on the carotid artery against the vertebrae. (5) Bleeding from the armpit.—Place a compress in the armpit and bind the arm tightly to the side. If this fails compress the subclavian Artery behind the clavicle between the thumb and first rib, or compress it with a key, the handle of which has been padded. (6) Bleeding from an arm, forearm, or hand.—Apply pressure on the brachial artery on the inner side of the biceps and then apply a tourniquet a little higher up. In case of hemorrhage in the fore- arm a pad may be placed in the bend of the elbow and the forearm forcibly flexed on the arm. In case of hemorrhage from the palm, either of these two methods may be used, or a large firm compress may be placed in the hand with the fingers very tightly closed over it and bandaged in place. (7) Bleeding from the thigh, leg, or foot.—Apply pressure on the femoral artery against the head of the femur just below the middle of the groin with both thumbs, then apply a tourniquet to replace the thumbs. In case the hemorrhage is in the leg or foot, place a pad behind the knee, flex the leg forcibly and tie it in that position. In the foot when bleeding is from the dorsal surface apply pressure on the anterior tibial artery at the instep. In the foot when the bleeding is from the plantar surface apply pressure on the posterior tibial artery behind the internal malleolus. (8) Hemorrhage from the stomach.—The vomited blood is usu- ally dark in color and may be mixed with food. It always should be remembered that vomited blood does not necessarily indicate hemorrhage from the stomach; blood coming from the back of the nose and throat may have been swallowed, and inquiry should be made to find out if there has been any nosebleed. The treatment consists of keeping the patient quiet and applying an ice bag over the stomach. (9) Hemorrhage from the lungs.—May result from wounds of the lungs, but more often is due to disease of these organs. The patient is usually seized by a fit of coughing and spits up bright red, frothy blood. The treatment consists in keeping the patient perfectly quiet and applying an ice bag over the chest. (10) Hemorrhage from the bowels.—This is bright red if the hem- orrhage is recent and if old the stools will be black and tarry in color. Cancer and hemorrhoids are the most common causes of blood in the 135 TM 8-220 143-144 MEDICAL DEPARTMENT stools. If recent hemorrhage, keep the patient quiet and apply an ice bag over the abdomen. 144. Shock.—a. Shock is a profound depression of all physical and mental processes usually resulting from injury or severe bleed- ing, but may be caused by exposure, fatigue, hunger, or extreme emotion. Some degree of shock follows all injuries; it may be slight, lasting only a few minutes, or it may be prolonged and end fatally. If an injury of any type is severe, it can safely be assumed that a corresponding degree of shock will be present. Even if evidence of shock has not appeared after severe injury, it is well to anticipate it and prevent it by instituting shock treatment. h. A person suffering from severe shock lies in a drowsy condition, with the limbs limp, but generally is not totally unconscious. The skin is pale and cold; the temperature subnormal; the pulse feeble, fluttering and rapid, and may be irregular and barely perceptible; the respirations are shallow and sighing; and the pupils are generally dilated. The sensibility of a patient in shock is lowered and pain is not felt as acutely as in a normal condition. If shock does not result in immediate death a condition known as reaction sets in. At first there is usually vomiting, then a gradual return of the color of the skill, with a rise in body temperature, stronger pulse and improved respiration. The patient then often falls into a sound sleep. c. Concealed hemorrhage resembles shock very closely and must be kept in mind in all cases of severe shock. d. The treatment of shock requires heat, correction of position of the body, and stimulants. The arrest of hemorrhage, if severe, is of prime importance. e. Heat applied to the body of an injured person is most important both in preventing and in treating shock. All types of additional clothing may be used; external heat with hot water bottles, hot bricks, or pads may be used freely, keeping in mind that it is easy to burn a person who is in shock. Rubbing of the limbs is of doubtful value. In examining the person remove no more of the clothing than is necessary and replace it immediately when through. f. The position of the patient will greatly affect the blood supply to the vital oj'gans. Lay the patient on his back with the head low. This can best be done by raising the body so that the head is lower than the rest of the body. If a fracture is present, immobilization of the fractured part where the patient lies is of paramount importance. g. Stimulants should be used only with conscious patients in the absence of bleeding, skull fracture, apoplexy, or sunstroke. Warmth may be applied internally by hot drinks such as coffee or hot beef 136 TM 8-220 SOLDIER S HANDBOOK 144-145 tea in small amounts given frequently, and hot enemas, such as 2 pints of hot saline solution or hot water. Stimulants may be used by mouth as a teaspoonful of aromatic spirits of ammonia in a glass of hot water, hot coffee, hot tea, hot beef broth, or plain hot water. If a patient is unconscious, inhalation of smelling salts or ordinary water of ammonia is of value. h. The most important treatment in electrical shock is artificial respiration, which should be continued for at least 4 hours in all cases. Shocked patients who have resumed breathing, often later stop breathing and they should be watched closely for hours after the treatment. 145. Asphyxia.—a. General.—Asphyxia is the condition where respiration or breathing has ceased. This condition occurs most fre- quently in drowning, electrical shock, or gas poisoning. The treat- ment is to first remove the cause or remove the patient from the cause; then give artificial respiration; later, treat for shock. h. Artificial respiration.—The prone pressure, or Schafer method, is the safest and most effective method of artificial respiration. As soon as the person is rescued, the mouth should be forced open and any foreign substances such as gum, false teeth, or food removed. As every minute is valuable, begin actual resuscitation without delay. The standard technique is as follows: (1) Lay the patient on his stomach so that his face is free for breathing. One of his arms should be extended over his head, the other bent at the elbow so that his face can be turned outward and rested upon his hand. (2) Kneel astride the patient’s thighs, knees placed at such dis- tance from the hips as will allow exertion of pressure on lower ribs as described below. Place palms of hands on the small of the back With fingers on the lower ribs, little finger just touching the lowest rib, thumbs and fingers in natural position and tips of fingers out of sight just around the sides of the chest wall. (3) With arms held straight, swing forward slowly so that the weight of the body is gradually brought to bear upon the patient. Do not bend the elbows. This operation should take about 2 seconds. (4) Now immediately swing backward so as to remove all pressure completely and suddenly. (5) After about 2 seconds repeat the operation. The movement of compression and release should take about 4 or 5 seconds; this should be done at the rate of about 12 to 15 respirations per minute. (6) Continue the operation without interruption until natural breathing is restored or until a medical officer declares the patient 137 TM 8-220 145 MEDICAL DEPARTMENT dead. Remember, many patients have died because artificial respira- tion has been stopped too soon. Always continue the operation for 4 hours or longer. (Y) Aside from resuscitation, the most yaluable aid that can be rendered is keeping the patient warm. After artificial respiration has been started, have an assistant loosen the clothing and wrap the patient in any clothing that is available. Use hot bricks, heaters, or similar means, but be sure the patient is not burned. (8) When the patient revives, he should be kept lying down and not allowed to stand or sit up; thus preventing undue strain on the heart. Stimulants such as hot coffee or tea can be given provided the patient is conscious. (9) At times, a patient, after temporary recovery of respiration, stops breathing again; artificial respiration should be resumed at once. (10) Due to the length of time this operation may be kept up, one or more operators may be necessary. A change of operators can be made without loss of rhythm of respiration. The great danger is stopping artificial respiration prematurely. In many cases breath- ing has been established after 3 or 4 hours of artificial respiration, and there are instances where normal breathing has been reestablished after 8 hours. c. Treatment for a person apparently drowned.—Begin immediately to loosen the clothing about the neck, chest, and abdomen. With a handkerchief or towel, gently swab out the mouth and throat to remove mud or mucus. Turn the patient over, face downward, place the hands under the abdomen, one on either side, and lift the patient in order to drain the lungs and stomach; then with a large roll of clothing under the abdomen, and by making firm pressure upon the loins, continue the effort to expel the water from the lungs and stomach. If the individual then does not breathe, proceed immedi- ately with artificial respiration. d. Treatment for a person in electrical shock.—The rescue of a person from a live wire is always dangerous. If the switch is near, turn the current off, but lose no time in looking for the switch. Use a dry stick, dry clothing, dry rope, or other dry nonconductor in removing the victim from the wire. Start artificial respiration im- mediately. Do not regard early stiffening as a sign of death; keep up the artificial respiration for several hours. e. Treatment for asphyxiation from poisonous gases.—Illuminating gas and the exhaust gases from gasoline engines are the most com- mon causes of gas poisoning. Here again, the rescue is dangerous. 138 TM 8-220 SOLDIER’S HANDBOOK 145-146 The first thing after the rescue is to get the patient into the fresh air. This does not mean cold air. The fresh air of a warm room is desirable. If breathing has stopped or is weak or irregular, start artificial respiration. Oxygen is an aid to these patients, but does not take the place of artificial respiration. /. Treatment of other causes of asphyxia.—Asphyxia from hanging, choking, blows on the head and abdomen, or burial in a cave-in are handled in a similar manner. 146. Unconsciousness.—a. General.— (1) To treat a case of un- consciousness is one of the most difficult things that may fall to the lot of the first-aid man. There are numerous causes for un- consciousness and in order to properly treat an unconscious person, the cause must be discovered. Frequently it is impossible to deter- mine the cause, and treatment must be general. Lay the patient on his back with the head and shoulders slightly raised; apply cold cloths or an ice pack to the head; insist on absolute quiet; do not move the patient unless urgent and then do so very carefully; have sufficient cover to keep patient warm; and use no stimulants until the patient’s condition permits. (2) In all cases of unconsciousness send for the medical officer imme- diately. In examining an unconscious patient, look carefully for the cessation of breathing and for symptoms of poisoning, bleeding, or sun- stroke, as special treatment for these conditions must be given at once. h. Fainting.—ls due to too little blood in the brain and is caused by mental impressions, exhaustion, heat, bleeding, overcrowded rooms, etc. There is sudden unconsciousness, pallor, cool moist skin, weak pulse, shallow breathing, and dilated pupils. The treatment is to lay the patient flat on his back with head low and legs raised, sprinkle cold water on the face and hold ammonia or smelling salts near the nostril. Get patient out of a crowded area and into fresh air. c. Epilepsy or fits.—In this condition there may be fits with insensi- bility, or a mere momentary unconsciousness with slight muscular twitching, but in which the patient does not fall. In severe forms the patient cries out in a pecular manner and falls in a fit; at first the entire body is rigid, then there are general convulsions with jerk- ing of the limbs, contortion of the face and foaming at the mouth. These convulsions are followed by deep stupor which passes off into a deep sleep. Often there is involuntary evacuation of the bowel and bladder and the patient bites his tongue. There is no treatment which will stop the fit or control it; all that can be done is to prevent the patient from hurting himself and to make him as comfortable as possible. Do not attempt to hold the patient but twist a handkerchief, 139 TM 8-220 146 MEDICAL DEPARTMENT passing it between his jaws, and tie it over the back of his neck until after the fit to prevent the tongue being bitten. After the fit is over let the patient sleep as long as he will. In the military service one must be on the lookout for men feigning epileptic fits in order to obtain a discharge. These feigned attacks usually occur at night, the man does not fall so that he hurts himself, he does not bite his tongue, he flinches when his eyeball is touched and the pupils are not dilated. The opposite is true of the epileptic and in addition there may be involuntary evacuation of the bowels and bladder. d. Concussion.—Concussion of the brain is a condition present when we say a man has been “knocked senseless” or “stunned.” It is a jarring and shaking of the brain due to blows or falls. The symptoms are unconsciousness, pallor of the face, breathing so quiet and shallow that it can hardly be detected. Fluttering pulse, pupils equal and usually contracted. The treatment consists of rest in a dark, quiet room; warmth externally, aromatic spirits of ammonia internally, or by inhalation if there is depression. e. Compression of the brain and apoplexy— Pressure on the brain is usualy due either to a piece of bone broken from the skull or to blood from a torn vessel which has escaped inside the cranium and. as it cannot get out, must compress the brain. This compression pre- vents certain parts of the brain from working. When the bleeding is the result of injury, the condition is called simply compression of the brain; when it is the result of the bursting of a diseased vessel without any violence, it is called apoplexy. The result and the symp- toms are the same. The symptoms of compression are profound un- consciousness; loud, snoring breathing; slow pulse; pupils usually unequal and not reacting to light, and paralysis on one side of the body. If the symptoms are due to a piece of broken bone, the symptoms come on immediately after the injury, while if it is due to bleeding they may come on later and gradually. The treatment of both con- ditions consists of keeping the patient quiet, at rest in a comfortable position, and applying cold compresses to the head during the acute stage. Do not administer any stimulants. /. Hysterical unconsciousness.—Hysteria is a disease of the nervous system accompanied by loss of control over the emotions and is mani- fested in a great variety of ways. It may be accompanied by con- vulsions. The patient usually has an attack of laughing or crying and gradually “works himself up” to such an extent that he has a convulsion. He appears to be unconscious but in falling always picks out some soft chair or spot to fall upon, being careful not to injure himself. The patient is to be treated with firmness. He 140 TM 8-220 SOLDIER S HANDBOOK 146-147 usually craves sympathy and this is the worse form of treatment that can be given. Leave him alone, being sure to watch that no harm comes to him. g. Uremia or the insensibility of Bright's disease.—The insensi- bility of Bright’s disease is really an acute poisoning from the reten- tion of the waste products which the diseased kidneys are not able to eliminate. The unconsciousness is often attended with delirium and convulsions. The pupils are contracted, the pulse is slow, there is a peculiar odor to the breath, and the breathing is loud and snor- ing. The distinguishing features are the history of Bright’s disease, the waxy color of the skin, sometimes dropsy, abnormal urine (al- bumen, casts, etc.) and ordinarily the absence of paralysis. Emer- gency treatment consists in applying cold cloths to the head and hot packs or mustard poultice to the back. h. Unconsciousness caused by acute alcoholism.—The use of alco- hol, if carried to excess, produces a condition of unconsciousness which is very likely to be confounded with other similar conditions. Too great care cannot be taken in examining these cases thoroughly, as mistakes are of frequent occurrence, and cases of fractured skull or apoplexy often are pronounced as alcoholism. The patient may have been drinking and had a stroke of apoplexy, or may, in falling, have fractured his skull. If there is the least doubt, it is better to give the patient the benefit of the doubt than to run any risks. A person suffering from alcoholic coma lies in a stupor but usually may be partially aroused and made to answer questions. The face is flushed, the pulse is first full and rapid, then feeble and slow, and respirations are deep. The pupils are usually dilated and the breath has the heavy odor of alcohol. Ordinary intoxication rarely requires any treatment but rest and sleep. If the patient is in an exhausted state, it is well to wash out the stomach and cover him warmly and apply heat to the extremities. If the pulse is weak, stimulants should be given. The use of strong coffee by rectum is often of great value if the patient will not take anything by mouth. One can determine by the Bogan’s test the amount of alcohol in the circulating blood or urine if the patient is in the hospital, and the urine should be saved for examination. 147. Injuries due to heat.—Injuries due to heat are classified as general, which embraces heat cramps, sunstroke, and heat exhaustion, and local, which includes bums and scalds. a. Heat cramps.—Heat cramps are painful, spasmodic contractions of muscles, usually of the abdomen and extremities and are caused by exposure to heat and conditions causing muscular fatigue. The 141 TM 8-220 147 MEDICAL DEPARTMENT condition is brought about by the excessive loss of body fluids and salts. This is the mildest form of generalized body injury from heat, and the treatment is essentially the same as that for heat exhaustion. h. Sunstroke and heat exhaustion.—Both conditions are caused by excessive heat, but thev differ in their symptoms and treatment. (1) Sunstroke.—(a) This is a very dangerous condition and is caused by the direct exposure to the rays of the sun, especially when the air is moist. Exhaustion and improper clothing are contributing factors, as they prevent the proper elimination of heat from the body surface. This condition is apt to occur most frequently on forced marches with the men in close formation, on a hot, sultry day. (h) The symptoms are headache, dizziness, irritability, frequent desire to urinate, and seeing things red or purple. Examination re- veals an intensely hot and dry skin; a rapid, full pulse; high tem- perature, often ranging from 107° to 110°. Unconsciousness usually results and the body becomes relaxed. Convulsions sometimes occur. (c) Treatment has for its object the rapid reduction in temperature and the restablishment of water balance and of the salts in the body. The patient should be brought to the coolest accessible spot in the shade. The clothing should be removed and cold applied to the head by means of wet cloths, ice bags, or ice. At the same time the body should be cooled by rubbing with ice, and if a tub is available, the body should be immersed in cold water. Wrapping a patient in a sheet and pouring on cold water every few minutes is a good method of treatment. If the body is immersed in a cool bath, mas- sage the limbs and trunk briskly. Observe the patient and do not overtreat. Observe the body temperature every few minutes, and if the skin is hot, repeat the treatment. Continue the treatment until the body temperature is reduced. If a patient is able to swallow, cold, but not iced, water to which table salt has been added in the proportion of one-half teaspoonful to each glass should be given freely. If the patient is unconscious, give copious and frequent ene- mas of 1,000 cubic centimeters of cool salt water (1 teaspoonful of table salt to each pint of solution). Give enemas every 30 minutes or hourly, depending upon the condition of the patient. (d) Serious results may follow a sunstroke, even when death does not occur. The most common after effects are permanent head- aches, paralysis, mental confusion, or even insanity. Moreover, one who has had a sunstroke is more susceptible to the action of the sun. (2) Heat exhaustion.—(a) Heat exhaustion is due to the same causes that produce heat cramps and sunstroke. It results from ex- 142 TM 8-220 SOLDIER S HANDBOOK 147 posure to high temperatures, especially boiler rooms, foundries, bak- eries, and similar places. This condition often occurs on the march and while soldiers are standing at attention on a hot day. (6) The warning symptoms are dizziness, often nausea and vomit- ing, cramping in the muscles, and an uncertain gait. Frequently cer- tain muscles or muscle groups are thrown into violent contraction, which causes excruciating pain. The patient usually falls, the face is pale, the skin is cool and cohered with profuse perspiration, breath- ing is shallow, pulse is weak, and one or several muscles may be in painful contraction. The patient is not unconscious and may be aroused. ( Postoperative care in the ward 23(i Paragraph 234. General.—Specific instructions for the care and treatment of dental patients are given by the dental surgeon when hospitalization is required. These will vary according to the nature and character of the dental disability. However, there are a few routine measures with which the ward attendant should be familiar. 235. Preoperative cases.—The most frequent dental causes for admission to the hospital during the absence of a dental officer are jaw fracture, root abscess, toothache, and trench mouth. These cases should be referred to the dental surgeon or, in his absence, to the ward surgeon at the earliest possible convenience for necessary emergency treatment. a. Jaw fracture.—Fracture of the jaws is usually accompanied by pain, the amount depending upon the nature, location, and severity of injury. As in the care of any sick patient, the first requisite of good hospital care is to relieve the pain and make the patient as comfortable as possible. The usual measures to follow in these cases are as follows: (1) For the relief of pain, codeine sulfate y2 Sr-> and aspirin 10 gr. In severe injuries, with intense pain, morphine may be indicated. (2) The patient should be put to bed in a semi-inclined position, with the head slightly raised. (3) Do not apply a head bandage unless specifically indicated to stabilize and support loose bone fragments or extensive soft tissue 251 TM 8-220 235-236 MEDICAL DEPARTMENT injury. If a bandage is used, it should not be applied too tightly, as this will tend to displace the parts backward, increasing the patient's pain and interfering with breathing. (4) Give the patient a warm saline mouth wash and instruct him to use it frequently. (Avoid the use of hydrogen peroxide or sodium perborate mouth washes.) (5) Place on a liquid diet. b. Root abscess (alveolar abscess').—A patient with an alveolar abscess should be given a sedative, if feeling marked pain. An ice cap should be applied to the affected side of the face; avoid the use of hot applications externally. c. Toothache {pulpitis).—The patient is instructed to brush the teeth thoroughly and free the offending tooth as much as possible of food particles or other debris. Paint the surrounding gnms with 3]/2 percent iodine in glycerine and carefully insert into the cavity a pledget of cotton moistened in eugenol. If this procedure fails to give relief after a reasonable length of time (10 to 20 minutes), a sedative may be given and applications of cold applied to the aching tooth. Cold water or ice will often afford temporary relief should the tooth be in a stage of abscess formation. d. Trench mouth {Vincent's infection).—Trench mouth is a com- municable disease and all reasonable precautions must be observed to prevent the spread of the infection. The following orders must be observed in the treatment of these cases: (1) Caution the patient as to the infectious nature of the disease and instruct him to use his'own towel, toilet articles, and drinking utensils. (2) Have the patient rinse his mouth thoroughly every few hours with one of the following mouthwashes: {a) Sodium perborate—l teaspoonful to y2 glass of warm water. {b) Equal parts of hydrogen peroxide and water. (c) Potassium permanganate 1-2,000 dilution. (3) Direct patient to brush the teeth carefully with a soft brush and tooth paste after each meal. (4) Place the patient on a soft diet, including orange and tomato juice. 236.—Postoperative care in the ward.—a. Following removal of impacted teeth, multiple extractions and, cdveolectomy, and other intraoral surgical operations.—Specific treatment must be adminis- tered in the ward to alleviate the pain, to reduce the liability of infec- tion about the field of operation, and to keep to a minimum the amount of tissue swelling. Ward instructions are usually as follows: SOLDIER'S HANDBOOK TM 8-220 236 (1) An ice cap to affected parts immediately following return to ward for a period of 4 hours (intermittent application—on 30 minutes, off 30 minutes). (2) The patient is not permitted to rinse his mouth for 4 hours to prevent a disturbance in the formation of a normal blood clot. The patient may have water to quench his thirst, (3) After 4 hours discontinue the use of the ice cap and have the patient rinse his mouth with a warm salt solution. The patient should be‘ cautioned to use the mouthwash mildly, and not forcefully to agitate between the jaws, in order to prevent the entrance of air into the tissues. (4) Following operations, for the relief of pain administer codeine sulfate y2 gr. (0.032 gm.) and aspirin 5 gr. (0.324 gm.) and repeat every 4 hours if needed, for the first night only. (5) The patient is placed on a soft or liquid diet. For cases without teeth, soft diet to be continued until dentures are provided. These instructions, complete or in part, as checked by the dental officer, should be carried out in the ward by the ward attendants. h. Following fractures of jaw.—When fractures of the jaw have been reduced and immobilized by the dental surgeon, it is the duty of the ward attendant to acquaint himself with the necessary procedures in the specific care and treatment of that patient. Ward orders are as follows: (1) Place the patient on a liquid diet, unless otherwise prescribed, with feedings from 7: 00 AM to 9: 00 PM, at 2-hour intervals-. (2) Direct patient to rinse the mouth with warm salt solution after each feeding. (3) Direct patient to clean the teeth with a tooth brush as well as possible a minimum of three times daily. (4) If the patient should strangle due to nausea, an acute asthmatic attack, or some other cause, cut the vertical wires holding the jaws together or remove the intermaxillary elastics which are commonly used for intermaxillary traction and fixation. Each patient with intermaxillary wires is provided with a small pair of scissors for this purpose, which should be suspended by a cord around the neck of the patient at all times. (5) Record the patient’s weight weekly. c. Postoperative hemorrhage.— (1) Examine the patient carefully to determine the point of origin of the hemorrhage. Extensive bleeding from the soft tissues may usually be checked by having the patient remain quiet and holding sterile gauze over the affected area 253 TM 8-220 236-238 MEDICAL DEPARTMENT with digital pressure. The application of cold directly to the bleeding area or, where this is not practical, to some related area is also helpful. (2) In the case of a bleeding tooth socket following the extraction of a tooth, if any large blood clots have formed in the patient’s mouth, these should be removed. A piece of sterile gauze folded about the size of a walnut is placed over the socket and the patient instructed to close firmly on the pack. If this is held for 10 to 15 minutes with constant pressure and then carefully removed, the hemorrhage is usually ar- rested. As a supplement to the pressure, the patient should be placed in bed, keeping the head higher than the body, and sedatives should be administered to lower the blood pressure; avoid all stimulants. Section VI VETERINARY PROCEDURE Paragraph General 237 The horse in health 238 Indications of disease 23h Nursing 240 Medication : 241 Records 242 237. General.—The proper care of animals aims at keeping them at their highest degree of military efficiency by the prevention of disease and injury. Most diseases and injuries are preventable if all concerned are vigilant, intelligent, and untiring in the application of simple preventive measures. Frequently the development of serious diseases or injury can be prevented by prompt first-aid measures and early treatment. The treatment of disease and injury among animals, as well as prevention of disease, is one of the func- tions of the Veterinary Corps, and present organization provides that the services of a veterinary officer or trained enlisted man of the veterinary service will be available under practically all situations. 238. The horse in health.—Health is the condition of the body in which all the functions thereof are performed in a normal manner. It is particularly essential that the normal functions of the body of the animal be thoroughly understood, or else one cannot hope to recognize quickly any departure therefrom. Even the most elementary study of diseased conditions must be founded upon a very thorough knowledge of the normal body. a. Posture.—The standing posture is the most common posture of the horse. Normally the front feet will both be on the same trans- verse line and bear weight equally. Any other posture of a forefoot is spoken of as “pointing” and is an indication of trouble. The hind 254 TM 8-220 SOLDIER’S HANDBOOK 238 legs are rested alternately; rarely does the horse stand with both hind feet squarely together on the ground; in fact it is difficult to make him take or maintain this position. Due to certain peculi- arities of structure the horse can maintain the standing position without tiring and can sleep standing. Some horses never lie down, but no doubt they would rest better and their legs would last longer if they took their rest lying down. The horse lies down either obliquely on the chest with the legs somewhat folded under the body and head extended with the chin or teeth on the floor, or flat on his side with the legs and head extended. The horse is a very light sleeper, sleeping with his eyes partly open, but gets his deepest sleep and greatest rest when lying down. b. Expression.—The expression should be alert but without evi- dence of fear or excitement. The normal horse notices what is going on about him; his eyes are bright and his ears are frequently moved toward the direction of sound. c. Mucous membranes.—The visible membranes of the eyes and nostrils are a bright pink and there should be no discharge from either of these organs. The nostrils may be moist with tears flowing from the opening of the tear duct but they are relatively clean. d. Appetite.—The appetite will be good, and unless overfed the horse will show an eagerness for his forage rations. He should readily consume an average (3 to 4 pounds) feed of grain. e. Skin.—The skin is loose, supple, and easily moved about over the structures underneath. One should be able to pick up a handful of skin with ease. The coat is smooth, sleek, and glossy. During cold weather the hair may stand up and the coat becomes coarse and heavy. The old coat should be shed quickly and easily in the spring. /. Pulse.—The normal pulse rate varies from 36 to 40 per minute, depending upon the age, sex, temperament, and breeding of the horse. The pulse rate increases with exercise or excitement. The rate after a 5-minute gallop will be 60 or TO per minute. After very strenuous work the rate may be as high as 80 to 90. In a horse that is well conditioned the rate should return to approximately normal in a few minutes after exercise. The pulse rate will not return to the normal rate at rest as rapidly as the respiratory rate will subside. The pulse should feel strong, full, and regular. It is determined by placing the tips of the fingers on an artery and counting the pulsations for 15 to 30 seconds at least twice, averag- ing the counts and multiplying the average by four or two, accord- ing to how many seconds were counted. The artery most commonly 255 TM 8-220 238 MEDICAL DEPARTMENT used is the maxillary, and the count is made where it rounds the lower jawbone in front of the large cheek muscle. g. Respiration.—The breathing should be free, soft, and noiseless. After fast work the breathing is heard as a rushing sound of air but there should be no harsh, fluttering, whistling, or roaring sound. The breathing rate per minute is approximately as follows: At rest 9-12 After walking 200 yards 28 After trotting 5 minutes 52 After galloping 5 minutes 52-70 The above rates are for horses in good condition. After cessation of exercise the breathing rate should subside quickly to normal. The quickness with which the breathing rate subsides is an excellent in- dication of the fitness or condition of the horse. The breathing rate increases with exercise more rapidly than the pulse rate and after work subsides more quickly than the pulse rate. The breathing rate is counted by watching the rise and fall of the flanks, the movements of the nostrils, or on a cold day the steamy expiration of breath. h. Temperature.—The normal body temperature of the horse at rest is about 100° F., but may vary 1° in either direction; however, a temperature of 101° F. is uncommon. The temperature varies with exercise and excitement and air temperature. One hour’s work at walk and trot may raise the temperature one or two degrees. Hard, fast, or prolonged work, especially under a hot sun may build the body heat up to 103° to 105° F. When the temperature reaches this reading the horse is approaching “overheating.” The temperature is taken with a clinical thermometer in the rectum. The thermometer is moistened or oiled, the mercury is shaken down to 96° or below, and the bulb of the thermometer is inserted in the anus and allowed to remain 3 minutes, when it is withdrawn and the temperature noted. i. Urine..—Urine is passed several times daily in quantities of a quart or more. During the act of urination, the animal straddles, grunts, and assumes a very awkward position that might be mistaken for pain. 'Lack of water and profuse sweating decreases the amount of urine voided. Some horses hesitate to urinate on a hard floor, but habitually wait until placed on bedding. The urine of the horse is a thick, yellowish fluid and at times cloudy. j. Defecation.—(1) Defecaticm occurs 8 to 10 times in 24 hours. Normal droppings should be fairly well formed but soft enough to flatten when dropped; free from offensive odor or mucous slime; vary in color from yellow to green, according to the nature of the food; and not filled with grains that are either wholly or partially 256 SOLDIER’S HANDBOOK TM 8-220 238-240 unmasticated. The amount of droppings passed in 24 hours varies from 36 to 40 pounds, depending upon the size of the animal and the amount of food given. (2) Because the droppings are a good indication of the condition of the teeth and the digestive tract, an examination of the fresh droppings should be made frequently. An examination may reveal the following irregularities: («) Hard droppings may indicate a lack of water, a lack of ex- ercise, too dry and indigestible food, or a combination of all of these. This can be corrected by giving a few bran mashes, by watching the watering, by grazing, and by an hour of exercise daily. (b) Very soft or watery droppings may indicate too hard work, fatigue, too much grazing, excessive use of bran, or a slight irri- tation of the intestines. Reduce the work; omit bran and grazing. If it persists, withhold all food for 24 hours. (c) Slimy or1 mucous covered droppings or those having an offen- sive odor indicate too highly concentrated food or an irritation of the intestines. Reduce the food; give bran mashes and plenty of water. (d) Unmasticated grains indicate that the teeth are sharp or dis- eased, or that the animal eats too rapidly. Have the teeth examined; feed chop and dry bran with the grain. 239. Indications of disease.—Every disease has different indica- tions, and the symptoms vary so greatly that only exhaustive study can acquaint one with these many indications. a. The most common preliminary indications of disease are partial or complete loss of appetite, elevation of temperature (101° F. or more), accelerated breathing, increased pulse rate, listlessness, de- jected countenance, profuse sweating, stiffness, nasal discharge, cough, diarrhea, constipation, pawing, rolling, lameness, inflamed mucous membranes, unhealthy coat of hair, itching, or unnatural heat or swelling in any part of the body. b. The best time to inspect animals for evidence of sickness or in- jury is while they are being fed and at time of grooming. One of the first and most important symptoms of sickness is impairment of appe- tite. Take the temperature of animals that refuse their feed. Sick animals in a corral are inclined to stand by themselves. 240. Nursing.—Good nursing is indispensable in the treatment of sick and injured animals. It implies the attention to every detail which conduces to the comfort or benefit of the patient. The chief points to consider in nursing are: 257 TM 8-220 240 MEDICAL DEPARTMENT a. Ventilation.—Allow plenty of fresh air but protect from draughts. Avoid extremes of temperature, and in the field provide shelter from wind and rain. h. Clothing.—The amount of clothing must be regulated by the cli- mate. In winter woolen bandages on the legs are useful, and as many as three or four covers may be used. In summer fly sheets are ex- tremely comforting. c. Bedding.—A good clean bed induces an animal to rest and pro- duces a soft springing surface for foot cases. It should be shaken up several times daily and be kept free of urine-soaked straw. Ani- mals which are weak from illness will occasionally lie down for days at a time and require considerable attention to prevent the occurrence of decubitus (bedsores). These are pressure galls on those regions where the weight of the animal is greatest when lying, and occur on the outside of the shoulder and point of the hip and stifle. To prevent these cases the patient should be turned over from time to time and the bedding leveled and kept thick and soft. d. /Stalls.—A roomy box stall, well bedded, should be used whenever possible. Keep a bucket of water in the stall and change the water frequently. Patients suffering from severe abdominal pain and those exhibiting certain central nervous disturbances may throw themselves so violently they become seriously injured. For these cases a large stall should be provided which is tight, free from mangers or other projections, and preferably equipped with a “knee board.” A knee board is a heavy false partition about 4 feet high with its lower edge set in the stall 2 feet to reduce the right angle of the floor and stall sides. A thick bed of saivdust affords good protection for violent cases. e. Shoes.—The shoes may be removed and the feet leveled if the animal is to remain in a stall for more than a few'days. f. Exercise.—Convalescent patients should receive just as much exercise as each individual case permits. It must be borne in mind, however, that absolute resr is frequently the best treatment. I g. Grooming.—Animals that are weak and depressed should not be worried writh unnecessary grooming. Such animals should be care- fully hand rubbed at least once a day, and their eyes, nostrils, and docks should be wiped out with a sponge or soft cloth. The feet, should also be cleaned. Animals that are only slightly indisposed should be groomed in the usual way. h. Food.—Some sick animals retain a good appetite. . The principal things to observe in their cases are that they are not overfed, that droppings are kept soft, and that they have plenty of water. Sick 258 TM 8-220 SOLDIER’S HANDBOOK 240-242 animals with impaired appetites require special attention. They often relish a change of diet, a bran mash, steamed oats, chopped alfalfa, grass, roots, and apples. Feed small amounts often; do not allow uneaten portions to remain in front of them; keep mangers and feed boxes clean; induce eating by hand feeding; sprinkle a little sweetened water over the hay and grain. The forced feeding of liquid foods by means of the stomach tube or enema may be used as a last resort-. 241. Medication.—Frequent medication for the average sick animal is unnecessary and may even be harmful. Medicines are ad- ministered to animals through the same agencies as to man. They are introduced into the mouth by means of capsules placed on the back of the tongue with a “balling gun”; liquids are injected into the pharynx with a dose syringe or gravitated directly into the stomach through a stomach tube. Any of these methods require a technique which can be learned only by personal instruction and prac- tice, and all of them are more or less dangerous to the patient when attempted by a novice. Until the animal nurse has learned by su- pervised practice to administer medicine he should not attempt ir, as more harm than good may result. In some cases medicines are administered by placing them in the food or water. 242. Records.—Ward records include a list of property pertain- ing to the ward, individual feeding and watering instructions (usually indicated on a card on heel post or stall door), any special instructions as to care and treatment, and such clinical records as may be nec- essary, (See sec. VI, ch. 6.) 259 TM 8-220 243-244 MEDICAL DEPARTMENT Chapter 5 APPLIED HYGIENE AND SANITATION Paragraph Section I. General 243-245 11. Personal hygiene 246-247 111. Prevention and control of respiratory diseases 248-249 IV. Prevention and control of intestinal diseases 250-255 V. Prevention and control of insect-borne diseases- 256-262 VI. Prevention and control of venereal diseases 263-264 VII. Prevention and control of miscellaneous diseases 265-270 VIII. Oral hygiene 271 IX. Prevention and control of infectious diseases of animals 272-289 Section I GENERAL Responsibility for sanitation , 243 Communicable diseases 244 Control measures 245 Paragraph 243. Responsibility for sanitation.—Military sanitation is the use in the military service of practical measures for the preservation of health and the prevention and control of disease. Its primary purpose is to maintain the maximum effective strength of the military personnel. Figure 57.—Factors in the control of communicable diseases. 244. Communicable diseases.—For definition, cause, and classi- fication see paragraphs 228 to 230. a. Sources.—(l) A person who is actually ill with a disease is spoken of as a case. 260 TM 8-220 SOLDIER S HANDBOOK 244-245 (2) A person who, although not ill, is giving off from his body organisms or viruses capable of causing disease is known as a carrier. Some of the diseases known to be spread frequently by carriers are typhoid fever, diphtheria, meningococcic meningitis, and various types of dysentery. (3) In certain diseases, such as bubonic plague and Rocky Moun- tain spotted fever, the source may be an infected animal. b. Susceptibility.—A susceptible person is one who will develop the disease if infected with the organisms of that disease. c. Immunity.—A person is immune to a given disease when the tissues of his body have developed the power to combat and over- come the specific organisms or the poisons produced by them. A person may be rendered immune or nonsusceptible to some diseases by an attack of the disease. An attack will confer a more or less permanent immunity to chickenpox, measles, mumps, scarlet fever, smallpox, typhoid fever, and a few other and less common diseases. Immunity to typhoid fever and smallpox can be conferred by vac- cination, and vaccination against these diseases is required by Army Regulations. 245. Control measures.—a. The following measures should be used to prevent the spread of communicable diseases. (1) Control of sources by supervision of cases and carriers. (2) Control of transmitting agencies by— {a) Proper ventilation of barracks and tents. (b) Prevention of overcrowding. (c) Purification of water. (d) Proper sanitation of messes. (e) Proper waste disposal. (/) Control of disease-bearing insects. (3) Protection of susceptibles by the use of all possible measures for improvement of general health. (4) Vaccination against smallpox, typhoid fever, and such other diseases as may be directed by competent authority. (5) Instruction of all individuals in personal hygiene, and the rigid observance by them of its rules. b. In the application of control measures against communicable diseases, the following terms are frequently used: (1) Contact.—A person who has been closely associated with a sick person is known as a contact. (2) Suspect.—A person who has been exposed to a communicable disease and is ill, but in whom the symptoms and signs present are insufficient to warrant a diagnosis of the particular disease, is spoken of as a suspect. 261 TM 8-320 245-246 MEDICAL DEPARTMENT (3) Isolation.—In the Army, cases of communicable diseases are hospitalized if possible, and are there kept separate from other per- sons. This is termed “isolation.” (4) Incubation 'period.—The incubation period of a disease is the time between exposure and the earliest symptoms of the disease. It varies with different diseases and in different persons. (5) Carrier.—See paragraph 244e(2). (6) Quarantine.—(a) Quarantine is the separation from other people of carriers or of the contacts of a case of communicable dis- ease to prevent the spread of the disease to the unexposed members of the command. Quarantine may be applied to one or to a large number of persons. (b) Quarantine may be absolute or modified. 1. In absolute quarantine the carriers and contacts of a com- municable disease are completely isolated or confined so that they are entirely separated from all other per- sons. This type of quarantine is seldom employed in the Army. 2. Modified quarantine, termed “working quarantine”, is ordi- narily employed. In working quarantine the group in- volved are messed and quartered together and are separated from all other persons but continue to carry on such training or other activities as do not bring them into close association with persons outside the contact group. All members of the quarantined group are examined once or twice daily by a medical officer. Any individuals showing suspicious symptoms are im- mediately isolated. (c) Quarantine is continued until a time equal to the longest usual incubation period of the disease concerned has elapsed since the last case developed in the group. -Section II PERSONAL HYGIENE Paragraph General I 246 Measures to protect and improve health 247 246. General.—a. Personal hygiene deals with the efforts each individual must put forth to keep in good physical condition and with the precautions he must take to protect himself from disease. Before being allowed to enlist in the Army, the soldier is given a thorough physical examination to determine the absence of disease. 262 TM 8-220 SOLDIER'S HANDBOOK 246-247 It then becomes his duty to keep himself in the best possible physical condition. In so doing, attention to personal hygiene is of great importance. b. If at any time a soldier feels sick or for any reason believes that he has contracted a disease, he should report at once to his first ser- geant or to the noncommissioned officer in charge of quarters, who will send him to a medical officer for examination. Soldiers should never try to treat themselves, since nearly all medicines may be harmful or possibly even fatal in unskilled hands. Furthermore,, a sick person may be a source of danger to his associates. c. Most acute diseases and many chronic ones are caused by tiny organisms or viruses commonly called “germs.” These are much too small to be seen with the naked eye. The usual ways in which disease- producing germs gain entrance to the body are as follows: (1) By food or water or other liquids which contain the germs. (2) By inspired air in which certain germs float. (3) Through the skin, the germs having been injected into the body by the bites of mosquitoes, lice, ticks, or fleas, or introduced through cuts, scratches, or abrasions. (4) By contact with diseased persons. 247. Measures to protect and improve health.—a. livery indi- vidual has some degree of natural resistance to infection. This natural resistance is improved by any measures which serve to im- prove his general health. Among measures serving that purpose are the following: (1) Protection from cold and chilling by suitable clothing, blan- kets, and housing facilities. (2) Adequate and proper food. (3) Physical training, including athletics. (4) Sufficient sleep (at least 7 to 8 hours each night). (5) Avoidance of undue fatigue. (This is particularly important in training camps in the presence of epidemics of respiratory diseases.) (6) Recreation of suitable nature. (The morale of an organiza- tion has a very definite relation to the phyical condition of its members.) b. An unclean body may favor the entry of disease germs. There- fore, the entire body should be bathed at least twice a week, and oftener if possible. The hands should always be washed before eat- ing and after going to the toilet. When facilities for a complete bath are not available, the body should be frequently scrubbed with TM 8-220 247 MEDICAL DEPARTMENT a wet cloth, paying particular attention to the armpits, crotch, and feet. c. Underwear and shirts should be changed and washed at least twice a week. If water is not available, clothing should be crumpled up, shaken well, and exposed to the sun for at least 2 hours. d. It is very important to brush the teeth at least twice a day, one of these brushings to occur before going to bed. In cleaning the teeth, brush the inside and outside surfaces away from the gums and toward the cutting surfaces. Particles of food between the teeth should be promptly removed, care being taken not to injure the gums. e. The most important factor in the marching ability of the soldier is the care of the feet. Serious defects of the feet can be prevented by properly fitted shoes and socks and by proper care of the feet. (1) Shoes.—(a) Only field shoes issued by the Quartermaster Corps should be worn in the field by enlisted men. Each shoe is fitted to the foot of the wearer so that no undue constriction or pressure will occur at any point when the foot is expanded by the weight of the body and pack. It is equally important that shoes not be so large as to permit friction by the foot’s slipping inside the shoe. Shoes can be properly fitted only by actual test. (b) To test, the shoe is laced snugly, and the wearer with a 40- pound burden on his back places his entire weight on the foot wear- ing the shoe. The leather of the shoe in front of the instep above the ball of the foot should then be grasped between the fingers and thumb. As the finger and thumb are brought together, the leather should be loose enough to prevent the fingers’ slipping easily over the surface but not sufficiently lax to produce a wrinkle. If it wrinkles under the grasp, the shoe is too wide, and if there is no looseness apparent, it is too narrow. The proper length of the shoe is determined by measuring the space between the end of the great toe and the end of the shoe. This space should be not less than three-quarters of an inch when all the body weight plus that of a 40-pound burden is borne by the foot being fitted. This space is measured by pressing down the leather with the thumb. The width of the thumb may be considered as representing the desired width between the toe and the end of the shoe. (c) All shoes should be well broken in and adjusted to the feet before being used for marching. (2) Socks.—Only woolen socks (light or heavy) should ordinarily be worn for marching. Socks should be large enough to permit free movement of the toes but not so loose as to permit wrinkling 264 TM 8-220 SOLDIER'S HANDBOOK 247 Woolen socks should be one-half size larger than cotton socks in order to allow for shrinking. Darned socks or socks with holes in them should never be worn on the march, since they will cause abrasions and blisters. Wearing two pairs of socks will aid in preventing friction between the shoes and feet, (3) Feet.—(a) Clean feet are as important to the avoidance of foot defects as are properly fitted shoes and socks. The feet should be washed and the socks changed each day. This is especially im- portant on a march. As soon as possible after reaching camp after a march, the feet should be washed (not soaked) with soap and water and the soldier should then put on clean socks and change his shoes. (h) If blisters have appeared on the feet they should be painted with iodine and emptied by pricking them at the lower edge with a pin which has been passed through a flame. The skin should not be removed. The blister should then be covered with a dressing. Serious abrasions on the feet, corns, bunions, and ingrowing nails should be treated at the dispensary or aid station. (c) The toenails should be kept short and clean. They should be cut straight across to avoid ingrowing nails. (d) “Athlete’s foot” is a common and frequently irritating foot infection. It should be treated only by a medical officer or as or- dered by one. Unskilled treatment will often make the condition worse instead of curing it. /. Following are some of the rules which should be followed by every person in order to protect his health and the health of other people, especially during service in the field. (1) Da not drink water which has not been declared potable by a medical officer unless it has been purified by boiling or chlorination. Do not take water from a water sterilizing bag by dipping a cup into the bag or putting mouth to faucet. (2) Do not soil the ground with stools or urine. Always use the latrine or the night urine can provided in the company street. (3) Be sure that the mess kit, knife, fork, and spoon are thoroughly washed in hot, soapy water and rinsed in hot, clear water after they are. used. (4) Use a mosquito bar in regions where mosquitoes are present. See that it is well tucked in and is free from holes. (5) Do not sit or lie directly on the damp ground. Avoid drafts when perspiring or while the clothing is damp. (6) Ditch the tents as soon as put up, even if the camp is for only one night. TM 8-220 247 MEDICAL DEPARTMENT (7) Prepare the beds before dark. In temporary camps or bivou- acs, raise the beds if suitable materials such as straw, leaves, or boughs can be obtained. The raincoat can be used as a ground sheet. (8) Never use a cup which is used by others. Do not exchange pipes, cigars, musical instruments played with the mouth, gas masks, handkerchiefs, towels, or shaving outfits. (9) Water discipline is essential. No water should be drunk from springs, wells, or other unauthorized sources along the route of march. The amount and rate of consumption of water should be controlled by company officers. During a march of 15 miles in aver- age summer temperature, about 2 quarts of water and considerable salt are lost from the body in perspiration. Unless these are replaced there is marked thirst and exhaustion, the loss of salt being equal in importance to the loss of water. Replacement of salt can be accom- plished by adding 1 teaspoonful of common table salt to each canteen- ful of water. This is advisable during hot weather, it is not necessary in cool weather. Men are encouraged to drink all the water they need before starting a march; they are cautioned to drink sparingly during the course of the march. Canteens should be completely filled at the start of the march, and provision made for refilling them at about the midpoint of the day’s march. During very hot weather, too rapid consumption of water which does not contain salt will result in excessive perspiration, diarrhea, nausea, and fatigue. Thirst may be relieved somewhat by chewing gum or keeping a pebble in the mouth while marching. Some individuals find that a canteenful of weak tea quenches the thirst more satisfactorily than does plain water. This custom has some merit but hardly enough to justify the trouble involved in preparing the tea. Commanders are required to have all water for drinking and cooking purposes chlorinated unless procured from a source found to be safe by the medical service. They make the necessary arrangements for the replenishment of canteens in accordance with anticipated needs; they permit no straggling from the column for this purpose. In large commands, replenishment of canteens from local sources is often impracticable; therefore water must be transported in water vehicles or tank trucks. Troops exer- cise economy in the use of water in order to make the available supply suffice for the march. When combat is in prospect, the replenishment of water consumed during the march requires special attention. Ani- mals suffer more from lack of water than from lack of food. If insuf- ficiently watered, they rapidly lose condition. The times of watering are largely dependent upon march conditions and available facilities. 266 TM 8-220 SOLDIER'S HANDBOOK 247-248 (10) Acquire the habit of having the bowels move regularly once each day and at as nearly the same time as possible. (11) Wear clothing of proper weight for the climate. Clothing should fit loosely. Wet clothing, particularly shoes and socks, should be changed as soon as possible. (12) Keep the hair cut short and the fingernails clean. (18 i Never throw pieces of food or refuse around the camp or in the trench. Such debris attracts flies, and flies carry disease organisms. (14) If possible, avoid all contact with diseased persons. (15) Avoid venereal diseases. These diseases are almost always contracted by sexual intercourse with an infected woman. If sexual intercourse is had, report as soon as possible (value decreases with every hour’s delay) to the hospital or other designated place for “prophylaxis.” This prophylactic treatment must be carried out thor- oughly and the directions followed exactly if its full protective value is to be obtained. (16) Relax completely during rest periods on a march. Section 111 PREVENTION AND CONTROL OF RESPIRATORY DISEASES General 248 Control measures ; 249 Paragraph 248. General.—Respiratory diseases are the most common cause of admission to sick report. They are particularly frequent during the winter and spring and when large groups of recruits are assem- bled. They are spread in the secretions of the respiratory tract and may be transmitted by air, hands, food, mess equipment, or anything else which comes in contact with secretions from the mouth or nose. The principal respiratory diseases are— Bronchitis, acute. Chickenpox. Coryza (common cold). Diphtheria. Influenza. Laryngitis, acute. Measles. Meningitis, epidemic. Mumps. Plague, pneumonic. Pneumonia. Poliomyelitis. Scarlet fever. Tonsillitis, acute. Septic sore throat. Smallpox. Tuberculosis, pulmonary. Vincent’s angina. Whooping cough. 267 TM 8-220 249 MEDICAL DEPARTMENT 249. Control measures.—a. Control measures are chiefly directed at the transmission agencies and at increasing and maintaining the group resistance. b. (1) Poor ventilation of barracks or quarters causes the occupants to exchange organisms by rebreathing each other’s expired air, the germ content of which is increased by coughing and sneezing. (2) The air in sleeping quarters should have a movement easily felt on the back of the hand but without uncomfortable drafts. A properly ventilated room will not feel stuffy or hot when entered. For practical purposes, whether or not a barracks is properly ventilated may be determined by the temperature as shown on the thermometer and by the effect of air movement on one’s senses. The temperature range should be 64° to 70° F. Overheating, as shown by the ther- mometer, means poor ventilation regardless of its cause. PiGUiiE 58.—General factors in the control of respiratory diseases. (3) There are two methods of ventilation, natural and mechanical. Natural ventilation is usally obtained by opening windows at the bottom on the windward side and at the top on the other side. The area of these openings depends upon the number of occupants, the velocity and direction of the wind, the difference in temperature between the indoor and outdoor air, and the construction of the building. If the windows are on one side only, or if the inlet and outlet are at the same level, the air will be short-circuited with an uneven distribution in the room. Drafts can be prevented by having several small inlets rather than a few large ones. Also, the use of deflectors in the window openings aids in decreasing drafts. (4) If troops are quartered under canvas, the sides of the tent should be rolled up daily and the hoods opened, weather permitting. 268 TM 8-220 SOLDIER S HANDBOOK 249 (5) Noncommissioned officers in charge of quarters should check the window ventilation several times each night, especially during the respiratory disease season, November to April. c. (1) In barracks, each man should have a floor space of 60 square feet. In extreme emergencies the minimum allowance may be re- duced to 50 square feet of floor space per man. With double decker bunks the standard should be 100 square feet of floor space per bed. Beds must be so placed that under average conditions the deep breath- ing of sleeping occupants will not spray secretions from the nose and throat into the air to be inhaled by those in nearby beds. With an allowance of 60 square feet per man there exists 6 feet distance between the heads of the men. Beds should at all times be so ar- ranged that there is head-to-foot sleeping. When necessary, stagger- ing of beds will aid in securing the desired distance between men. Figure 51i.—Ventilation of squad rooms, showing method of arranging window openings A—lnlet. B—Outlet. (2) If head-to-foot sleeping and staggering of beds still allow less than 5 feet between the heads of the men, the beds in the squad rooms should be separated by screens to convert each bedspace into a cubicle. The cubicle screen is readily made from an ordinary shelter tent half, blanket, sheet, or boards. The screen made from a shelter half may be fixed on a bed or cot by tent poles. The screen extends 2to 4 feet above the surface of the head of the bed, the height decreasing toward the foot, and extending 1 foot below the cot or bed. If the screen is too short, too low, or does not extend below the bed, air currents may carry the infectious secretions of an occupant to adjacent occu- pants. If cubicles are too high or extend too far beneath the bed, they interfere with the movement of the air and cause improper ventilation. Cubicles should be used for all recruits during the 269 TM 8-220 249-250 MEDICAL DEPARTMENT respiratory disease season and for all troops in the presence of or during a threatened epidemic. d. Proper barracks sanitation means cleanliness. Spitting on the floors, dry sweeping of the floors, careless coughing, sneezing, and the use of common drinking cups and towels must be prohibited. An ample supply of cuspidors containing a 2 percent solution of cresol to a depth of Ito 2 inches is important. Cuspidors must be cleaned daily. Bedding should be aired twice weekly. Beds should be cleaned with soap and water at frequent intervals. Figure 00.—Method of constructing cubicles in squad rooms by the use of shelter tent halves with head-to-foot arrangement of beds. e. Mess gear and utensils should be thoroughly disinfected. Any food handlers showing evidence of respiratory disease should be promptly relieved from duty. Section IV PREVENTION AND CONTROL OF INTESTINAL DISEASES General 250 Control measures 251 Field water supplies 252 Disposal of wastes 253 Fly control 1 254 Mess sanitation 250 Paragraph 250. General.—a. The intestinal diseases are those in which the causal agents are eliminated from the body in the feces and urine. They are usually transmitted by contaminated food and water which 270 TM 8-220 SOLDIER'S HANDBOOK 250-252 may be transmitted by the hands or by eating utensils. The principal intestinal diseases are— Amebic dysentery. Bacillary dysentery. Cholera. Diarrhea. Food infection. Food intoxication. Helminthic infestations (worms). Paratyphoid fever. Protozoal dysenteries. Typhoid fever. Undulant fever. h. Carriers of typhoid fever, amebic dysentery, or other of the intestinal diseases are relatively common. This fact must be kept in mind in considering the control of the intestinal disease group. 251. Control measures.—The following measures are essential to the control of intestinal diseases: a. Purification and protection of water supplies. h. Inspection and protection of food supplies. c. Mess sanitation. d. Waste disposal. e. Fly control. /. Immunization (routine only for typhoid fever). g. Rigid personal hygiene of all individuals. h. Rigid discipline in matters of sanitation, particularly as regards avoiding unauthorized sources of water and food. 252. Field water supplies.—a. Requirements.—Water require- ments vary under different conditions. Individuals cannot maintain good health in active field service with less than 1 gallon of water per day for drinking and cooking. Troops on field service and in temporary camps will ordinarily use 2 to 5 gallons of water per per- son per day for all purposes. In semipermanent camps the per capita consumption varies from 20 to 40 gallons per day. In permanent stations the per capita consumption may vary from 50 gallons to as much as 200 gallons per day. Animals ordinarily require 10 gallons of water per day each, but in combat conditions, may be reduced to 5 gallons each per day. h. Sources.—All sources of water in the field must be considered as contaminated and all water should be properly treated before use. Some sources of water are, however, better than others. Surface water (ponds, rivers, or small streams) is generally more heavily contaminated than ground water (wells or springs). c. Responsibility.—(l) The Quartermaster Corps is responsible for the procurement and treatment of water for all stations and camps in time of peace, and in the zone of the interior in war. except 271 TM 8-220 252 MEDICAL DEPARTMENT in the case of smaller units, when supply of water by the Quarter- master Corps may be impracticable. (2) The Corps of Engineers is responsible for all water supplies in a theater of operations except at times, in the case of smaller units, when supply by the Corps of Engineers may be impracticable. (3) If for any reason the Quartermaster Corps or the Corps of Engineers does not supply treated water, unit commanders are re- sponsible for the procurement and treatment of water supplies. Unit commanders are at all times responsible for the protection and control of the use of water supplies within their organizations. Figure 61.—Pollution of well by seepage from pit privy. (4) The Medical Department is responsible for making recom- mendations as to the most satisfactory source and method of treat- ment of water supplies. d. Protection.—Every source of water supply should be carefully guarded against pollution by human or animal wastes. Pollution can occur either by surface or subsurface drainage. Latrines and kitchen soakage pits should be located so that drainage is away from the water source. If a stream is to be used as the source of the water supply of an organization, it should be marked off in zones, indicated by markers, and water guards should be posted. e. Purification.—(1) Preliminary treatment.—The water selected should be as clean as possible, and the heavier organic matter re- moved by straining or settling. A pit dug 4to 5 feet from the edge of a stream or pond and 3 to 4 feet below the stream level makes a satisfactory settling basin. Another method is to remove both 272 TM 8-220 SOLDIER S HANDBOOK 252 ends from a barrel or oil drum and sink one end into the bottom of a shallow stream or pond, dipping water from inside the barrel. (2) Boiling.—Boiling is the safest method, but is undesirable be- cause of the flat taste and because of the lack of containers for boiling other than small quantities. Five minutes of boiling is required for sterilization of water. (3) Chlorination.—Chlorination is the choice method and may be carried out in the water sterilizing bag (Lister bag), in water carts, FigUke G2.—Protection of water supply by proper use of stream from which water Is taken for various purposes. in small reservoirs, or by the purification units operated by the Corps of Engineers. The exact amount of chlorine required will vary with the characteristics of the water being treated. Water con- taining considerable organic matter requires considerably more chlorine than does clear water. (a) Water sterilizing hag method.—The procedure is as follows: 1. Suspend the bag on a tripod. Fill it with water to the mark 4 inches from the top, straining the water through cheesecloth. The capacity is 36 gallons. 2. Draw a small quantity of water through one of the faucets into a canteen cup, 3. Break a tube of calcium hyperchlorite into the canteen cup, stir with a clean stick, then fill the cup two-thirds full of water. 273 TM 8-220 253 MEDICAL DEPARTMENT Empty this solution into the water bag and stir thoroughly with a clean stick which is long enough to reach to the bottom of the bag. 6. Draw at least one-half canteen cup of water from each of the faucets and pour it back into the water bag. This serves to sterilize the faucets. 6. Wait 30 minutes after chlorination before using the water. 7. When especially trained technical personnel and facilities are available it may be practical to control accurately the de- gree of chlorination and thus provide a more acceptable water supply when judged from the point of both taste and safety. This controlled chlorination requires the use Figure 63.—Water sterilizing bag. of an orthotolidine test solution and may be employed after the calcium hyperchlorite is added to the water in the following manner: Wait 10 minutes, then wash out one of the faucets by allowing a small amount of water to run through onto the ground. Fill a clean canteen cup two-thirds full of water from the same faucet. Add 1 cc. (15 drops) of orthotolidine testing solution to the water in the cup. Wait 5 minutes and note the color produced. Below is a guide for read- ing the color reaction between the free chlorine and orthotolidine: (a) No color.—lnsufficient chlorination. Add more calcium hypochlorite. 274 TM 8-220 SOLDIER’S HANDBOOK 252-253 (b) Canary yellow.—lnsufficient chlorination. Add more calcium hypochlorite. (c) Deep yellow.—Satisfactory chlorination. This represents about one part per million (p. p. m.) of chlorine. (d) Orange red.—Overchlorinated. Add more water and retest. (e) Bluish green.—Alkaline or hard water. Add a few more drops of orthotolidine to get a cor- rect color reading. 8. The cover should be kept on the bag to prevent recontam- ination. The unpleasant taste of chlorine is diminshed by allowing chlorinated water to stand several hours before use. If for any reason orthotolidine testing solu- tion is not available, it can safely be assumed that one tube of calcium hypochlorite will adequately chlorinate 36 gallons of water. It will never dangerously over- chlorinate this amount. (h) Wafer cart method.—Chlorination may be done directly in water carts, stirring in calcium hypochlorite at the rate of about one tube to each 36 gallons of water. The exact amount needed can be determined by the orthotolidine test. These carts must be thoroughly cleaned at frequent intervals. (c) Canteen method.—Fill a canteen with water and dissolve into it the contents of one tube of calcium hypochlorite, being sure that it is evenly mixed throughout. Add one canteen cap (6 cc.) of this solution to each canteen of water. Wait 30 minutes before drinking the water. This method is less accurate than chlorination in the water sterilizing bag and requires very close supervision of all in- dividuals. The concentrated calcium hypochlorite solution may be prepared in a 1-quart bottle instead of in a canteen. (4) Use of iodine.—ln the absence of calcium hypochlorite, tinc- ture of iodine may be used as a temporary expedient. Two drops of tincture of iodine will purify one canteenful of water. Thirty minutes should be allowed before the water is used. This method is rarely practicable in combat since iodine will not, ordinarily, be available for this purpose. 253. Disposal of wastes.—a. General.—The disposal of waste materials is essential in the control of communicable diseases, espe- cially those belonging to the intestinal group. h. Classification.—The wastes which must be disposed of are— (l) Human wastes.—Excreta, solid and liquid, and bath water. 275 TM 8-220 253 MEDICAL DEPARTMENT (2) Kitchen wastes.—Liquid and solid. (3) Animal wastes (manure). (4) Rubbish. c. Human.—Human wastes play the most important role in the transmission of intestinal diseases because they are frequently carried from cases or carriers into water which is to be used for drinking, or are conveyed to food by the hands or by insects, rats, and mice. The problem of disposal of human wastes is increased in bivouacs and in temporary or semipermanent camps. d. Latrines.—The following general guides apply to latrines con- structed in camps of those types: (1) Latrines are company installations, maintained by the per- sonnel of the company concerned. (2) Latrine seats or space is provided to accommodate 8 percent of the command at one time, each man being allowed 2 lineal feet of latrine space. (3) Latrines should be flyproofed. (4) Latrines should not be dug below the ground water level. (5) Latrines dug in clay are unsatisfactory, since liquids will not soak away into the ground. (6) Latrines should be placarded when closed, showing the date and the organization. (7) Latrines should be located at least 100 yards from any mess, and so that drainage into a source of water supply is impossible. The preferable location is about 30 yards from the end of the company street. (8) A lighted lantern should be hung at each latrine at night unless the military situation demands concealment. e. Construction and care of latrines.—(l) General.—The types of latrines used in temporary and semipermanent camps differ in con- struction, but their care is similar. The primary objectives in all types of latrines are to control nuisances and to prevent access of flies to human excreta. (2) Shallow trench.—(a) Shallow trench (often called straddle trench) latrines are used for the disposal of feces and urine in bivouac, in camps of less than 1 week, and at the noon halt on a march. They may also be used until deep pit latrines can be constructed in camps of longer duration than 1 week. The shallow trench latrine is usually constructed by digging a trench 1 foot wide, 2 feet deep, and 8 to 10 feet long. Sometimes, however, it may be desirable to dig small units of shallow trenches, each 2to 4 feet long. The earth removed should 276 TM 8-220 SOLDIER S HANDBOOK 253 be piled at one or both ends of the trench, and be used by each man to cover his excreta. Boards placed along the edges of the trench provide better standing. Fiquek 04.—Trench latrine. (i) Shallow trenches should be closed by refilling with earth when the contents have reached within 1 foot of the surface of the ground. The trenches should, if possible, be sprayed with crude oil daily. 277 TM 8-220 253 MEDICAL DEPARTMENT (3) Deep pit.— (a) When troops are in camp 1 week or longer, deep pit latrines and urinal troughs or urine soakage pits are con- structed. Deep pit latrines may be used even in camps of rather per- manent nature. The deep pit latrine is used together with the standard quartermaster latrine box, and must be dug of exact dimensions to conform to the size of the box. (b) The latrine pit is dug 2 feet wide, 8 feet long, and 4 to 10 feet deep. The depth is dependent on the character of the soil and the length of time the latrine is to be used. A latrine to be in use 1 week is dug 3 feet deep, and 1 foot is added for each additional week the latrine is to be used. For example, if a latrine is to be in use 4 weeks, it should be lug 6 feet deep, and if for 8 weeks, it should be 10 feet Figurio 05.—A—Standard latrine box. B—Trough urinal. V—Pipe leading from urine trough into latrine pit. deep. Striking rock or ground water may limit the possible depth. A company of 100 men requires 16 feet of latrine space (2 standard latrine boxes). (e) Pit latrines must be flyproofed to prevent access of flies to fecal material, and to prevent the escape of larvae in case flies have gotten into the pit and breeding has taken place. Flyproofing is accom- plished in the following manner: An area 4 feet wide surrounding the pit is excavated to a depth of 6 inches. This area is then covered with burlap and soaked with crude oil. This burlap hangs down the walls of the pit to a depth of 18 inches and is turned down into the ground at the outer borders of the area. The earth is replaced, tamped down, and more oil added. If burlap is not available, as will often be the case, oil alone may be used, and if oil is not obtainable, the earth may be hardened by moistening with water and tamping. Earth should be tightly packed around the edges of the box to seal all openings to the pit. 278 TM 8-220 SOLDIER S HANDBOOK 253 (d) The latrine may be enclosed by a canvas screen. If this is not available, a brush screen should he used. A large wall tent may be used to enclose a latrine. A drainage ditch, 6 inches deep, should be dug outside the latrine enclosure to carry surface water away from the pit. (e) Latrines must be kept clean and free from odors. Crude oil or a mixture of crude oil with fuel oil or kerosene applied to the inte- rior of pits and boxes is of value in eliminating odors and repelling flies. Crankcase drainings may be used but they are less satisfactory. Lime is of no practical value in latrine pits except as a deodorant. The burning out of latrine pits is not advisable since it does not accom- plish incineration of excreta and does interfere with measures taken for making the pit and box fly proof. Special attention must be given FionsE (la.—Ely proofing bit rim* pit. .1—Oil-soaked burlap extending completely around pit. B—Opening of pit. C—Sidewall of excavation in which burial) is placed. to the cleanliness of .urine troughs. Constant attention by a latrine orderly is necessary for proper care of latrines. The following points are particularly important: 1. The contents of the pit, the sides of the pit, and the intermr of the box should be sprayed with crude oil daily. 2. The seats should be scrubbed daily with soap and water, and twice a week should be scrubbed with a 2 percent cresol solution. They should be dried after cleaning. 3. The urine troughs should be scrubbed daily with soap and water, Jf. The seat covers should be kept closed when not in use. 3. The box should be kept flytight by repairing it as necessary. 6. Fly traps should be placed near each latrine. An ample supply of toilet paper should be available. (/) Deep pit latrines should be closed when filled to within 2 feet of the surface. The box should be removed, the pit contents sprayed with crude oil and covered with burlap, and the pit filled with dirt domed 12 to 18 inches above surface. The site should be placarded TM 8-220 253 MEDICAL DEPARTMENT with the date of closure and the name of the organization. The same spot should not be used again for at least 1 year. Figure 67.—Latrine with screen dropped on one side to show box and urine trough. (4) Fail.—If the character of the soil or any other reason makes it impracticable to dig deep pit latrines, a pail latrine may be substituted. By placing hinged doors on the rear of, and a floor in the standard 280 TM 8-220 SOLDIER 8 HANDBOOK 253 latrine box, it may be used for a pail latrine. The pail is placed di- rectly below the seat and, if located in a building, the hinged doors should open directly to the outside. The latrine seats and rear doors should be selfclosing and the box made as nearly flyproof as possible. The floor should be waterproof, concrete if possible, and have sufficient slope to promote rapid and thorough drainage of the wash water. A trough urinal may be installed within the latrine building with a drain pipe leading into a container outside the building.' The pails must be removed and emptied daily, being replaced by clean pails, the bottom of which should contain about 1 inch of a 2 percent solution of eresol. The latrine box must be cared for as pit latrines. The disposal of the excreta from pail latrines may be accomplished by burial or incineration. It may be possible at times to empty the pails into a manhole of a nearby sewer. i-'icCUH r>S.—Method of adapting standard latrine box for use as pail latrine. I—Katrine pail. U—l linked doors. V—Self-closing lids. f. Urine trough and xoalutge pit.— (1) Trough.—lf a deep pit la- trine is dug in ground which will absorb liquids well, a urine trough drains into the pit and is included within the latrine enclosure. This trough is constructed from tin, galvanized iron, or wood. If from wood, it should be lined with tar paper. The trough should be U- or V-shaped, and 5 feet in length. It is connected to the pit by short sections of pipe. (2) Sgnkage pit.—lf the latrine pit is in ground having poor ab- sorbing qualities, a urine soakage pit should be used for the disposal of urine. This consists of a pit 4 feet square and 4 feet deep, which is filled with pieces of broken rock, flattened tin cans, brick, or broken bottles. Urinals made of 2-inch pipe are placed at each corner of the pit extending 8 inches below the surface and 30 inches above. A tar-paper funnel containing grass or straw is placed in the upper end of each pipe. Important precautions in the proper opera- 281 TM 8-220 253 MEDICAL DEPARTMENT tion of such a soakage pit are changing the grass or straw in the funnels daily, cleaning the funnels daily with soap and water, chang- ing funnels weekly, and keeping the pit surface free from debris, oil. or any substance which might clog it. The soakage pit may receive urine from a trough urinal located within the latrine enclosure, the pit itself being outside the enclosure. Urine pipes or spaces at a urine trough should be provided at the rate of 5 per 100 men. A soakage pit should serve 200 men indefinitely. When it is closed, the pipes should be removed and the pit covered with dirt and sod. Fioiiki: (>!).—Urino soakage pit. A—Rocks filling pit. B Ventilator shafts. C—Pipe urinals. ff. Ni) Gift, sale, or composting.—The more commonly used methods of disposal arfe by sale or gift to civilians, or by composting. If disposal is by sale or gift, care must be taken that the manure is properly col- lected and transported, and that it is finally disposed of far enough away from the camp that a fly menace will not occur. This method is satisfactory in any type of camp if properly supervised. Disposal by composting is recommended in semipermanent camps. (See par. 254.) (c) Burning.—ln temporary camps manure may be disposed of by burning, but enormous amounts of wood and oil are required unless the manure is thoroughly dried beforehand. This method is impracti- cable in a wet climate. i. Kitchen wastes.—(1) General.-—Kitchen wastes consist of the food remnants accumulated after meals and in the preparation thereof, as well as the water in which kitchen utensils and mess gear have been washed. The amount of kitchen wastes varies considerably, especially the liquid portion. However, the solids average about y2 pound per person per day and the liquids average 200 to 1,000 gallons per com- pany of 200 men per day. These wastes must be disposed of to prevent giving rise to offensive odors and attracting flies and rats to the mess area. Solid kitchen wastes may be disposed of relatively easily, but the disposal of liquids becomes increasingly difficult as larger quantities of water are used. For camps of short duration, one night to a few days, both liquids and solids may be disposed of by burial, either in deep pits or in trenches about 2 feet deep. At least 1 foot of earth should be refilled over the garbage. The scattering of lime over garbage is of no practical value. (2) Garbage.—Garbage is often disposed of by sale or gift to civil- ians to be used as fo'od for hogs, and it may be used on military reserva- tions for the same purpose. Its disposal by sale or gift to civilians may lead to unsanitary conditions about a camp through spilling in transfer from garbage cans to other containers, leakage of containers, failure of collection, or unsatisfactory cleaning of cans. When thor- ough cooperation with the contractor can be maintained so as to insure cleanliness in the procedure, there is no objection to this method of disposal. However, the site of final disposition should be far enough 283 TM 8-230 253 MEDICAL DEPARTMENT removed from the camp that odors and flies will not become a nuisance in the camp area. Garbage should not be transferred from one con- tainer to another within the camp area. When garbage is to be used as food for swine, it is necessary to separate it into edible and nonedible portions, the latter being disposed of by incineration. Except when it is disposed of by burial, it is necessary that garbage be separated into liquid and solid portions by passing it through a strainer. Figure 70.—Garbage drainer. j. Sodkage pits and trenches.— (1) Pits.—Liquid kitchen wastes in amounts not in excess of 200 gallons per day are best disposed of by a soakage pit similar in construction to a urine soakage pit. A hole 4 feet deep and 4 feet square is filled with broken rock, varying in size from about 3 inches in diameter at the bottom of the pit to 1 inch at the top. Tin cans or broken bottles may be substituted for the broken rock. Ventilating shafts similar to those in the urine soakage pit are advisable but not essential. A grease trap is necessary in conjunction with a soakage pit as grease, if not removed from the liquid waste, will soon clog the soakage pit. Two such pits should be constructed for each kitchen if the camp is to last several weeks. A daily rest period of several hours will increase the efficiency of soakage pits. If two 284 TM 8-220 SOLDIER S HANDBOOK 253 pits are available, they should be used on alternate days. In camps of long duration each soakage pit should be given a rest period of 1 week every month. If, in spite of these precautions, the pit becomes clogged with organic material, the application of 5 gallons of 10 per- Figurb 71.—80 x grease trap with outlet trough. cent solution of either calcium hypochlorite or caustic soda may clear it. It is desirable to locate soakage pits near to the kitchen if suitable soil can be found there. If not, they must be located where satisfac- tory drainage can be secured. Figure 72.—Soakage trench. A—Central square area. B-—Radiating lateral trenches. - V—Pail grease trap. (2) Trenches.—lf the ground water level or a rock stratum is en- countered near the surface of the ground, a soakage trench may be sub- stituted for the soakage pit. This trench consists of a central pit 2 feet square and 1 foot deep, from each corner of which a trench radiates outward for a distance of 6 feet. These radiating trenches are 1 foot wide and vary in depth from 1 foot where they leave the central pit to 18 inches at the outer end. The central pit and the radiating trenches 285 TM 8-220 253 MEDICAL DEPARTMENT are filled with broken rock. A grease trap must be employed in conjunction with this trench. (3) Pit under field range.—Another optional method is to construct a soakage pit under the firebox of a field range. Liquids are thus disposed of by evaporation as well as by soakage. (4) Sullage pit.—Attempts to dispose of liquid wastes by merely digging a deep hole in the ground into which liquids are poured will meet with little success. Filling with rock or similar material is neces- sary to secure efficient operation of a soakage pit. Figure 73.—Baffle grease trap. A—Strainer. B—Baffle. C—Outlet. h. Grease traps.— (1) General.—The water before being placed in the soakage pit must be passed through a grease trap to remove food particles and as much grease as possible; otherwise, the side walls of the pit will soon become coated with grease and debris and the leaching of water into the soil is prevented. (2) Baffle.— (a) The baffle grease trap is made of a half barrel or a box divided into unequal chambers by a wooden baffle extending to within 1 inch of the bottom, the larger chamber, two-thirds of the bar- rel, being the influent and the smaller, the effluent chamber. The trap is provided with a hinged removable lid. A metal strainer 8 inches square and 6 inches deep, the bottom of which contains many perfora- tions and which is filled with straw to prevent the coarser solids from entering the trap is inserted into the lid of the influent chamber. The strainer is made removable to facilitate cleaning. A 1-inch pipe is inserted in the upper third of the effluent chamber leading to a V-shaped trough which carries the effluent to the soakage pit. In oper- 286 TM 8-220 SOLDIER'S HANDBOOK 253 ating the trap, both chambers are filled with cool water. When the warm liquid waste meets the cool water in the influent chamber, the grease congeals and rises to the surface and is prevented by the baffle board from reaching the outlet to the soakage pit. (h) Careful attention is necessary in order to prevent such a trap from becoming a nuisance. The trap should be drained daily, the sediment removed and burned, and the trap including the removable strainer thoroughly cleaned with soap and water. Figure 74.—Baffle grease trap made of a half barrel. .4—Influent chamber into which greasy fluid is emptied. B—Baffle. C—Effluent chamber. D—Outlet pipe. K—Space under baffle leading from influent chamber to effluent chamber. (3) Ash barrel.—An ash barrel grease trap is prepared by taking a barrel of 30- to 50-gallon capacity and boring thirty 1-inch ho4es in the bottom. Place about 8 inches of gravel or small stones in the bottom, and over this place 16 inches of wood ashes. Fasten a piece of burlap oA'er the open end of the barrel as a strainer. This trap may be placed either directly on a soakage pit or on a platform with, a drainage pipe or trough to the pit. It is necessary to empty this type of grease trap, wash or throw away the ashes and refill with ashes at least every 2 days. The burlap covering should be washed or re- newed each day. This type of trap is generally less satisfactory than a baffle grease trap. (4) Pail.—An old metal pail or can with perforations in the bottom and filled with hay, grass, straw, or an old blanket will remove food particles and part of the grease from liquid wastes. However, much of the grease will pass through. This type of trap should be used only while waiting for a better grease trap to be constructed. 287 TM 8-220 253 MEDICAL DEPARTMENT I. Incinerators.—(l) General.—ln bivouacs solid wastes are gen- erally disposed of by burial in shallow trenches. These trenches should be dug 1 foot wide and 2 feet deep. In temporary camps solid wastes are best disposed of by incineration by individual companies. In semipermanent camps common incineration for several or all units may be desirable. Figure 75.—Ash barrel grease trap. (2)' Cross french.— (a) The cross trench incinerator is the most satisfactory company incinerator. It is constructed by digging two trenches, each 8 feet long, 1 foot wide, and 1 foot deep, crossing at their centers. A grate of pieces of scrap iron is constructed over the inter- section of the two trenches. Over the grate is erected a stack which may be constructed in many ways. The simplest stack is an old galvanized iron can, the bottom of which has been removed. Such an incinerator is satisfactory for camps of less than a month duration. Cross trench incinerators work better when three of the trenches are closed off. leaving the one open toward the direction from which the wind is blowing. Properly fitted pieces of tin may be used to tempo- rarily block off the trenches. The incinerator should be stoked from the top only, the rubbish, flattened cans, and wood mixed with the drained garbage acting as fuel. It is also necessary to keep the burning mass loosened. The fire is built on the grate. 288 TM 8-220 SOLDIER'S HANDBOOK 253 (5) A more efficient incinerator may be constructed on the same principle but using stone or bricks instead of the galvanized can and plastering puddled mud or clay on the outside. (c) A still better incinerator stack may be built by setting a wooden barrel, both ends of which have been removed, over the grate and covering the outside of the barrel with several inches of puddled Figure 76.—I’ail grease trap. clay. A slow fire is kept under the barrel for several hours to bake the clay. Then a brisk fire is built to burn out the barrel and the incinerator is ready for use. Carefully built, such an incinerator will last for several weeks. (3) Rock pit.—The simple rock pit incinerator is very inefficient and extravagant of fuel. Its use is never advisable, (4) Inclined plane.—(a) The inclined plane incinerator is the most efficient of .the smaller improvised incinerators for use in semiperma- 289 TM 8-220 253 MEDICAL DEPARTMENT nent camps. Its capacity is suitable either for a company or for a battalion. In such an incinerator the garbage is fed into the upper end of an incline and is gradually pushed down to the lower end, dry- ing and burning as it progresses, final combustion taking place on a grate at the lower end. The incline is closed over so as to retain the Figuue T7.—Cross trench incinerator with stack made from galvanized iron garbage can the bottom of which has been removed. heat and direct it onto the mass of drying garbage. In the incinerator shown, the incline is made of corrugated iron resting upon a rock bed, and the incline is covered over with portions of steel oil drums. There is a loading and stoking area at the rear and a grate area at the front. The stoking area is closed over with a hinged iron cover, a vent 5 by 290 TM 8-220 SOLDIER'S HANDBOOK 253 16 inches for draft being left at the outlet of the incline, and the grate covered with a door which may he opened as desired for draft. (l>) The walls of the incinerator may be laid np with stone, brick, or concrete. Sections of two oil drums are used to form the cover, (he I-’IODUK 78.—Barrel and trench incinerator. Kicork 70.—Barrel ami trench incinerator with the barrel made of packed day molded over a wooden barrel. drums being cut longitudinally 4 inches above the center and the smaller sections used, the ends being left in place. These sections are placed end to end. supported on the side walls 8 inches above the in- clined floor. Puddled clay to n depth of 2 inches is placed over the top of the drums. TM 8-220 253 MEDICAL DEPARTMENT (c) In use, a fire of wood and rubbish is built on the grate, and. after the incinerator has become hot, a canful of drained garbage is emptied onto the stoking area, some being pushed part way down the incline. As the garbage dries on the incline it is pushed farther down until it burns, being replaced by other garbage from the stoking area. The cover over the stoking area serves to retain heat so that consider- able drying and even burning takes place. The ends of the sections of oil drums serve as baffles which give rise to swirling of the burning gases and aid greatly in the drying and combustion. Piqdkh SO. Rock pit incinerator (schematic). A—Rock wall. B—Earthen embankment to support rock walls. C—Open end to permit draft. (5) Rock 'pile.—The rock pile incinerator may be employed for the disposal of the garbage of organizations up to the size of an infantry regiment. It is very extravagant of fuel but is relatively simple of construction. It consists of a circular pit in the center of which is a cone to divert the air currents upward and thus create a draft. The wall, bottom, and cone are made of loose rock. The pit is about 16 feet in diameter and 24 to 30 inches in depth. The floor and walls should be 12 to 18 inches thick. The draft may be improved by in- stalling draft holes at the junction of the wall and bottom of the pit. The fire is built about the base of the cone. Garbage is placed between the fire and the side wall and, after partial drying, is gradually pushed onto the fire. This incinerator requires on the average about 1 cord of wood to burn 2 tons of garbage. m. Tin cans.—Tin cans or similar nonflammable kitchen wastes should be burned out thoroughly in incinerators, pounded flat, and then disposed of either by burial or on a dump. 292 TM 8-220 SOLDIER S HANDBOOK 253 n. Rubbish.—Accumulations of rubbish attract flies and rats, which in turn act as the transmitting agents of certain diseases to which man is susceptible. All rubbish, not garbage, should be collected daily in containers such as gunny sacks which are placed on poles at both ends of the company street and in latrines. It should then be trans- Figukb 81.—Inclined plane incinerator. Figukk 82.—Inclined plane incinerator, side view. ferred to company incinerators and burned. In semipermanent camps it may be disposed of on a dump, being burned there daily. Care should be taken that no unflattened tin cans or boxes remain on the dump to permit accumulation of water with the resulting possibility of mosquito breeding. Dumps should preferably be located several hundred yards from the tents occupied by troops. 293 TM 8-220 254 MEDICAL DEPARTMENT 254. Fly control.—a. General.— (1) Importance.—Flies, espe- cially the ordinary housefly, frequently transmit intestinal diseases. This transmission is accomplished in a mechanical manner. If the fly has access to human excreta it collects small amounts of excreta on its Figure: 83.—Hock pile incinerator. Fiudug 84.—Rock pile incinerator showing draft holes at junction of wall and bottom of pit. legs and body and in its digestive tract. If it later has access to food or eating utensils, some of the excreta is deposited on the food by defecation, regurgitation, and contact of food with the legs and body of the fly. 294 TM 8-220 SOLDIER S HANDBOOK 254 (2) Development.—ln its development the fly passes through four stages—the egg, larva, pupa, and adult. (3) Characteristics,—The characteristics of the fly which are im- portant in its control include— (a) Their breeding places of choice, which are horse manure, human excreta, and fermenting vegetable wastes. (h) The necessity of moisture, warmth, and soluble food for the development of the larvae. (c) The fact that temperatures of 115° F. or above will kill the eggs and larvae. FlGumo 85.—Housefly ; stages in development. (d) The tendency of the larvae to migrate from the breeding material prior to pupation. (e) The ability of the larva and adult to crawl through loose manure or earth. (/) The attraction of adult flies to food by odor. (g) Their tendency to go toward light. (A) Their tendency to rest on vertical surfaces and hanging objects. (i) Best temperature for breeding is 80° to 95° F. (y) The range of flight is 200 to 1,000 yards. (k) The number is greatest in the late summer and early fall. 295 TM 8-320 254 MEDICAL DEPARTMENT (?) Continuous breeding may occur during the winter in heated buildings. b. Control.— (1) Breeding places.—The control of breeding places is essentially the problem of the proper disposal of horse manure, human excreta, and garbage. The disposal of horse manure in temporary camps is considered in par. 253h. Disposal in semipermanent camps may be accomplished by composting, which is the close packing of manure on a platform. In properly composted manure a temperature of 140° to 160° F. is reached at a depth of 1 foot below the surface; FiGUitii 8U.—Manure compost pile with ditches for the control of migrating larvae. such a temperature will quickly kill the fly egg and larva. By the use of larvicides the fly larvae on the surface can be destroyed. The compost pile should be located over 1,000 yards from the camp and where it will not be an unsightly nuisance. A compost platform is constructed by leveling off an area of ground 50 feet long and 20 feet wide and digging a trench around the area 12 inches wude and 12 inches deep with vertical sides. The manure is placed on the platform as follows: Beginning at one corner, place the manure on an area 3y2 feet long and 10 feet wide, piling it to a height of 4to 5 feet, packing it down very tightly, and dressing the sides neatly. The sides must at all times be kept vertical. The second day’s sup- ply of manure is placed on the adjacent corner in a similar manner. On the third day the supply of manure is placed immediately ad- jacent to the first pile and on the fourth day, adjacent to the second pile, and on the fifth day the supply is piled on top of the first pile. The manure is thus placed on the platform in the succeeding small 296 TM 8-220 SOLDIER'S HANDBOOK 254 sections as shown in figure 86. This is done for the purpose of con- fining the fly breeding to the smallest possible area. The manure should be kept moist so as to promote decomposition. The sides of the pile should be sprayed daily with a mixture of cresol, kerosene, and fuel oil. Crude oil or a light road oil is used in the trench, the earth in the trench being kept visibly moist with oil. In the prepa- ration of the platform all vegetation should be removed for a dis- tance of 2 feet from the edges and the earth here tamped down firmly and oiled thoroughly; similarly, the earth beyond the trench should be freed from vegetation, packed down, and oiled. The trenches are to be kept clean at all times. A platform this size should care for the manure of 100 animals for 2 months. (2) Larvicides.—Larvicides are used chiefly in connection with compost piles and latrines. The following larvicides are effective in destroying fly larvae and are listed in order of efficiency: (a) Cresol 2 parts. Kerosene 20 parts. Fuel oil 78 parts. (h) Cresol 2 parts. Soap suds 1 98 parts. (c) Waste motor oil. (d) Crude oil. The above larvicides have the disadvantage that they render the compost somewdiat unsatisfactory as fertilizer. The following lar- vicide, while not rapid in action, is very efficient and has the added advantage that it does not render the compost unsatisfactory for fertilizer : Commercial sodium arsenite 4 pounds. Molasses 2 quarts. Water 50 gallons. (3) Destruction of adult -flies.— (a) Swatting.—Swatting is one of the essential methods of destruction of flies which have entered a screened building. It is, however, labor-consuming. (h) Traps. 1. General.—Fly traps are the most valuable means for de- struction of adult flies in camps. Many types are used but all consisting of two main parts—the bait chamber and the trap chamber. The former is the lower and darker part into which the flies are attracted by the odor of the bait. The upper and lighter part is the trap chamber and is connected with the bait chamber 297 TM 8-220 254 MEDICAL DEPARTMENT by a small opening through which the flies crawl toward the light after having fed on the bait. The construction of fly traps is simple. 2. Square.—A square fly trap such as shown is made 12 to 18 inches square and 18 to 24 inches high. The corner uprights and connecting lateral strips are made of boards 1 inch thick and 1y2 inches wide. The frame- work is covered with No. 14 mesh wire screening tacked to the corners and connecting strips. The lid is a Figuke 87.—Square fly trap with removable top and pyramidal bait chamber. screen frame which fits down over the top. The bait chamber is inside the trap and is made of screening tacked to the edges of the lower lateral strips and terminating in an apex 10 to 14 inches above the bottom of the trap. At the apex is a i/j-inch hole through which the flies enter the upper chamber. The corner uprights extend 1 inch below the lower edge of the trap to form the supports for the trap. 3. Bov.—A box fly trap is made essentially as above except the sides are made of wood. It is constructed as fol- lows: Make a closely fitting top for an ordinary packing box 12 by 18 by 11 inches, and cover with screen. Cut a 0- to 8-inch hole in the bottom of the box, over which TM 8-220 SOLDIER’S HANDBOOK 254 a wire cone about 10 inches high with a 14-inch hole at the top is tacked. The corners are raised from the ground by 1-inch blocks. Fiorina 88.—Fly trap constructed of packing box. Qprner cut away to show method of installing cone. FronnE 89.—Triangular fly trap with cone-shaped bait chamber. Single opening at apex of cone leading into trap chamber. The small tin disk covers an opening through which flies may be removed from the trap chamber. Jf.. Triangular.—A triangular fly trap such as shown in figure 89 is the most satisfactory for use in camps because of its simple and durable construction, but it is less effi- cient than the square trap. It should be about 18 inches 299 TM 8-220 254 MEDICAL DEPARTMENT long and 12 inches high. A-hole Ito 2 inches in diam- eter, covered by a tin flap, is cut in one end of the trap for the removal of dead flies. 5. Pail.—A trap may be constructed from an old 3- to 5-gallon metal bucket. The bottom of the bucket is cut out except for 1 inch around its outer border, to which a wire cone is soldered. A top is made which fits down into the bucket a distance of 1 inch and is screened Figure 90.—Fly trap, showing method of construction, using ordinary metal bucket. except for 1 inch of metal around the outer border. The top is held in place by three pieces of copper soldered to the outer side of the bucket so that they may be bent over the cover. The bucket is supported by three pieces of metal 1 inch high. 6. Baits. (a) A satisfactory bait must have an odor attractive to flies, and in turn not be offensive in appearance or odor to people in the vicinity. Fermented baits are generally very satisfactory. The best fermented bait is— 300 TM 8-220 SOLDIER’S HANDBOOK 254 Cornmeal 1 pound. Molasses % pint. Water 1 quart. Yeast 14 ounce. Mix the water and molasses and heat to boiling. Stir in the cornmeal and allow the mixture to cool. Then add the yeast and allow to stand in a warm place 1 or 2 days. It is then ready to use. Figdhb 91. -Square fly trap with board windshield to protect trap from wind. (b) Other fermented baits are two parts molasses and one part vinegar, crushed over-ripe bananas in milk, brown sugar, and sour milk. (c) Decaying meat or fish are efficient baits but may result in offensive odors. 7. Location.—Traps in sufficient number should be located near manure piles, latrines, in vicinity of kitchens, mess halls, dumps, and other buildings or areas where flies congre- gate. They are more efficient if placed in groups of two or three. Traps should be protected from the wind, and this may be done by utilizing a fly trap stand pro- vided with a windshield. Also, traps may be placed behind objects such as buildings, boxes, and garbage cans which protect them from the wind. If placed on 301 TM 8-220 254-255 MEDICAL DEPARTMENT a stand the trap should be at least 12 inches away from the sides of stand so as not to exclude the light from any side of the trap. Traps placed in dark corners or under shade are practically useless. 8. Care.—Liquid fly bait should be placed in wide, shallow containers with at least 2 inches between the edges of the bait pan and the edges of the trap. The baits should be inspected daily, the containers kept filled to the desired level, cleaned and refilled whenever a scum forms or sediment accumulates, and should be kept free from dirt and dust. The traps should be emptied when- ever a sufficient number of flies accumulate to interfere with the admission of light to the trap chamber. The captured flies may be killed by immersing the trap in soap suds. Practically constant attention is necessary if fly traps are to be effective in the control of flies. Necessary care includes not only cleaning and replenish- ing bait but also moving the traps about to conform to changes in wind and sunlight. 255. Mess sanitation.—a. General.—The company mess is a very potent factor in the transmission of intestinal diseases, and to a lesser degree, of respiratory diseases. Furthermore, the character of the mess has decided influence on the morale, physical fitness, and natural resistance of the individual. The basic consideration of mess sanitation is cleanliness. The essential features in proper mess sanitation are inspection and supervision of food handlers; inspec- tion, protection from dirt and flies, storage, and preparation of food; cleansing and protecting from dirt and flies of mess gear and kitchen utensils; control of flies; and exclusion from the vicinity of the mess of any factors which might result in the contamination of food. h. Food handlers.—(l) Personnel.—The personnel of a mess con- sists of both permanent food handlers and temporary kitchen police. The dividing line is not a sharp one, but as a working basis, mess sergeants, cooks, butchers, bakers, and mess orderlies assigned for duty in excess of 8 days should be considered permanent food handlers. (2) Examination.—Army Regulations require that such permanent food handlers be examined by a medical officer before beginning duty in the mess, and each 6 months thereafter. The purpose of the examination is to detect cases or carriers of communicable diseases. Those individuals found to be free from communicable diseases will be so certified to the company commander by the examining medical 302 SOLDIER'S HANDBOOK TM 8-220 255 officer. These certificates should be posted in a conspicuous place in the mess. (3) Daily observation.—Temporary kitchen police are not rou- tinely required to have food handler examinations. However, it is vitally important that both the temporary kitchen police and the permanent food handlers be closely observed at all times for evidence of communicable diseases. This is a responsibility of the mess offi- cer and mess sergeant. Any food handler, temporary or permanent, showing evidence of an illness, particularly of a cold or other respira- tory disease, or of diarrhea or other intestinal disease, should be promptly relieved from duty. (4) Cleanliness.—lt is equally important that all mess personnel wear clean clothing and have clean hands at all times. The finger- nails should be cut short. The hands should be washed immediately after visiting the latrine. Convenient facilities for washing the hands must be provided. In addition to washing the hands in soap and water, rinsing in a 2 percent solution of cresol is a valuable precaution. c. Food inspection.—All food should be inspected for freshness and quality when received at the mess and, if stored, again while in stor- age and before being prepared for consumption. d. Food storage.— (1) General.—Food supplies should be protected from insects such as flies and roaches, from dust and dirt, and from rats and mice. Perishable foods should be stored at a temperature that will inhibit the growth of molds and disease organisms. Refrig- eration at a temperature of 55° F. or less is desirable for meat and dairy products and for some vegetables and fruits. An important point in the storage of foods, particularly meat, is to avoid packing or hanging so closely that ventilation is impaired. Various devices may be improvised for the storage of food in temporary and semi- permanent camps. (2) In temporary camps.—(a) In temporary camps food may be stored in watertight containers and immersed in springs or streams, care being taken to prevent contamination. Food may be buried below the surface of the ground where the temperature is lower, lining a pit with burlap and placing boards on the bottom. (b) A suspended food contained consists of a screened box that permits free circulation of air but prevents contamination by insects. The cooling effect may be increased by wrapping the box in burlap which is kept damp. Fresh meat, bottled milk, and vegetables may be temporarily stored in such a container. It should not be used where there is much dust in the air. 303 TM 8-220 255 MEDICAL DEPARTMENT (c) The underground ice box or cooling box is a simple device consisting of a double-walled box. It is constructed by placing a packing box within a larger one, sunk into a pit in the ground so that the outer lid is slightly above the surface of the ground. A space 3 to 6 inches wide, filled with sawdust, grass, hay, or straw, separates the outer walls and the two bottoms. Two lids are necessary, one for the inner and one for the outer box. A drainage ditch should be dug around the box and a drain pipe should lead through the bottom of the box to a small soakage pit below. A box 4 feet long, Figuke 92.—Suspended food container. 3 feet wide, and 3 feet deep, inside measurements, has sufficient ca- pacity for the average company mess. If ice is available, an ice compartment should be constructed at the end containing the drain pipe. Also the box may be used above ground as an ice box. The cooling effect is increased by dampening the packing material be- tween the walls or wetting down the earth around the box. To fa- cilitate cleaning, the inner box should be easily removable. Meat, milk, vegetables, or other perishable foods may be stored in such an ice or cooling box. {d) Bread boxes or storage cabinets should be well ventilated but screened to prevent access of flies to the food. e. Food 'preparation.— (1) Thorough cooking and immediate serv- ing after cooking are the best safeguards against the transmission of communicable diseases by food, provided care is taken not to con- taminate the food after cooking. 304 TM 8-220 SOLDIER S HANDBOOK 255 (2) Disease-producing organisms will multiply rapidly in many cooked foods even when placed in the ordinary ice box. This is par- ticularly true in the case of meat hash, sausage, fresh pork, veal, Figurk 93.—Underground ice or cooling box. A—Outer wall. B—lnsulating material. C—lnner wall. Figure 94.—Underground food box. meat broths or soups, or dishes containing a preponderance of these materials. These foods should not be served as leftovers without adequate reheating. 305 TM 8-220 255 MEDICAL DEPARTMENT (3) All vegetables that are to be eaten raw, and which cannot be peeled, should be thoroughly washed in running water before serving. This applies particularly to leafy vegetables such as lettuce, greens, and radishes which may have become contaminated with disease-pro- ducing organisms from materials used as fertilizers, especially in the Tropics. /. Care of utensils.— (1) General.—All eating and cooking utensils should be disinfected immediately after use by washing in hot soapy water, followed by rinsing in hot clear water. This is necessary to destroy disease organisms. The utensils should then be air-dried. Dish towels should never be used. When not in use all utensils should be protected from dust and flies. (2) Mess hits.— (a) If mess kits are used, they must be disinfected by each individual. Fragments of food should be scraped from mess kits into a can or pit in the ground before washing. Washing of mess kits is usually done in galvanized iron cans. A trench 8 feet long, 1 foot wide, and 1 foot deep is dug near the kitchen. A fire is built in this trench. Over it are placed three galvanized iron cans, preferably supported by strips of metal. Two of the cans contain hot soapy water, and the third hot clear water. The water in all three cans should be kept close to boiling/while in use. Each man thoroughly washes his mess equipment in each of the two cans of hot soapy water, then rinses it in the hot clear water, and permits it to air-dry. The cans must be emptied of water and thoroughly cleansed after each meal. The food particles are disposed of by burial or incinera- tion. The water is disposed of in the soakage pit or trench. (h) In semipermanent camps a different apparatus for washing mess kits may be used. It consists essentially of a fire trench with a stack at one end. built over a soakage pit. The pit is 11 feet long. 4 feet deep, and 2 feet wide and is filled to within 1 foot of the sur- face with varying size stone. Along the two sides and one end a wall of stone, brick, or concrete is built extending 2 feet above the ground level, forming a firebox. The water containers are made from 50-gallon oil drums cut along the longitudinal axis, 4 inches above the center line. Drums with bungs should be used and so cut that the bungs will be dependent when placed on the fire. Pieces of iron pipe of sufficient length are threaded at one end to fit the bung holes and drilled at the other end to receive an iron rod used to turn them in or out. After the drums are placed on the firebox the space between the drums and walls, between the ends of the drums, and between the rear drum and the stack should be filled with clay. This device will require a relatively small amount of fuel 306 TM 8-220 SOLDIER S HANDBOOK 255 to boil the water. The draft will be such that it will be found de- sirable to place a damper in the stack. The men can wash their mess equipment without being bothered by flames and smoke. When the washing is completed, the iron pipes are removed and the water escapes into the soakage pit. Figuuk 95.'—Fire trench and cans for washing mess khs. PiGUitE 90. -Washing mess kits. g. Mess tables.—Where tables are available, they should be so con- structed that the middle leaf or board can be removed to permit cleaning the space between the boards, and removal of food oarticles. Tables should be scrubbed with soap and water after each meal. 307 TM 8-220 255 MEDICAL DEPARTMENT h. Fly control.—lf the mess is housed in a screened building, the screening must be kept in repair. Screen doors should be kept closed when not in use. Flies gaining entrance into the mess hall should be destroyed by the use of traps, flypaper, and sprays, and by swatting. Figure 97.—Device for washing mess kits in the field. i. Disposal of garbage.—All garbage and liquid wastes should be promptly disposed of so as not to attract flies to the vicinity of the mess. Constant police of the mess is necessary to prevent accumula- Figuue 98.—One method of labeling garbage cans for the collection of classified garbage. Concrete garbage stand. tion of fragments of food. Where practicable, all garbage should be collected, as produced, in garbage cans equipped with well-fitted lids. These cans should be kept outside the mess, either on a garbage 308 TM 8-220 SOLDIER'S HANDBOOK 255-256 stand or on firm, well-tamped soil. Garbage stands, if used, should not be screened, as this increases the difficulty of keeping them clean and serves to attract flies. Garbage should be removed from garbage cans for incineration or burial at least twice daily, and preferably after each meal. This is done by personnel of the mess unless gar- bage is being hauled away for disposal outside the company area. The garbage cans should be scoured with hot soapy water and lye at least once each day. Section Y PREVENTION AND CONTROL OF INSECT-BORNE DISEASES Insect-borne disease 2r>fi Mosquito control 2.TT Control of lice 2">S Control of ticks__. 2-V.) Control of bedbugs 260 Control of roaches and ants 261 Control of fleas ___ _ 262 I'am graph 256. Insect-borne disease.—a. Definition.—A disease is classified as insect-borne when a bloodsucking insect is the only agent, or the usual one, by which the causal organisms are transmitted from person to person or from animal to man. b. Tabulation of vectors.—The following tabulation of insect-borne diseases with their vectors includes those diseases of particular interest to the Army: Disease Principal vector Malaria __ Anopheles mosquito (several species). Yellow fever Aedes egypti mosquito. Dengue Aedes egypti and Aedes albopicttis mosquitoes. Tularemia Flies, ticks, lice, and fleas. (Also contact with infected material.) Rocky Mountain spotted fever Tick. Relapsing fever Lice and ticks. Typhus fever (epidemic) Body louse. Typhus fever (endemic) Fleas (usually). Trench fever Body louse. Bubonic plague Rat flea. Filariasis Several varieties of mosquitoes and biting flies. c. Transmission.—Transmission of insect-borne diseases is accom- plished by the vector’s first sucking blood from an infected person or animal and later biting a susceptible individual. 309 TM 8-220 257 MEDICAL DEPARTMENT 257. Mosquito control.—a. General.—Mosquitoes are of impor- tance to health, not only as transmitting agents of disease but also as sources of discomfort. Among the diseases known to be transmitted by mosquitoes are malaria, dengue, yellow fever, and filariasis. The most important of these from a military viewpoint at this time is malaria. b. Life cycle.—There are four stages in the life cycle of the mos- quito—the egg, larva, pupa, and adult. The first three stages are passed in water, while the adult is a free-flying insect. c. Breeding places.—Mosquitoes may breed in practically any col- lection of water which persists longer than 10 days. Most types pre- fer slow-moving streams, ponds, swamps, drains, water receptacles, and roof gutters. Various species differ in their preferences for types of breeding places. Some prefer breeding in and around habitations and are termed domestic. Some prefer to breed in sunlit places, while others prefer shady places. Some prefer fresh water, and others water containing organic material. Detailed discussion of these characteristics may be found in FM 8-40. d. Range of flight.—Some mosquitoes, including the Anopheles, can fly at least 1 mile and with a favorable wind possibly several times that distance. e. Control measures.— (1) Elimination of breeding planes.—Meas- ures designed to eliminate breeding places are applicable only in semipermanent and permanent camps. They are highly effective when possible of execution. {a) Filling.—Filling is effective and is practical for small depres- sions where streams overflow or storm water collects. Earth, rocks, garbage, cinders, ashes, rubbish, and old manure may be used as a fill. (b) Drainage.—Drainage is applicable in the case of small ponds of water or swamps. It may be accomplished either by surface or by subsurface drainage. Surface drainage can be accomplished by open U-shaped ditches. These ditches may be lined with tile or cement. Unless lined, attention is required to keep out vegetation. Subsurface drainage can be accomplished either by a trench filled with small rocks or by a line of loosely joined tile just under the surface of the ground. (c) Stream training.—Stream training is effective but requires considerable labor. The stream edges should be straightened, pot- holes removed, and grass and underbrush removed for a distance of 4 feet from the edge of the stream. If time, labor, and material permit, stone or cement walls may be constructed to retain, the stream. 310 SOLDIER’S HANDBOOK TM 8-220 257 {d) Emptying water containers.—All water containers should be emptied weekly. Frequent inspections should also be made for col- lections of water in tin cans, flower pots, old automobile tires, or gutters. Figure 9n.—Drainage ditches. .4—Showing splash board for ditch junction. Ji—Show- ing splash board at ditch junction and culvert under roadway, with concrete slab at downstream end of culvert. Figdkb 100.—Knapsack oil sprayer. (2) Destruction of larvae.—Measures for the destruction of larvae are all of a temporary measure and must be repeated at least every 7 to 10 days. The most common larvicides are crude oil, waste motor oil, kerosene, paris green, and Panama larvicide. (a) Oiling.—A continuous film of oil must be maintained on the surface of the water for 2 or 3 hours in order to kill the larvae. 311 TM 8-220 257 MEDICAL DEPARTMENT About one-half pint of oil is required for each 100 square feet of water surface. Crude oil, fuel oil, waste motor oil, or various mix- tures of these oils may be used. The heavy grades of oil must be thinned in order to obtain a film, especially in cool weather. The killing effect is caused by the toxic action of the volatile gases after Pir.mtK ]Ol. Drip oiler made from o-gallon oilcan. Regulator consists of nail and cotton plug. Suitable for oiling water in small ditch. inspiration by the larvae. Nonvolatile oils are ineffective. There are various methods of applying oil: 1. The knapsack sprayer consists of a container for oil. a pump, and a spray nozzle. It holds about 5 gallons and is operated by one man who carries it strapped,, on his back. Its range is up to 25 feet. It is used for small ponds, pools, ditches, and the banks of streams. Larger sprayer's may be used for larger bodies of water. #. A watering can may be used, but it is a slow method. 3. A drip oiler may be used in slow-moving streams. It will maintain a film of oil over indentations in stream banks and over stream eddies. It requires little attention. The oil must be adapted to the temperature. The oiler 312 SOLDIER S HANDBOOK TM 8-220 257 is made from a container such as a galvanized iron can, a 5-gallon oilcan, or a bucket. A small hole is made in the bottom. In this is inserted a regulator or wick consisting of a nail wrapped in cotton or gauze. The oiler is set on boards over the stream. The rate of flow should be regulated to about 20 drops per minute for each foot width of the stream. 4- A submerged oiler may be used either in streams or ponds. One method is to fill a burlap sack with oil-soaked saw- dust, weigh it down with rocks, and place it in the stream. Oil will gradually come to the surface. An- other method is to anchor to the bottom of the stream a tin can of oil with small holes in the top and bottom. (h) Paris green.—Paris green is mixed with 100 parts of road dust or fine ashes before application. It is useful only against the Anopheles mosquito, which feeds on the surface. The mixture may be applied by hand, by hand blowers, or by spreading from an air- plane. One-half ounce of paris green diluted with 100 times its volume of road dust will be sufficient for 1,000 square feet of water surface. In this amount it will not harm fish. {c) Panama larvicide.—Panama larvicide is a phenol larvicide. It is made by heating 5 gallons of crude carbolic acid until it is steaming hot, stirring in 6 pounds of crushed rosin, then stirring in 1 pound of caustic soda dissolved in 1 pint of water. This larvicide is mixed with five parts of water and is ready for use. In treating bodies of water enough of the larvicide is added to form an emulsion of about Ito 5,000. It is thus necessary to know the volume of the water being treated. The larvicide may be applied with a spray or may be poured into the water. It will not destroy fish. {(I) Natural enemies.—Many fish will eat mosquito larvae. The most efficient of these is Gamhusia afjinis, a top feeding minnow. These are particularly valuable in small ponds or slow flowing streams. (3) Destruction of adults.— {a) Swatting.—Swatting is the sim- plest means of disposing of mosquitoes which have entered buildings. It can be more easily accomplished at twilight and just after day- break, at which time mosquitoes collect on screens, doors, and windows. An ordinary fly swatter or folded paper may be used. {h) Spraying.—Spraying is of value in buildings. The ordinary pyrethrum spray is effective for the purpose. The spray should be directed at the walls and ceilings. 313 TJt 8-230 257 MEDICAL DEPARTMENT (4) Protection.—Protection from mosquitoes is necessary both for patients under treatment for insect-borne diseases and for healthy individuals. Its object is both control of disease and freedom from discomfort. I'kjuke 102.—Equipment for mixing and applying paris green larvicide. Figukh IQ:!.—Method of producing dust cloud of parts green larvicide with hand-operated dust blower. (a) Screening.—Screening is of value only if maintained in perfect repair. A mesh of 18 wires to the inch is necessary to exclude Anopheles. Vestibules with double screen doors are of value in 314 TM 8-220 257-258 SOLDIER’S HANDBOOK excluding mosquitoes from buildings. Screen doors should open outward and should have strong springs. (h) Netting.—Mosquito nets or bars are to be used on beds in all areas when mosquito-borne diseases are endemic. Their use must be enforced by the unit commander. They may be used on T-bars or suspended from the inside or over the outside of the shelter tent. No part of the net should touch the sleeper. They must be tucked in on all sides while in use. During the daytime they must be rolled. They should be inspected regularly for holes, ripped seams, and tears* Nets are to be carried as part of the soldier's equipment in malarial coun- tries. Where Anopheles are prevalent, head net and gloves should be used for members of the guard and others on outside duty. (c) Repellents.—Repellents are mixtures which, .when daubed on the skin, partially or completely repel mosquitoes. They are for the most part difficult to secure and keep. The following ones are easy to prepare. 1. Melt 60 grains of white petrolatum and add 15 cc, citronella oil, 8 cc. of spirits of camphor, and 8 cc. of oil of cedar wood. Stir well, pour into jars, and cool rapidly. This must be kept cool and tightly capped. A small amount applied to the face and neck will last through the night. 2. A mixture of 1 part Epsom salts and 10 parts water daubed on the skin is moderately effective in repelling mosquitoes. 258. Control of lice.—a. Diseases transmitted.—Lice transmit typhus fever, trench fever, and relapsing fever. I). Classification.—The species of lice which infest man are— (l) Pediculus humanus corporis (“body louse,” “cootie”). This species is the one chiefly responsible for the transmission of louse-borne diseases. (2) Pediculus humanus capitis (head louse). (3) Phthirius pubis (crab louse). c. Military importance.—The louse-borne diseases are particularly important to the Army in time of war since lice thrive in conditions of crowding and difficulty of personal cleanliness. d. Life cycle.—The life cycle of the louse consists of three stages— the egg, larva, and adult. e. Characteristics.— (1) The head louse ordinarily remains attached to the hairs of the head. The crab louse is found mainly about the genital region but may be found attached to the hairs of any part of the body. The body louse, however, remains attached to the clothing except when feeding. 315 TM 8-220 258 MEDICAL DEPARTMENT (2) Lice are spread by adult lice or eggs being dropped off the body in straw, debris, blankets, clothing, or latrine seats. Crab lice may also be disseminated by sexual intercourse. (3) Lice and their eggs are killed in 5 minutes by dry heat of 131° F. and in 1 minute at 155° F. They are killed in 30 seconds in boiling water. (4) Lice do not transmit disease by the act of biting. They defecate as they feed. The disease viruses are contained in their excreta and are scratched into the skin by the human host. /. Delousing.—(l) Delousing must be universally effective through- out the unit. All individuals, their clothing, and their equipment should be disinfested simultaneously. If one individual is missed, reinfestation of the entire unit will soon occur. Prompt action should be taken at the first indication of lice in a unit. (2) Delousing of a unit includes the following procedures: {a) All individuals to bathe thoroughly and to shave various parts of the body if necessary. (b) Clothing and equipment to be deloused. (c) Latrines, beds, and any objects possibly harboring lice to be disinfested or destroyed. {(I) Clean clothing to be issued to all individuals. g. Bathing.— (1) General.—Bathing is an essential part of any de- lousing program and should be performed while clothing and equip- ment are being deloused. It may be carried on either in a fixed installa- tion such as a quartermaster bathing and delousing unit or by means of improvised shower baths. An excellent soap to use is made as follows: Boil one part of ordinary issue soap in four parts of water. Add two parts of kerosene. Mix with four parts of water. (2) Showers.—{a) A simple device for bathing can be made from a water sterilizing bag suspended from a scaffold or a tree limb. One faucet of the bag is replaced by a rubber tube, in the end of which is placed a short section of pipe closed at one end and perforated in nu- merous places to act as a shower head. A stone-filled soakage pit should be constructed underneath the shower, being covered with boards on which the men may stand, A grease trap should be installed if the pit is to be in use for more than 2 days. (£>) A large tin can, such as a gasoline can, with a perforated bot- tom may be suspended from a tree or platform. In its operation one man pours water through the can while another bathes. 316 SOLDIER’S HANDBOOK TM 8-220 258 (c) A more elaborate device may be made by inserting a small per- forated tin can into a hole cut in the bottom of a barrel. The valve is constructed of a plunger which fits into the can. This plunger is controlled by means of a lever and handle within reach of the bather. Figure 104..—Improvised shower bath. h. Shaving—Bathing with soap will not always destroy all of the eggs attached to the hairs of the body. When infestation is evidenced by the presence of eggs on the hairs or by indication of louse bites, the hair in the armpits, about the genitals, and if necessary on the chest and legs should be shaved or clipped. In peacetime, shaving should be routinely employed for the removal of crab lice. If at any time shaving or clipping is not practicable, the infested parts of the body should be thoroughly scrubbed with vinegar, kerosene, or gasoline. This will remove the eggs as well as the adults. i. Shampooing.—lf head lice are present, disinfestation can be ac- complished by loosening the eggs from the hairs by the thorough application of vinegar followed by shampooing the scalp with hot, soapy water containing 25 percent of kerosene. This removes the 317 TM 8-220 258 MEDICAL DEPARTMENT detached eggs and kills the adult and larval forms. After shampoo- ing. the hair should be combed with a fine-toothed comb to remove any nits not removed by washing. Where practicable the hair should he clipped short. l-'i<:l'i:K 1 or.. I )isintVs|i>r. Sfrbijui Imrrol lyjM*. j. Disin/(’.station of clothing and egai/nnent.— (1) General.—lm- proper treatment will damage certain materials. Steam will not seriously affect cotton or woolen cloth but will seriously damage art ides made of leather, felt, or webbing. Boiling water will shrink woolen cloth. Dry heat is practically harmless for all articles except wool, which it will damage somewhat. (2) Available method*.—Outside of permanent installations and delousing units, the disinfestation of clothing and equipment is done by means of one of the following methods; {a) Mobile disinfestor (quartermaster function). (b) Serbian barrel type of disinfestor. Fn:i;ici: UM»,—Hooks for suspending innleiial in Serbian barrel 318 TM 8-220 SOLDIER'S HANDBOOK 258 (c) Improvised hot air disinfestors. (d) Hot irons. (e) Hot water. (/) Storage. {(/) Chemicals. Fhjuuk 107.—Disiafestor, Serbian barrel type, showing water pan and wire netting across lower opening of steamer. k. Serbian ban'el.—Serbian barrel type disinfestors are company installations. They consist of a barrel or a similar container for the material to be disinfested, below or in the lower part of which there is a receptacle for water and an improvised furnace or firebox. l. Hot air.—Clothing and equipment may be placed in ovens, boxes, or cans and subjected to dry heat. Small buildings or dugouts may be converted into hot air disinfestors by installing heating apparatus which will heat the air to 160° F. Clothing should be hung loosely and exposed for about 30 minutes. m. Hot irons.—Clothing can be deloused by removing the adult lice by hand and then killing the eggs by ironing the cloth, especially the seams and folds, with a hot iron. An ordinary sadiron or a piece of iron pipe or scrap iron with a wooden handle may be used for this purpose. This method is laborious and uncertain. 319 TM 8-220 258-259 MEDICAL DEPARTMENT n. Hot water.—Cotton, linen, or silk clothing may be disinfested by immersion in boiling water for 1 minute. This will kill the virus of the insect-borne diseases as well as the lice. A temperature of 135° F. for 5, minutes will kill lice but will not destroy the viruses. This method should not be used for wool, leather, felt, or web material. o. Storage.—Storage of infested clothing and equipment will accom- plish disinfestation by depriving the lice of a food supply. The exact time required is dependent on the temperature. A safe rule is keep articles in storage at least 30 days. In this time successive batches of eggs will have hatched, and the larvae and adults will have died. This method is frequently very practical for disinfesting clothing and blankets in hospitals and camps, providing storage facilities are available and clean clothing and equipment are available. The stor- age rooms should be kept dry. Freshly infested articles should not be placed with those that have been in storage for some time. No article should be removed from a room until all articles have been in storage at least 30 days. p. Chemicals.—Leather, web materials, shoes, and hats which can- not be disinfested by other means should be immersed in a 5 percent solution of cresol for 30 minutes. Clothing may be disinfested in 2 percent cresol, but this is rarely advisable. 259. Control of ticks.—a. General.—The common wood tick is the most important tick found in the United States insofar as trans- mission of disease to man is concerned. This tick is the vector for Rocky Mountain spotted fever. In endemic areas it is estimated that 1 percent of wood ticks harbor the spotted fever virus. It is also one of the agents by which tularemia is transmitted from animal to animal and from animal to man. It is found quite generally throughout the United States. The rabbit tick and dog tick are also concerned in the transmission of Rocky Mountain spotted fever. Ticks have been found to be the transmitting agent of relapsing fever in Central America, Venezuela, and Colombia. b. Characteristics.—Adult ticks can live for 2 years without food. Cold delays the development of the immature forms, but extremely cold weather will not kill ticks in any stage, nor will it destroy the virus of Rocky Mountain spotted fever. c. Control.—(1) Control of tick-borne diseases by the eradication of the tick is difficult to achieve and is in many instances impracticable. Buildings of little value infested with ticks should be burned. If found desirable, a kerosene or cresol insecticide may be applied to tick-infested floors, walls, ceilings, or furniture. It should be applied as described in paragraph 260. Control of the tick must be attained 320 TM 8-220 SOLDIER'S HANDBOOK 259-260 mainly by control of its wild animal hosts. As the tick feeds princi- pally on the smaller animals such as squirrels, rabbits, prairie dogs, or woodchucks, the eradication of these animals from an infested area is an important factor in tick control. This may be done by trapping, shooting, and poisoning of wild rodents. Where practicable, burning of the underbrush will reduce the number of animals and will also destroy some of the ticks. Sheep grazing is also a valuable means of reducing the number of ticks. Ficijuk 108.—Dermacentor andcinoni (wood tick) (2) All individuals in tick-infested localities should frequently examine their exposed skin areas and promptly remove any ticks found. This may prevent disease since ticks may not infect a person until some time after they have attached themselves to him. 260. Control of bedbugs.—a. General.—Bedbugs exist wherever they can live in close association with man. They frequently become a serious pest in barracks and guardhouses. It has not been proved that bedbugs transmit any disease to man. Because they are blood- sucking insects, however, it is possible that they may transmit any disease in which there is a blood stream infection. h. Characteristics.— (1) Bedbugs develop through the egg, larva, and adult stages. The eggs are white, oval in shape, and about 1 millimeter long. They are deposited in cracks, crevices, and any place which affords protection and concealment. (2) Bedbugs feed at night. They are capable of surviving for 6 months or more without food. (3) Bedbugs are usually spread from place to place in clothing, bedding, baggage, or furniture. They hide in the seams of mattresses and pillowcases and in cracks and crevices of any wooden or metal structure. TM 8-220 260-261 MEDICAL DEPARTMENT c. Control measures.— (1) Fumigation.—Fumigation is the most effective bedbug control measure but should not be attempted by untrained personnel. (2) Liquid insecticides.—Liquid insecticides are effective if thor- oughly and repeatedly used. An effective mixture for this purpose is kerosene containing 10 percent of cresol or 5 percent of turpentine. Kerosene alone may be used. A kerosene or alcoholic extract or pyre- thrum is also effective. A paint brush should be used in the appli- FicruK lOU.—Clmc-r Irctiihirins (common bedbug of temporallo zone) cation of the liquid insecticide. A spray is not as effective. This procedure should be repeated three or four times at intervals of 1 week to kill all developing eggs. Steam should be used to eradicate bedbugs from mattresses, blankets, and other bedding. Dry cleaning with gasoline and washing in hot water will usually get rid of them. Hand picking, brushing, and shaking is recommended. Flaming the cracks of steels cots with a blowtorch is quite effective. Kerosene may be used as a repellent by saturating with it wicks of woolen material placed in the coil springs of metal cots. Fresh applications of kero- sene should be made weekly. 261. Control of roaches and ants.—a. General.—Roaches and ants are not transmitting agencies for any insect-borne diseases. They are, however, serious nuisances in messes and may transmit intestinal diseases by contamination of food. h. Control.— (1) The most important control measure is to deprive ants and roaches of an available food supply by cleanliness of the 322 TM 8-220 SOLDIER S HANDBOOK 261-262 mess and by protection of food supplies by refrigerators and screened cabinets. The placing of table and refrigerator legs in cans con- taining water will protect food from ants. (2) Sodium fluoride should be placed in cracks and corners and about water pipes two or three times a week. Spraying of cabinets, corners, and cracks in the wall with the issue liquid insecticide will destroy many roaches. This is best done at night, (3) Complete eradication of ants can be accomplished only if their nest is found and destroyed. Once located, the nest may be destroyed by pouring boiling water or kerosene into it. 262. Control of fleas.—a. Geverah—Several varieties of fleas are vectors of bubonic plague and endemic typhus fever. Various small animals, particularly rodents, serve as reservoirs of infection from which fleas may transmit bubonic plague or endemic typhus fever to man. The rat flea is the most common vector. Fleas rarely select man as the host of choice, but they may transfer themselves to man whenever he comes in association with their usual small animal hosts. h. Control.— (1) Elimination of animal hosts.—Elimination of ani- mal hosts is the essential control measure. It must include attention not only to rats and squirrels but also to pet dogs and cats. (a) Pet animals may be freed of adult fleas by a variety of com- mercial preparations. Washing in 3 percent solution of cresol or 10 percent emulsion of kerosene, followed by thorough rinsing, will also destroy fleas. While pets are being treated, blankets or beds occupied by them should simultaneously be distinfested. (h) Rats are not only important as reservoirs of infection of bu- bonic plague and typhus fever but are also factors in the spread of several other diseases. Control of rats is a difficult problem. The supervision of rat-control campaigns is a normal function of the Medical Department. The principal control measures are as follows: 1. Trapping is an effective rat-control measure but requires considerable skill since rats quickly become suspicious of traps. It is very important not to leave the odor of human hands on trap or bait. A snap type of trap is preferable to a cage trap. The bait may be fried bacon, fish, cheese, liver, fresh bread, doughnuts, canta- loupe, or tomato. The bait must be securely fastened to the trap. Traps should be located at points normally frequented by rats. Traps may be deodorized by flaming or by dipping in hot paraffin. 323 TM 8-220 262-264 MEDICAL DEPARTMENT 2. Poisoning is the most valuable control measure. It is, how- ever, a rather complicated procedure if properly done. See FM 8-40. (2) Destruction of fleas.—Fleas in buildings may be destroyed by scrubbing the interior of the rooms with soapy water containing 10 percent kerosene and 5 percent cresol. The floor should be thoroughly wet. Barns and barnyards may be disinfected by spraying with a creosote oil containing 10 percent tar acids. Section YI PREVENTION AND CONTROL OF VENEREAL DISEASES General 263 Control measures 264 Paragraph 263. General.—a. Venereal diseases are by far the most important causes of noneffectiveness among troops. b. Venereal diseases are in no sense military diseases. Their prev- alence among civilian populations is difficult to determine but is probably greater than in the Army. Studies have shown that at least 60 to 70 percent of prostitutes in the United States are in- fected, and it is probable that the actual incidence is much higher. c. The four diseases claimed as venereal are— (1) Gonorrhea.—Caused by the gonococcus. (2) Syphilis.—Caused by a corkscrew-shaped organism; the Treponema pallidum. (3) Chancroid.—Caused by the bacillus of Ducrey. (4) Lymphogramuloma inguinale.—Cause by a filterable virus. (5) Gramdoma inguinale.—Probably caused by Donovan body. d. These diseases are usually transmitted during sexual inter- course. Syphilis is most commonly transmitted during sexual inter- course, but the primary lesion, the chancre, may occur on any part of the body. Infection may result from using a common drinking cup, from kissing, or from being bitten by a woman who has open lesions of syphilis in her mouth. 264. Control measures.—a. Responsibility.—The venereal dis- ease rate of an organization is usually a rather close index of the state of discipline, training, and administration of that organization. The responsibility for venereal disease control rests primarily on unit commanders. The principles of transmission of venereal disease are simple and are easily understood by all persons. h. Prevention of exposure.—The most important fact to be kept in mind by all individuals is that almost all women who will permit 324 TM 8-220 264 SOLDIER S HANDBOOK promiscuous sexual intercourse are infected with venereal disease. Sexual intercourse is not essential to health, and efforts should be directed toward preventing exposure to infection. c. Prophylactic measures.—ln spite of warning, many individuals will expose themselves to infection. Mechanical and chemical means- of preventing the development of infection give a fairly high degree of protection, but only so when promptly, intelligently, and thor- oughly applied. (1) Mechanical.—The condom affords the only practical mechan- ical protection against venereal infection. Post exchanges are re- quired to stock condoms of approved quality. A condom will pre- vent gonorrheal infection, which must enter the urethra. It is not cer- tain protection against syphilis, chancroid, or lymphogranuloma ingui- nale, which may enter the skin and tissues about the genitals. Conse- quently, chemical prophylaxis must be given even after a condom has been used. (2) Chemical.— («) Prophylactic stations.—The Medical Depart- ment is responsible for operating sufficient prophylactic stations to serve adequately each command. In many situations it is advisable to establish such stations in civilian communities adjacent to Army stations or camps. Prophylactic stations may be established even in bivouacs. Chemical prophylactic treatments are given in these sta- tions by trained enlisted men of the Medical Department. Any soldier may apply for treatment regardless of the hour. The chemical prophylaxis given is highly effective if administered within 30 to 60 minutes of the time of exposure. Its effectiveness decreases rapidly after that time. The attendant at the station gives each soldier a signed record of the treatment, showing the date, hour, and place of treatment. This treatment cannot be satisfactorily administered to a man who is drunk because individual cooperation is necessary. (h) Prophylactic equipment.—The following equipment is neces- sary for a prophylactic station: 1. Protargol solution, 2 percent, freshly prepared weekly, Keep in amber-colored bottles. 2. Bichloride of mercury solution, 1-1,000. Poisonous. Does not deteriorate. 3. Sufficient calomel ointment, 30 percent. Well mixed. Does not deteriorate. 1.. Sufficient liquid soap in a bottle with a shaker top made by inserting a glass tube through the cork. 325 TM 8-230 264 MEDICAL DEPARTMENT 6. At least 1 dozen serviceable urethral syringes. Keep in a closed jar. 6. Tongue depressors. Keep in a closed container. To be used to remove the calomel ointment from the jar. 7. Sterilizer for syringes. They must be washed thoroughly in soap and water, then sterilized by boiling for 5 minutes. 8. Sponge holder, to be used by soldiers in removing syringes, tongue depressors, gauze, and sponges. 9. Running water or at least 1 dozen wash basins. 10. Sufficient 2-ounce medicine glasses, into which protargol is poured before use by the soldier. 11. Clock. 12. Roll of absorbent paper. 13. Towels, linen or paper. Ilf,. Large, easily read labels for everything the soldier is re- quired to use. 16. Well lighted room, preferably with an anteroom as a wait- ing room, and a small adjoining room or booths with either a large trough with running water or individual porcelain troughs in each booth. 16. Sufficient blank forms W. D., M. D. No. 77 (Venereal Pro- phylaxis Slip) to be made out properly and kept on file for at least 3 months. When the soldier receiving pro- phylaxis is from another organization, send a duplicate copy of W. D., M. D. Form No. 77 to his commanding officer next day. 17. Place to wash hands. (c) Prophylactic proccdvre.—The prophylaxis must be given by a trained attendant. Some of the steps in the prophylaxis may be self- administered but they should be closely supervised by the attendant. 1. Examine penis for signs of venereal disease. If any sign of venereal disease is seen, do not administer prophylaxis until soldier is seen by a medical officer. 2. Have soldier urinate and wash his hands. 3. Have soldier wash penis, scrotum, and adjacent area of his body thoroughly with liquid soap and warm water. Flush off with 1-1,000 bichloride of mercury solution. If.. By means of a syringe inject a teaspoonful of 2 percent pro- targol into penis. Have soldier close the opening with his thumb and finger and retain the solution for 5 min- utes by the clock. Too much pressure must not be placed 326 TM 8-220 SOLDIERS HANDBOOK 264 at the end of the penis. This is where the germs, if present, are likely to be most numerous. Release pres- sure very slightly at intervals to allow for thorough bathing of end of opening. 5. Have soldier pull back the foreskin; thoroughly rub into the penis and surrounding body area about a teaspoonful of calomel ointment, 30 percent. Rub in for at least 3 minutes. Wrap penis in a towel or paper. Instruct the soldier not to urinate for at least 4 hours if possible. 6. Complete the prophylaxis slip. Have soldier sign. Give him one copy. File another copy for 3 months. (3) Emergency.—lf a soldier has exposed himself and has neither a prophylactic tube nor access to a station, he should empty his bladder, and then scrub his genitals and the surrounding skin areas with soap and water. This may serve to prevent infection. d. Punitive measures.—Any individual who knows or believes that he has contracted a veneral disease must report that fact to his im- mediate commanding officer without delay. Trial by court martial or other disciplinary action for concealing a veneral disease is discretion- ary with the commanding officer. No disciplinary action is authorized for failure to take prophylaxis or for having contracted a venereal disease, (2) Any person in the military service who loses time from duty because of a venereal disease forfeits his pay during the time so lost and must make good the time lost, e. Physical inspections.—The periodical physical inspections which are conducted at least once each month for all enlisted men below the first three grades include inspection for evidence of venereal disease. Additional inspections may be arranged if it is believed that some men may be concealing venereal disease. These are most effective if con- ducted early in the morning or just after return from outdoor activity. /. Treatment.—All cases of-venereal disease should be promptly sent to the hospital or dispensary for treatment. Early treatment offers far better chances of cure than does delayed treatment. Self- treatment and treatment by unskilled individuals are both ineffective and dangerous. 327 TM 8-220 265-268 MEDICAL DEPARTMENT Section VII PREVENTION AND CONTROL OF MISCELLANEOUS DISEASES Paragraph Lockjaw (tetanus) , 265 Gas gangrene __ 266 Rabies 267 Scabies 26g Ringworm 269 Poison ivy, poison oak, and poison sumac (plant dermatitis) 270 265. Lockjaw (tetanus).—a. Tetanus (lockjaw) is a serious dis- ease, having a mortality rate which may be as high as 80 percent. It is caused by the tetanus bacillus which is an anaerobic organism (one which lives in the absence of oxygen). Tetanus bacilli enter the body by way of wounds. h. Any wound other than small, superficial scratches should be treated by skilled medical personnel. This is especially true of punc- ture wounds from nails or from spikes on athletic shoes. The treat- ment should be obtained promptly so that wounds may be cleaned out before tetanus bacilli gain a foothold. (See AR 40-240.) 266. Gas gangrene.—a. Gas gangrene is an acute infection oc- curring in large, crushed wounds contaminated with human or animal wastes found in soil. The infection is usually associated with com- pound fractures and large wounds that come in contact with the soil, but it has occasionally followed puncture wounds. Once the disease develops it is extremely difficult to control. The mortality is very high. b. Control depends on early and proper surgical treatment and the use of sera. The first-aid precautions are the same as those for tetanus. 267. Rabies.—a. Control of rabies depends on the prevention of the disease in dogs, treatment of wounds, and prophylactic treatment to prevent the development of the disease. (See par. 142 c.) b. Dogs can be protected against rabies by specific vaccination which should be repeated each year. A metal tag giving the date the treatment was given should be attached to the collar of the dog. 268. Scabies.—a. Scabies, also known as seven-year itch, is an acute inflammatory condition of the skin due to the presence of the itch mite. b. Scabies is an important condition because of its adverse effect on the morale and efficiency of the individual or groups. It entails an average loss of time of about 10 days in cases admitted to quar- 328 SOLDIER'S HANDBOOK TM 8- 220 268-269 ters and hospital. Complicated cases are frequently in hospital for several weeks. c. The source of infestation is the person with scabies. Direct body contact is the common mode of transfer but indirect contact through clothing, blankets, or equipment may occur. Clothing from infested individuals may harbor the live parasites for at least 11 days. d. A medical officer should supervise the disinfestation of a group of individuals having scabies. The spread of scabies from infested recruits or isolated cases is controlled by securing body cleanliness, cleanliness of clothing and blankets, and by preventing overcrowding. 269. Ringworm.—a. General.—The terms “trichophytosis” or “ringworm” includes a group of skin infections due to parasitic fungi. Numerous different fungi may be responsible for these infections, and all parts of the human body may be involved. All of these infections tend to become chronic, and all thrive in warm weather or under other conditions which result in perspiration. They are very com- mon in all walks of life. They may be go mild as to be barely noticeable, or so severe as to be completely disabling. h. Control.— (1) General.—The control measures for all the forms of ringworm infection are essentially the same. The main objective is to prevent the bare skin of noninfected individuals coming in contact with any objects which may have been contaminated by in- fected persons. (2) Care of feet.—Proper care of the feet is particularly important in the prevention and control of trichophytosis. It is especially important to keep the feet dry. If the feet tend to perspire exces- sively, the issue foot powder should be applied twice daily. For- maldehyde or other drying solutions should not be applied to the feet unless advised by a medical officer. (3) Foot baths.—If ringworm of the feet is prevalent in a command, all bathhouses should be equipped with foot baths. The tubs should be located at the entrances to the showers and should be broad enough so that all individuals will have to step in them going both to and from the showers. They should be at least 6 inches deep, and should be constructed of concrete or rubber. They should contain a solution of grade A calcium hypochlorite in the proportion of 1 ounce of the dry chemical to each gallon of water. A fresh solution should be prepared daily. (4) Disinfection.—The most effective control measure is disinfec- tion of bathhouse floors and equipment, and by the disinfection of towels, swimming or gymnasium suits, and similar articles. Bath- house floors and equipment, including mats, benches, and chairs, 329 TM 8-220 269-270 MEDICAL DEPARTMENT should be scrubbed daily with soap and water. It is also advisable to scrub them with a disinfectant such as 2 percent cresol, or a solution of calcium hypochlorite, 1 ounce to the gallon of water. There should be removable duckboards in shower baths. These should be thor- oughly scrubbed and then exposed to the sunlight for several hours each day. Individual slippers of rubber are useful in preventing contact of the bare feet with infected surfaces. The exchange or common use of towels, gymnasium suits, slippers, shoes, or gloves should be avoided unless they have been thoroughly disinfected after use. All articles that will not be damaged by boiling should be sterilized in that manner. Leather and rubber goods can be disin- fected with cresol solution. Shoes can be disinfected by a 1 percent solution of thymol in gasoline or alcohol. This solution is poured into the shoes and allowed to evaporate. (5) Swimming fools.—Swimming pools constitute a potent means for transmission of fungi unless properly operated. 270. Poison ivy, poison oak, and poison sumac (plant der- matitis).—a. General.— (1) The poison ivy, poison oak, and poison sumac are the common plants that produce skin irritation in sus- ceptible persons. The poison ivy is distinguished from other suspected creepers of a similar appearance by its possession of three leaves instead of five. The poison oak, which grows especially in the western part of the United States, is a shrub or small tree. The poison sumac, also know as poison elder or dogwood, is a shrub or small tree growing in swampy places. (2) The harmful part of these plants is the resinous sap which exudes from all injured surfaces. Actual contact with the sap is necessary; however, contact with the plant may not be essential as the sap can be carried on clothing, tools, and hands, or transmitted on the bodies of insects or in the smoke coming from fires burning the plants. h. Control.—(l) One should learn to recognize the plants and avoid them when possible. Destroy the plants in occupied areas. Contam- ination in camps can be avoided by requiring all men working in or about the plants to— (a) Wear gloves while at work. (h) Change outer clothing and gloves before associating with the other men in the camp. (c) Keep contaminated tools and implements separate. (d) Burn poisonous vegetation to a considerable distance from the camp site and always at such time and place that the wind will carry the smoke away from the camp. 330 SOLDIER’S HANDBOOK TM 8-220 270-271 (2) The following personal measures should be obserA^ed: («) Contaminated clothing and implements should be well washed with water (soda water if possible) or exposed to the direct rays of the sun for several hours. (5) All parts of the body that have been exposed to the plants should be well washed with a strong soap solution or alcohol. Gaso- line or kerosene may be used. The washing must be prompt and thorough or else it will tend to spread the poison. (c) Skilled medical treatment should be promptly sought if the skin eruption appears. Section VIII OEAL HYGIENE Paragraph Oral hygiene 271 271. Oral hygiene.—a. Definition.—The term “oral hygiene” re- fers to all the measures used by the individual to keep the mouth in a healthy condition. h. Factors concerned.—The health of the mouth and teeth is de- pendent upon three factors: first heredity; second, the general health of the individual; third, the daily care of the teeth and gums. The teeth and gums should be brushed thoroughly twice a day (night and morning) with proper brush and dentrifice (paste or powder) and each individual should have his mouth examined by a dental surgeon at least twice a year. c. Purpose.—Many diseases that result from mouth conditions may be avoided. Even decay (caries) of the teeth and inflammation and infection of the gums and the membrane which holds the teeth in their sockets may be controlled to a great extent by simple methods of cleaning at regular intervals. d. Professional and individual care.—(1) The program of oral hygiene for the soldier should be a cooperative one between the patient, who is responsible for individual care, and the dental surgeon, who advises and directs it. The dental surgeon has the added re- sponsibility of keeping the mouth in such condition that individual care may be most effective. Professional care by the dental surgeon should be considered only as an aid to individual care. Cleaning by the dental surgeon should be necessary only where individual care fails to show the desired result or as a check-up on errors or lack of interest and effort on the part of the soldier. A dental survey is made once or more each year to encourage the soldier in his efforts as well as to make an estimate of the dental situation in the command. 331 TM 8-220 271 MEDICAL DEPARTMENT Periodic cleaning by the dental surgeon is not necessary if the soldier s cave is 'perfect. (2) The individual care that is simple and easy will produce excellent results. After simple methods have been mastered, the dental surgeon will give further instructions to the individual soldier if and when necessary. Each soldier should possess two tooth brushes of proper size and stiffness and use them alternately night and morn- ing. A thorough brushing before retiring is most important as the fluids and food left in the mouth through the night are more liable to cause fermentation or the acid formation that plays such an important role in tooth destruction. Before and after brushing the teeth, rinse the mouth thoroughly with water, closing the teeth and lips and forcing the water back and forth between the teeth. This removes loose food particles and cleanses those surfaces that it is impossible to reach with the brush. e. Tooth brush.— (1) The selection of the proper brush is very important for each individual. The dental surgeon will recommend the proper brush if requested. As a rule a small brush is more desirable than a large one, and the bristles should be deeply notched crosswise, not set too closely together, and as stiff as can be used without causing pain. All brushes will soften with use to some extent so this must be considered when purchasing a new brush. The bristles on the end of the brush should be short enough to allow free movement far back in the mouth. Those with long tufts on the end should be avoided. (2) The brush should be rinsed in water a few moments before using. After each use, it should be hung in the air to dry and not allowed to touch any other object. /. Dentifrice.—Paste or powder, as desired, may be used on the brush, but care should be used to select one that bears the seal of approval of the American Dental Association. Liquid dentifrices or mouth washes should not be used regularly unless prescribed by a dental surgeon. g. Dental f oss.—Dental floss may be used in routine cleaning if necessary. If dental floss is used, the individual must be careful not to injure the gums. h. Brushing procedure.—A routine procedure for morning and night brushing is as follows: v(l) Place the brush against the gums, far back on the lower right side of the mouth (opposite last two teeth) with the point of the bristles down, that is, with the sides of the bristles parallel to the long axis of the teeth. By rotating the wrist the bristles should 332 TM 8-220 SOLDIER’S HANDBOOK 271 be brought up from this position over the crest of the gums and outer surfaces of the teeth. The pressure on the teeth should be increased toward the end of the stroke to force the bristles into the spaces between the teeth. This movement stimulates the gums and cleans the exposed surfaces of the teeth at the same time. This movement should be executed about twelve times then the brush moved to another position, movement executed, and so on around the lower jaw until all teeth and adjoining spaces have been cleaned. Only two or three .teeth can be covered with one application of the brush, depending on the position in the mouth and the size of the teeth. The same should be done for the upper jaw using a down- ward stroke by rotating the wrist in the opposite direction. (2) The motions for the inner (lingual) surfaces of the teeth in both arches should be the same as those for the outer surfaces, but they are much more difficult due to the concave arrangement of the teeth. (3) In the front of the mouth, place the heel of the brush well up or down on the gums and pull the brush forward. This produces the same massaging motion to the gum margins (toward the teeth) and cleans in between the teeth and the inner surfaces. (4) The grinding surfaces (occlusal) of the back teeth are best brushed with the points of the bristles forced into the grooves or sulci and the brush moved from side to side, back and forward, and in a rotary movement to cleanse and remove all debris from the grooves. i. Dentures.—Dentures (false teeth) should be thoroughly washed with soap and water—never hot water as it may warp the vulcanized rubber part of the denture. A hand brush makes a good denture brush. Wash dentures after each meal and rinse the mouth with Avann salt water. Dentures should not be worn day and night. When out of the mouth they should be kept in salt water. Section IX PREVENTION AND CONTROL OF INFECTIOUS DISEASES OF ANIMALS General 272 Resistance 273 Pathogenic parasites 274 Incubation period 275 Mode of infection 276 Significance of communicable disease 277 Discovery of communicable disease. 278 Paragraph 333 TM 8-220 272-274 MEDICAL DEPARTMENT Disposal of carcass 280 Important communicable diseases 281 Glanders 282 Mange 283 Shipping fever .. 284 Dermatitis gangrenosa ' 285 Equine encephalomyelitis 286 Tetanus, .... 287 Botulism (forage poisoning) 288 Anthrax _ 286 Paragraph 272. General.—a. The primary objective of disease control meas- ures among animals of a military force is to promote military effi- ciency by preventing a communicable disease from attaining such prevalence that it will interfere with the efficiency of the animals of the command. h. Animals of military commands differ mostly from those of civil communities in the nature of their environmental conditions, especially with respect to crowding and close contact between indi- viduals. c. It is necessary to maintain a constant lookout for the appear- ance of communicable diseases or of conditions which may tend to encourage their spread among animals of the command. 273. Resistance.—The normal animal possesses a certain degree of resistance to all infection. The unbroken skin and mucous mem- branes are the first line of defense against infection. Gastric and intestinal secretions and certain agencies in the blood and lymph offer their share of resistance. Good grooming, wholesome food, regular exercise, fresh air, clean stables and corrals, and dry stand- ings are important aids to the natural resistance offered by the body itself. A healthy animal well cared for can withstand and fight off a certain amount of infection, but will succumb to large quantities. Long shipments, change of environment, exposure, insufficient food, overwork, poor grooming, muddy, filthy corrals and picket lines, and poorly ventilated stables all lower the animals’ resistance and render them more susceptible to attack by parasites or bacteria. 274. Pathogenic parasites.—Infectious diseases of animals are caused by pathogenic parasites of which there are several kinds: a. Microscopic bacteria, as in glanders, anthrax, and tetanus. b. Ultramicroscopic viruses, as in influenza, encephalomyelitis, and infectious anemia. c. Moulds and fungi, as in thrush and ringworm. d. Highly organized ectoparasites, as in mange and pediculosis. 334 TM 8-220 SOLDIER S HANDBOOK 274-278 e. Protozoa, as in surra, where the organism is transmitted by the bite of infected flies and possibly other blood-sucking insects, and Texas fever, where the organism is transmitted by the bite of an infected tick. /. The gastrointestinal parasites, of which the eggs and other infective material may be taken into the tract in contaminated food and water. 275. Incubation period.—A time interval between infection and the appearance of the symptoms is known as the incubation period. This period may vary from a few hours to several weeks. 276. Mode of infection.—The specific organism which is the cause of a given communicable disease reaches the animal body through— a. Direct contact with another animal harboring the causative parasite or bacteria; this latter animal may be in the incubation stage, may be visibly sick, or may be apparently recovered. b. Indirect contact with sick animals through the media of stables, corrals, picket lines, stock cars, stock yards, buckets, bits, grooming equipment, hands and clothing of attendants, etc., which have been contaminated by excreta, discharge, or other material of an infective nature. c. Intermediate vectors, such as mosquitoes, flies, ticks, lice, fleas, etc. d. Channels of infection. Infection may enter the body with the air which is breathed, in the food and water, through the skin, through the mucous membranes of the nasal passages, mouth, or gen- ital organs, or through wound infection. 377. Significance of communicable disease.—The chief reasons why communicable diseases are so important and require so much attention are that they spread rapidly and if uncontrolled cause a high percentage of ineffectives and permanent losses. Some com- municable diseases common to-animals are transmissible to humans and therefore receive special consideration for that reason. 278. Discovery of communicable disease.—The early detection of new cases is of primary importance in the effective control and early eradication of any communicable disease. In order to accom- plish this, frequent inspection of all animals is necessary. One of the first indications of disease is the loss of appetite. Discharges from the nose or eyes, labored breathing, coughs, loss of hair, or other general symptoms should result in a general physical exam- ination. Early temperature recordings are valuable in the detec- tion of the first stages of disease. An animal standing apart from others should receive careful physical examination. 335 TM 8-220 279-280 MEDICAL DEPARTMENT 279. Control.—The primary object of all control measures in a military force is to promote military efficiency by preventing a com- municable disease from attaining such prevalence that it will inter- fere with the mission of the command concerned. This may best be effected by prompt isolation or quarantine measures. a. Isolation.—This is the removal of the sick from the well animals and the placing of such restrictions on their care and movement that the possibility of spreading infection beyond their immediate sur- roundings is impossible. b. Quarantine.—This is the separation of a group containing ani- mals that are actual or potential sources of infection from the re- mainder of the command for the purpose of preventing the trans- mission of the infection and is usually applied to animals having contact with a known communicable disease. When it seems reason- able to expect that animals of a group are free from infectious disease but further observation is necessary before final decision is made, it is possible to initiate a working quarantine which allows continued training provided the area used is denied other animals. 280. Disposal of carcass.—a. General.—Animals that die or are destroyed as the result of a communicable disease will be disposed of in accordance with best sanitary practices. Animals to be destroyed should, if possible, be led to the place of disposal. Otherwise, de- stroy and move the carcass in a vehicle, care being taken to prevent contamination of additional area. Disinfect the ground upon which the carcass lay by covering with straw saturated with oil and burning. b. Bwrying carcass.—The hole should be deep enough to allow 3 feet of earth on top of the carcass. The required size of the hole may be reduced by dismembering the carcass and puncturing the abdom- inal viscera to prevent the accumulation of gases. Care should be exercised to prevent contamination of surrounding areas. Cover the carcass with several inches of lime before filling the hole. c. Burning carcass.—Dig two trenches intersecting at their center at right angles, each trench being T feet long, 15 inches wide, and 18 inches deep at the intersection, becoming shallower at the end. The earth is thrown up in the angles formed by the trenches, and two stout pieces of iron rail or wood are placed thereon. Approximately a cord of coarse wood is then placed on these cross members and the carcass is then placed thereon. Coarse wood is then piled over the carcass and the pile ignited with smaller fuel in the trench below. Five gallons of crude oil or kerosene poured over the carcass will hasten the burning. The carcass is usually consumed in sor 6 hours. 336 SOLDIER S HANDBOOK TM 8-220 280-283 Blood, manure, nasal discharges, etc., scattered about the ground should be scraped up with the earth and thrown into the fire. 281. Important communicable diseases.—Common infectious diseases of horses which are of importance from an Army standpoint are glanders, shipping fever, dematitis gangrenosa, equine encephalo- myelitis, tetanus, botulism, and anthrax. A brief outline of the causes, symptoms, diagnosis, and control measures of each is given in the following paragraphs. 282. Glanders (AR 40-2100).—a. Cause.—Glanders is a com- municable disease to which horses and mules are peculiarly suscep- tible, and is caused by infection with the Bacillus mallei. It may be acute or chronic and may be transmitted to man. It is practically incurable and practically always results in death. The disease is usually transmitted by the ingestion of food or water which has been contaminated with pus, discharge, or other secretions and excreta of infected animals. Occasionally infection occurs through the respira- tory tract. h. Symptoms.—Many cases show no outward signs. Principal clinical signs are greenish yellow, glue-like, blood-stained nasal dis- charges, with ulcers or star-shaped scars of the nasal mucous mem- branes, nonsuppurative, nonsensitive, hard, adherent swelling of the submaxillary lymph glands, and in the cutaneous form (farcy), chains of indurated lymph glands which break down and discharge pus. c. Diagnosis.—Clinical diagnosis is based on the symptoms, which may be confirmed by mallein and serological tests. Suspicious cases should be isolated until a positive diagnosis has been made. d. Control.—(l) Isolation of suspects until a positive diagnosis is made. (2) Destruction of positive cases followed by burning or burial of the carcasses. (3) Quarantine of all contacts and retesting after 21 days, this date starting from the time of the last positive case found, if any. (4) Disinfecting and cleaning of area, equipment, etc. 283. Mange (AR 40-2125).—a. Cause.—This is an infectious skin disease which may be transmitted to man. It is caused by very small parasites commonly called mites. Of all the causes of wastage of animals in war by the element of communicable disease, this disease stands out as one of greatest importance. h. Varieties of parasite.—There are three varieties of’the parasite causing mange, all of which produce an intense irritation, inflamma- tion, and a progressive destruction of the skin. 337 TM 8-220 283 MEDICAL DEPARTMENT (1) The sarcopfes, which burrows into the skin, is usually found about the head and neck, but occasionally on other parts of the body. (2) The psoroptes, which attaches itself to the outer surface by the mouth apparatus, obtaining its nourishment from the skin, is usually found in the region of the mane and tail. (3) The symbiotes, which lives on the epidermal scales, is usually found on the legs. c. Symptoms—Yiolent, unceasing itching of the affected parts, the patient rubbing, scratching, and biting continuously. The hair falls out and the skin becomes thickened, wrinkled, and covered with scabs. d. Diagnosis.— (1) Clinically the disease is suspected from the char- acteristic lesions, namely, loss of hair over affected areas and the thickening of the skin as a result of the irritation from the para- sites. These areas are usually denuded and covered with crusty scabs. (2) The condition spreads slowly at the start of an outbreak but due to contamination of stable equipment soon affects large numbers of animals. (3) Microscopically the parasite is demonstrable in scrapings of the affected areas. Since the parasite lives on the lymph, it is necessary to scrape the area until it begins to ooze blood and fre- quently it is necessary to make several scrapings of the area, as the mite is difficult to find. e. Prevention.—Thorough grooming tends to prevent the develop- ment of this disease. It is important to prevent contact of normal animals with cases of the disease, or with contaminated grooming kits, blankets, or other equipment. Stalls and stables which have housed mangy 7 animals should be thoroughly cleaned and disinfected prior to their use for normal animals. /. Control.—lsolation of infested animals and contacts, clipping, good grooming and destruction of parasites on animals, together with disinfection of all articles of equipment are essential measures. g. Treatment.—-The successful treatment of mange depends pri- marily on the destruction of the parasite, whether on the affected animal or anywhere else, as well as such dietetic and constitutional measures as may be indicated. As a preliminary to any antipara- sitic procedures, the affected animals should be clipped, care being exercised to burn the hair and disinfect the apparatus and all equip- ment used. h. Destruction of parasite.—For the purpose of destroying the parasite on the animals, various types of dips and hand treatments 338 SOLDIER’S HANDBOOK TJVC 8-220 283 may be used. They are designated under the name of the para- siticide which forms their base, such as lime and sulfur dip, arsenical dip, tobacco-sulfur dip, tobacco dip, crude oil, sulfurous acid gas in gas chamber, etc. In handling small numbers of animals, the parasiticide may be applied by hand, by spray, or, when available, by gas chamber. When large numbers are to be treated the only practical method is by dipping. The procedures hereinafter de- scribed are approved as practical and economical, and should be adopted unless good reason to the contrary exists and equally effi- cient measures are available. (1) Hand or spray method.—(a) The animal should be well rubbed all over with soft soap to which 10 percent of liquid cresol solution compound may be added with advantage. This will serve to soften scabs and after 12 hours the animal should be thoroughly washed, soap and debris being removed. The following parasiticide is then applied: Sulfur sublimed 2 pounds. Oil of tar 8 ounces. Oil of linseed or cottonseed 1 gallon. (b) These ingredients are mixed and heated gradually but not allowed to boil. The mixture should be well rubbed into the skin with a stiff brush at a temperature as high as can be comfortably borne, and allowed to remain for 10 days, when it may be washed off and the application repeated. (o) The dipping mixture made as described in (2) below is equally effective by hand or spray in the absence of a dipping vat. When the spray is used a second attendant should follow with a brush to see that the entire surface is covered. (2) Dipping method.—When a dipping vat is available, the lime and sulfur dip is a valuable parasiticide. When used it will be prepared and applied strictly in compliance with the following in- structions. {n) The ingredients and the proportions in which they ap,e to be used are as follows: Sulfur, sublimed 24 pounds. Lime (unslaked) 10 pounds. Water 100 gallons. (b) The mixture is prepared as follows: The lime is slaked so as to form a rather thick paste; the sulfur is then added, and the whole well mixed. In a kettle containing 25 gallons of boiling water, the lime and sulfur mixture is placed, a small amount at a time, with constant stirring, and the contents are then boiled for about 2 hours 339 TM 8-220 283-284 MEDICAL DEPARTMENT (3 or 4 hours’ boiling concentrates the mixture), being stirred at intervals. After the sulfur disappears from the surface the mixture, including the sediment, is poured into a barrel provided with a spigot 6to 8 inches from the bottom. When settling has taken place the liquid is drained off through the spigot into a suitable container and enough warm water added to make 100 gallons. The sediment remaining in the barrel must not be used for dipping purposes but can be utilized to advantage in the disinfection of fences and buildings. ( tahlespoonfuls yolk powder plus 1 tablespoonful water. 1 white equals 1 tablespoonful egg white powder plus 2 tablespoonfuls water. 1 whole egg equals 2 tablespoonfuls whole egg powder plus 2 table- spoonfuls water. Add powder to liquid and stir well until smooth. (3) Milk (the equivalent of 1 pint).—Milk contains a variety of nutrient substances, and it is very difficult to construct a diet adequate in calcium without some form of milk or cheese. (a) Fresh milk.—Unless absolutely sure that the milk has been adequately pasteurized and properly handled to prevent contamina- . tion after pasteurization, bring all fluid milk to a boil before using. (b) Caimed evaporated milk.—Canned evaporated milk is sterile and when diluted with an equal quantity of water has approximately 396 TM 8-220 SOLDIER S HANDBOOK 331 the same nutritive value as fluid milk. Water should be boiled and cooled when used to dilute evaporated milk. (c) Dried milk.—One pound of dried skim milk plus one-half pound of butter is the approximate nutritional equivalent of 5 quarts of fluid whole milk, (d) Cheese.—Cheese may be counted as part of the milk allow- ance. Five ounces of American cheddar or other hard cheese is almost equivalent in food value to 1 quart of milk. (e) Substitutes.—If milk is not available, an adequate supply of calcium should be assured by an increased consumption of green leafy vegetables, beans, and, if necessary, calcium (lime) salts. Note.—Cream soups are very desirable because of the added milk and may i>e made of almost any vegetable. Cook the vegetables until tender in a small amount of water. Use this water and rub the vegetable pulp through a sieve, combine with hot milk thickened with flour, season, and serve hot. (4) Fats (2.5 ounces).—Fats are concentrated sources of energy. Butter produced when cows are eating fresh green food, commonly called summer butter, is an excellent source of vitamin A. If butter is not available, a butter substitute fortified with vitamin A is to be preferred. Otherwise, any edible fat or oil may be used, but. it is then especially important to secure an adequate intake of whole milk or leafy green and yellow vegetables. (5) Bread, flour, and cereals (8 ounces).—Cereals and breads are' most important as sources of energy and vegetable protein and may he consumed in any quantity to satisfy the appetite, provided other nutritional requirements are first met. The less refined the cereal the better its mineral and vitamin content. Whole grain products (such as rolled oats, cracked wheat, whole wheat, rye, and corn meal) are one of the good sources of the daily requirement of vitamin B1? while white bread contains very little. Whole grain products are not so essential if the diet contains an abundance of vegetables, fruits, milk, and meat. Only white flour is being furnished because of its keeping qualities. (6) Dried heans, peas, and other legumes (0.5 ounces).—These contain protein and a moderate amount of calcium and vitamin Bt and may be used as the main dish several times a week. It is not necessary to use the quantity mentioned each day. They may be used in larger quantities at irregular intervals. Because of their tough outer skin, beans and peas sometimes cause indigestion. This difficulty may be avoided by rubbing them through a sieve. (7) Sugar (4 ounces).—Pure sugars do not contribute anything but energy. Heavily sweetened foods should,be taken only at the 397 TM 8-220 331 MEDICAL DEPARTMENT end of a meal; otherwise, they dull the appetite for more nutritious foods. Crude sugars, such as molasses and sorghum, supply some minerals as well as energy, and are therefore to be preferred. (8) Leafy green and yellow vegetables (T ounces).— {a) These are necessary for their minerals, vitamins (especially provitamin A) and for bulk, which has a laxative value. (b) If there is no danger of cholera, dysentery, typhoid, etc., raw vegetables and fruits are desirable. Cabbage, carrots, turnips, and onions are usually available and may be used raw in salads. Note.—Fresh vegetables should be cooked in a minimum amount of water and only long enough to soften the fiber. Vitamin and mineral loss is reduced to a minimum when vegetables are steamed. It is preferable to cook vegetables with the skins on. Soda should not be added, since this destroys all of the vitamin C. Juices drawn out in cooking or water added in cooking contain valuable nutrients and should not be discarded. Properly canned vegetables are about the equivalent, nutritionally, to freshly cooked vegetables. In this case, also, the liquid should be used. (9) Tomatoes and citrus fruits (5 ounces).—Tomatoes and citrus fruits are especially valuable fresh, cooked, or canned because of their high vitamin C conent, and should be eaten every day. Cab- bage and turnips are also good sources of this vitamin. (10) Potatoes (Bounces).—Potatoes are especially valuable because they are usually available in large quantities, inexpensive, and can be eaten day after day. They supply iron and vitamins Bi and C. If potatoes are not available, substitute 2 ounces of cereals and in- crease the intake of other vegetables. (11) Other vegetables (8 ounces).—Other vegetables add to the vitamin and mineral content of the diet and provide bulk. (12) (canned and fresh, 8 ounces; dried, 1 ounce).—Fruits have roughly the same nutritive value as the root vegetables. Berries of all kinds, cherries, apples, peaches, pears, and melons add to the vitamin and mineral content of the diet. If fresh fruits and vege- tables are not available, properly canned or dried fruits may be substituted. Dried prunes, apricots, peaches, apples, raisins, and dates may be used, but they have lost some of their vitamins. (13) Coffee, tea, chocolate, etc.—As desired. (14) Diet fortifications and concentrates.— (a) Debittered dried brewer’s yeast powder to meet certain vitamin requirements when the intake of meats and legumes is deficient may occasionally be ordered by a medical officer. (h) Dried yeast is not soluble in water. It may be stirred into milk, tomato juice, or eggnog or mixed with peanut butter. How- ever, it settles quickly and hence must be taken promptly after mix- 398 TM 8-220 SOLDIER S HANDBOOK 331-332 ing. In order to avoid lumping, the liquid should be added to the yeast while stirring. It may also be sprinkled on cooked cereals, mashed potatoes, etc. However, since dried yeast is not always palat- able, it is better not to spoil the flavor of the total food, but to take the yeast as a medicine mixed with a small amount of food. 332. Planning’ meals.—a. General.—The objective in planning meals is to obtain a combination of foods and methods of preparation that will satisfy the habits and desires of the members of the mess and, at t!ie same time, furnish an adequate diet. The number of foods available is relatively limited. It is necessary, therefore, to obtain variety and interest in meals by changing the method of preparation or the combination of foods. Surprise is an important factor in maintaining interest. Monotony in menus or the periodic repetition of meals, especially at weekly intervals, results in dissatisfaction even with the most interesting foods. Numerous factors influence the appetite, especially the weather and amount of exercise. Use the periods of increased appetite to encourage the consumption of foods that are needed but not particularly relished. Anticipation of coming events, whether pleasurable or otherwise, affects the men’s interest in food. Study the habits of the members of the mess and the prog- ress of events as an aid in planning meals. Use the interesting foods or ways of preparation to keep men satisfied, but use them intel- ligently, especially when the supply of foods is limited. h. Breakfast.— (1) The breakfast is built around meat or eggs, cereal, milk, and bread, with coffee or cocoa for a drink. Fruit is desirable. It should not, however, be reserved for use at breakfast if it is more useful in improving the other meals. It is desirable to add a spread of some kind, such as butter, syrup, or a jam or gravy, to aid in the consumption of bread. If dried fruits are used for breakfast, they can often be prepared as a jam and used as a spread. The bread may be the ordinary baker’s bread or it may be some special bread‘such as raisin bread, corn bread, whole wheat bread, biscuits, graham muffins, muffins with sugar frosting, wheat cakes, doughnuts, etc., or toast (it is practical to prepare toast in the oven), (2) Eggs, sweets, etc., are most effective when used in the prepara- tion of special -breads which will not require as much spread, if any, for their consumption, as the straight wheat bread. It is often desirable to prepare meat and eggs in such form that they stimulate the consumption of either cereal or bread; for instance, frizzled dried beef gravy on bread or toast, creamed hard boiled eggs, etc. On the other hand, variety and interest in food is maintained by the use of meat and eggs. 399 TM 8—220 332 MEDICAL DEPARTMENT c. Dinner.— (1) The dinner is built chiefly around the meat, po- tatoes, and the leafy green or yellow vegetables. The flavor of the meat may be extended by preparing dishes in which meat is in combination with other foods. Special care must be taken in the preparation of combinations of meat with a vegetable or carbohydrate foods, since such mixtures when kept overnight in a refrigerator are likely to spoil. This means that any combination with meat should be prepared fresh each day or at least the combination should be made on the day it is to be used. The combination of meat with vegetables and bread in the form of meat loaves, stews, hashes, or scalloped dishes are valuable ways of adding variety to the meals. Such combinations are also useful ways of promoting the consump- tion of vegetables that some men do not relish. Gravy is an im- portant part of any roast or fried meat; it is often as important as the meat itself. (2) In addition to meat, it is customary to serve potatoes and a leafy green or yellow vegetable unless they have been combined with some other dish. A dessert may be used at noon or at night, or both, depending upon the character of the meal. When supplies are re- stricted. if the meal is particularly attractive at noon because of the combination of foods or the use of clear meat, it is sometimes desirable to postpone the dessert until the evening meal when the main dish may not be so attractive. (3) The selection of the mode of preparation of food must take into consideration the consistency of the other dishes of the meal. Do not make all of the dishes of a soft or of a hard texture. Include some firm or crisp foods with the soft and vice.versa. For example, do not have all boiled foods or creamed dishes at one meal. Toast or croutons help soups. d. Supper.— (1) The supper may or may not contain meat, de- pending upon the supplies available. The main dish may contain some meat or cheese or tomatoes combined with macaroni, spaghetti, rice, or beans, or in combination with one or more root or leafy green or yellow vegetables. Sauces of different kinds add to the va- riety of such dishes. In addition, it is desirable to have a second leafy green or yellow vegetable, preferably an uncooked vegetable in the form of a salad based on cabbage as cole slaw, cold cooked string beans, or a combination fruit and vegetable salad. A good fruit salad may often take the place of dessert when facilities for service are restricted. Occasionally raw onions are desirable, as well as a direct serving of cold tomatoes. A dessert may be a special bread, bread 400 TM 8-220 SOLDIER’S HANDBOOK 332 or other pudding, cake, or fruits, especially fruits in season. Pota- toes may or may not appear at this meal. (2) It is not desirable to reserve all of the main dishes made of macaroni, spaghetti, beans, etc., for one meal. They should be di- vided occasionally between the noon meal and the evening meal. It is just as important to have a good supper occasionally as it is to have a good dinner. Moreover, the changing between two meals adds a certain amount of variety. (3) Coffee, tea, cocoa, or occasionally lemonade may be the drink at dinner or supper. Always supply water. e. Comments.— (1) At dinner and supper combinations of food, if carefully prepared with particular attention to their palatability, are economical and offer variety. Among such dishes are stews; macaroni and spaghetti dishes combined with cheese, meat, or to- matoes; scalloped potatoes combined with meat or bacon; and meat loaves made with bread and/or vegetables. Meat, fish, and vegetable chowders are also very good. (2) Individual dishes, such as meat pies, have been successfully served under suitable conditions. (3) Soups can be used effectively if well flavored. They may help to increase the consumption of vegetables, especially if the vegetables are finely divided. (4) Particular attention should be given to the proper service of food. Such service includes a moderate quantity of food carefully placed on the plate. If more food is needed, additional helpings can be given. Such type of service, to be successful, must be uniform for all men. Complete satisfaction of the appetite is to be obtained through repeated helpings, provided the previous food has been eaten. Garnishing of foods is possible at the service table in cafeteria service, such as sauce over the meat, spaghetti, etc. Bread crumbs browned in fat placed over macaroni adds to its attractiveness and makes it more palatable. (5) In the preparation of stews, etc., there are two ways of pre- venting overcooking of vegetables: (a) Cook the vegetables separately and not quite done, and then add to the meat a short time before the food is to be served. They will finish cooking in the hot meat, especially if the mixture is brought up to cooking temperature. (h) Add the vegetables late in the process of preparation so that they will just be done when the food is served. (6) Holding the food for a long time in kettles results in a de- terioration of their nutritive value as well as their palatability. The 401 TM 8-220 332-333 MEDICAL DEPARTMENT final preparation of foods, especially the vegetables, should be de- layed as long as possible. When there are two messes it is better to start the food for the second mess after that of the first one so that it will just be done when it is to be served. Satisfactory prepa- ration calls for careful planning. (7) In preparing food for stews or vegetables for soups or for cooking for the table, especially the roots, meat, and vegetables, ex- clusive of potatoes, it is desirable that the food be cut into small pieces; for roots about % to % of an inch on a side, and for meat from %to iy2 inches. In preparing meat it is desirable to remove excess fat, connective tissue that is not ordinarily eaten, and other nonedible parts before the food is sent to the kitchen. Such trim- mings are ordinarily not eaten at the table and are. a waste if served, whereas if removed in the meat room they may be rendered for fat. (8) In cooking in steam kettles, it is well to remember that once the food is well heated throughout, the heat in the mass of food is enough to complete the cooking of many foods with very little addi- tional heat. Guard against rapid, continual heating of foods that do not require long cooking. Even meat, once it is seared, will cook thoroughly at a low heat, but it takes a longer time. (9) Try new ideas. 333. Fundamentals of cooking*.—a. The details of cooking must be learned in the kitchen, where the technique of performing the various operations is obtained by actual experience. The necessity for a rotation of duty assignments in many hospitals requires the training of a number of the personnel in the fundamentals of cook- ing and diet. h. Effective cooking takes into consideration the characteristics of cereals, vegetables, fruits, spices, and meats, such as nutritive value and how to retain it, changes in texture and flavor that occur, the functions of foods and leavening agents in food preparation, and the possibilities of combining foods to obtain variety and increased palatability. The varied conditions under which the soldier must operate require care, ingenuity, attention to detail, willingness to meet emergencies, and application of fundamental principles if a satisfactory, economical, and adequate diet is to be produced with the foods and facilities available. Since a large part of the success of hospital diets depends upon the interest they create in the pa- tient, factors of palatability are even more important than with well- fed active men. c. Variety in food and method of preparation are the means of creating and maintaining interest in food or a satisfactory mess. 402 TM 8-220 SOLDIER S HANDBOOK 333 The number of foods is limited. Variety must be obtained by differ- ent methods of heating—baking, boiling, frying, sauteing; by differ- ent methods of preparation—whole, sliced, mashed, purees, soups; by combination in cooking—hashes, stews, pot pies, cakes; and by com- bination of foods or sauces in serving—meat or tomato sauces, pud- ding sauces, salad dressings, croutons. Cookbooks are valuable aids in food preparation. d. Time and temperature are important in food preparation and service. Food served when it is just ready is more attractive than underdone or overdone food. Hot foods should be served hot and cold foods cold. Lukewarm or indifferent foods are not attractive. Careful planning and experience is required to have everything conn? out just right and on time. e. Waste of food must be carefully avoided. Grease and drippings should be reserved for cooking. The juice from boiled vegetables should be served with them when possible; otherwise, saved for soups. /. (1) All foods undergo decomposition fairly rapidly. Protein- rich foods, especially animal foods, are likely to putrefy and may de- velop toxic products. (2) It is essential to take especial care of fresh foods. Putrefac- tion results from the growth of bacteria. Such growth requires the presence of heat, moisture, and organic matter; if any one of these conditions is absent, putrefaction is retarded. Hence, meats kept well when frozen (absence of suitable temperature), when dried (absence of moisture), canned (absence of bacteria which have been destroyed or retarded by heat), or when pickled (absence of bacteria and molds, which have been killed by high concentrations of salts and condiments and often by cold). The handling of food introduces bacteria. In addition, the removal of refrigerated food to the kitchen to work on it or mixing perishable food with warm food al- lows bacteria to develop. For this reason refrigerated food should be kept in the refrigerator as much as possible. Hashes and salads containing meat, poultry, or milk must be mixed just before cooking, and should be served soon after they are done or ready to serve. They should be prepared in amounts that will be consumed so that there will not be left-overs which may stand in warm dining rooms to allow bacteria a chance to grow. g. A clean kitchen and clean cooking utensils scalded with hot water (as with table dishes, knives, forks, and spoons) are a safe- guard to the health of troops. h. Cooking destroys bacteria and molds, improves flavor and tex- ture of food, and thus appeals to the appetite. New flavors are 403 TM 8-220 333 MEDICAL DEPARTMENT developed and proteins coagulated in meats; starch granules are broken down in vegetables; hard fruits and vegetables are softened; gases are liberated, held, expanded, and fixed in bread and cakes to give them lightness. The ordinary processes of cooking represent differ- ent ways of applying heat to food. They are boiling, braising, stew- ing and simmering, roasting, baking, frying, steaming, and broiling or grilling. (1) Boiling.— (a) In boiling, food is subjected to the action of boiling water. It is impossible to obtain higher temperature in the food than that of the water. Water boils at 212° F. at sea level and at lower temperatures at higher altitudes. (h) Meats should be simmered, not boiled, that is, cooked just below the boiling point, 180° to 210° F. at sea level. No particular advantage is attained by beginning boiling or simmering in hot water provided the temperature is brought up quickly, except to facilitate the rate of cooking, (c) Vegetables should be cooked in as small amounts of water as possible, and only long enough to make them desirably tender. Vegetables are too often overcooked, with resultant loss of flavor and texture and, what is more serious, destruction of vitamins. The cooking water contains valuable minerals and salts—it should be used in soups or served. (d) Potatoes should be boiled in their jackets because much of the vitamins and minerals are retained. (e) Beans, peas, rice, and other hard legumes and grains require a preliminary soaking; the legumes (beans, peas, etc.) do not soften satisfactorily on cooking in hard water. (2) Baking or roasting.— (a) In baking, food is cooked by in- direct heat, usually in an oven or upon heated metal. Roasting is the term usually applied to the baking of meats. The time required to cook meats depends upon a number of factors of which the degree of doneness, the temperature of the oven, the size of the piece of meat and, to a certain extent, the fatness of the meat are important. Well done meat requires a longer time than rare meat; a hot oven cooks faster than a moderately hot oven; a large piece of meat requires longer to cook than a small piece because of its size, but less time per pound; fat meats tend to roast more rapidly than lean meats. Meat can be cooked well done at any reasonable oven temperature, although the best results are obtained with a moderate to low oven tempera- ture because the meat is cooked more evenly than in a very hot oven. Furthermore, it has more juice and yields more servings. It is not necessary to sear meat before cooking except to develop flavor in the TM 8-220 SOLDIER'S HANDBOOK 333-334 outer surface. High temperature helps to develop flavor in the pan juice after meat is done. (5) The gravy of roasted meats plays an important part in satis- factory meals. A good gravy is as important as well roasted meat. When meat is roasted at low temperatures, flavpr may be developed in the gravy by heating it in the roasting pan, and color by adding (lour before heating. (3) Braising.—ln braising, meat is browned in a hot receptacle with a small amount of fat. It is then cooked slowly in the juices from the meat or in added liquid in a covered utensil. The added liquid may be water, milk, meat stock, diluted vinegar, or the juices of vegetables. The preliminary browning is to develop flavor in the meat. (4) Broiling and frying.—Broiling and frying accomplish roughly the same purpose—to cook food, especially meats, quickly and at the same time to develop flavor. In broiling, food is cooked by radiant (direct) heat from hot coals or gas flame. In frying, food is cooked in a deep layer of fat; it is also called deep-fat frying. Sauteing.— Cooking in an open pan with a small amount of fat is called sauteing. (5) Steaming.—ln steaming, food is cooked in steam with or without pressure. When pressure is used higher temperatures are obtained and the food, therefore, cooks more rapidly. Vegetables cooked in low pressure steamers do not lose their vitamin and min- eral content to the surrounding water as in boiling. When cooked under pressure vitamins affected by heat are destroyed to' a greater extent than in low pressure pr low temperature cooking. (6) Fricassee.—Fricassee is a dish made of fowl, veal, or other meat cut in pieces and served, often with vegetables, in gravy. Braising is the method used in making a fricassee. 334. Preparation of vegetables.—a. All vegetables require care- ful washing. Only thick-skinned vegetables require paring. Dam- aged or decayed parts should be discarded. Discolorations which sometimes occur on the cut surface may be avoided by placing the vegetable in water to exclude the air, although long soaking may result in a serious loss in nutritive value. Soaking wilted vegetables in cold water restores their crispness. If cauliflower and cabbage are to be cooked whole or quartered, they should first be soaked in cold dilute salt water (1 teaspoonful of salt to 1 quart of water! for one-half hour to drive out insects. Dried vegetables such as peas and beans are best when soaked overnight in soft water, h. So far as possible vegetables should be so prepared as to main- tain both food value and palatability. The methods of cooking 405 TM 8-220 334 MEDICAL DEPARTMENT affect the flavors of vegetables in different ways and must be chosen with care. The texture of the cooked vegetable should be tender but still firm. Overcooking causes flabby, soft, or mushy texture. Since the color of vegetables adds to their attractiveness, £ method of preparation should be selected which will retain so far as possible the characteristic color. c. Loss of food value in cooking vegetables is caused by dissolving some of the food materials in the cooking liquid, and by chemical changes in some of the constituents. The fact that some of the nutritive material dissolves in the cooking liquid makes no particu- lar difference in food value if this liquid is served with the vegetable or is used in making soups, or sauces, but the mineral content of the diet may be seriously reduced if vegetable juices are repeatedly drained away. Since it is not always feasible to use excess cooking liquid, it is well to cook vegetables by methods that require very little added water or none at all. d. Some of the valuable food constituents of vegetables dissolve in water more readily than do others. Sugars, the vitamins, and mineral salts are especially soluble, and the amount dissolved in the cooking water is increased if a large amount of liquid is used, if much cut surface is exposed, and if the time of cooking is prolonged. e. Vitamins A, B, and C are the ones most likely to be lost in cook- ing. The loss of vitamin Cis especially large. This vitamin is exceed- ingly unstable and is not only lost by solution in the cooking water but may also be destroyed by heating, especially in the presence of oxygen from the air, the cooking water, or the vegetable tissue itself. The destruction is less rapid in acid foods like tomatoes. Studies show that short cooking at the boiling point or just below is less destructive of vitamins than is longer cooking or cooking at a higher temperature. Holding food hot tends to lower vitamin content. /. The characteristic flavor of each vegetable depends upon the acids or acid salts, tannins, sugars, and essential oils that the vege- table contains. These flavoring substances may be broken down, dissolved, decomposed, or volatilized during cooking. Less flavorful materials, such as starch, may contribute definite flavor when chemi- cally changed by heat. Baking and deep-fat frying are outstanding examples of specific methods of preparation that have an effect on flavor. The high temperature of the oven in one case, and of the hit in the other, causes some of the starch of the vegetable to brown or dextrinize and some of the sugar to caramelize, developing char- acteristic flavors. TM 8-220 SOLDIER’S HANDBOOK 334 g. The addition of salt keeps the natural flavor, while fats and various sauces modify it. Other seasonings, such as pepper, curry powder, nutmeg, and cinnamon improve the taste of some vegetable dishes. Blended flavors are developed by cooking vegetables in combination. Well known and favorite combinations are peas and carrots, tomatoes and celery, beans and corn, and mixed greens. h. Vegetables should be cooked in the shortest time possible, since overcooking is harmful to texture and appearance as well as to food value and flavor. A firm though tender texture is desired. i. Baking a vegetable in its skin retains practically all of its min- eral content, causes very little destruction of vitamins, and develops flavor. Such vegetables as potatoes, squash, cucumbers, tomatoes, and onions lend themselves readily to baking because they contain enough water to form steam and keep them moist, the skin holding in .the steam as it forms. j. Steaming—that is, cooking in live steam—is the second-best method for vegetables from the viewpoint of food value. Much more of the soluble mineral material is conserved than in boiling, and the vegetable retains its original shape. Steaming is well suited to the cooking of carrots, squash, beets, parsnips, sweet- potatoes, wax beans, and many other vegetables. The exceptions are vegetables containing green pigment, but some of these—spinach, for example, and other thin green leaves—may be prepared by steaming if too-large quantities are not cooked at one time: Steamed vegetables may be salted either at the beginning of the cooking or just before they are served. Ic. Steaming under pressure, as in the pressure cooker, shortens the cooking time of vegetables such as dried peas and beans that require long periods of cooking by other methods. This method is not recommended for fresh vegetables, however, because it destroys some of the vitamins and causes undesirable changes in color, flavor, and texture. I. (1) Boiling is the most common method of cooking vegetables. The food value of boiled vegetables can be conserved if the cooking process is managed properly. Vegetables such as cabbage, turnips, onions, cauliflower, Brussels sprouts, and rutabagas should be boiled gentty in only enough water to cover them; green vegetables should be cooked in a very small amount of water. Leaving off the cover of the container permits the volatile acids to escape and aids in preserving the color, especially of green leafy vegetables, peas, and beans, but also allows some loss of flavor. In cooking vegetables the color and flavor of which are not easily affected, nutritive 407 Preparation for cooking Time of cooking when vegetables are— Vegetable Quantity as purchased required for 5 or 6 servings Baked Steamed Boiled Artichokes, globe or French Lbs. 3 Whole His. Mins. Mins. 35 IK Pared, whole K-l 35 30 15-20 Asparagus _ - 2 bunches _ - lHr-2 | pieces. _ — — _ 12 12-15 Beans, Lima, dried 1 icns, Lima, fresh—— .. 1 cup H 4, in pods. H IK 2 6-8 180 Shelled . 30 Beans, navy, dried _ Beans, snap 1 cup. . ' - - . Soaked overnight. _ In pieces — 6-8 > 25 30 180 20-30 ......V-,-. f With stems 15-20 Beet greens. _ _ 3 10 2 Whole 60-90 Beets, voung Broccoli. Brussels sprouts 2 bunches 1 large bunch 1 quart _ 2-2^ m 2 do__ Cut in strips. Whole . . _ 60 30-45 20-25 15-20 Cabbage 1 small head [ Quartered 15 10 10-15 5-10 |Shredded Carrots, mature 1K Diced or sliced 25-30 20-25 Carrots, young 2 bunches Whole 20- 30 15-20 Cauliflower. 1 medium head 2-2K |Separated 10-15 10-15 [Whole 25 30 20-30 Celeriac _ 6 medium-sized 2K 2 Diced . . _ 25 15-20 Celery _ _ 1 large bunch lK-inch pieces . 25 30 15-20 Chayotes 3 medium-sized IK 3 Sliced. 20 15 Collards 30 20 Corn. . 6 ears _ ... On cob _ 10 6-15 Table I.—Time required for cooking the more common vegetables by different methods. 408 Dandelion greens. 2 10-20 Eggplant _ . 2 small or 1 large 2 Diced 15 10 Fennell 6 medium-sized 2 y2 25 15-20 Kale _ 2-3 20-25 Kohlrabi 6 medium-sized i y2 Pared, sliced 30 25-30 Lentils, dried 1 cup H Soaked overnight 6-8 180-240 Mushrooms. _ i y2 Whole Ya 5 (in own juice) Okra \y2 do 20 10-20 Onions, Bermuda 6 medium-sized 1^-2 Peeled, whole 1 30 Onions, Spanish 3 medium-sized 2 Peeled, cut in half 1 35-40 Parsnips 6 medium-sized i y Whole Y-V\ 30-40 20-30 Peas, dried 1 cup _ y» Soaked overnight 6 8 180 Peas, fresh _ _ 3, in pods Shelled 10-20 Potatoes 6 medium-sized 1/4-2 Whole % 40 35 Rhubarb. _ 1 large bunch 2 1-inch pieces H 5 5 Rutabagas 2-3 2 Pared, quartered 20-30 Spinach. 2-3 1 With stems.. 10 [No stems ...' 5—6 5-8 Squash, summer _ 3-4 3 Pared, sliced 20 15 Squash, winter . _ 3 2-inch pieces H 1 30 40 20 Sweetpotatoes. 6 medium-sized. Whole* ■¥ 30 35 25-30 f With stems „ ... . _ .. .. 20-30 Swiss chard ... 2 [ Leaves alone 2 10 [Stems alone 2 30 Tomatoes. _ _ _____ 6 medium-sized. _ 1^-2 Quartered 14 Va 10-20 Turnip greens . _ 2-3 20-30 Turnips 2 bunches 2 Sliced or diced 20 25 15-20 Vegetable oyster, or salsify 1 large bunch Sliced _ . 20 20 > Cooked separately but combined for serving. 1 Green beans lose color on steaming. 409 TM 8-220 334-336 MEDICAL DEPARTMENT losses may be prevented by leaving the cover on and using as little water as possible. Salt may be added in the approximate propor- tion of 1 level teaspoonful to a quart of boiling water. Any left- over stock should be served with the vegetable or utilized in sauces or soups. (2) If water is actually boiling when vegetables are put into it, and if it is kept boiling gently throughout the cooking period, con- siderable time is saved. If tough stems of leafy vegetables are removed the cooking period is about halved and the vegetable under- goes small loss of food value. m. The approximate length of the cooking period for the more common vegetables is given in table I. The time required varies with the tenderness of the vegetable and the form in which it is cooked as well as with the method of cooking. The time can be shortened in different ways. n. A vegetable is considered sufficiently cooked when it is tender, but not soft and flabby. The time required under those methods most appropriate to the vegetable is given in table I. 335. Breadmaking.—See TM 10-410. 336. Hospital diets.—a. Medical diets.—Diets are classed as liquids, semisofts, softs, and lights, based on the degree of digesti- bility and are given to the patient according to his tolerance for food. A medical liquid is fluid, bland, easily digested, and has a low residue. For a semisoft diet add a few of the most easily di- gested solids to the liquid diet. The soft diet consists of very digestible solids with the addition of stewed fruits and vegetables in the form of purees. The light diet is practically a normal diet with all fried, highly seasoned, and indigestible foods omitted. The following outlines of foods may be used for each diet. (1) Liquid diet.—(a) Foods.—Allow 1% pints at each meal with three extra nourishments between meals at 10: 00 AM, 2: 30 PM, and 8:00 PM. All usual beverages. Cereal gruels. Milk—in all forms. Wheys. Albumins. Broths. Soups (strained). Fruit juices. Ice cream (plain). Ices (plain). (h) Sample menu. Breakfast Orange juice. Oatmeal gruel. Coffee. Dinner Broth. Vanilla ice cream. Milk. Supper Broth. Lemon albumin. Cocoa. 410 SOLDIER S HANDBOOK TM 8-220 336 10:00 AM Eggnog. 2:30 PM Ginger ale with ice cream. 8:00 PM Milk. (2) Semi-soft diet.— (a) Foods.—Allow 1% pints of food at meal- time with nourishments between meals at 10: 00 AM, 2: 30 PM, and 8:00 PM. Cooked cereals: Oatmeal (well cooked), Farina, Cream of Wheat, Cerevim, Pamlum—avoid those high in roughage. Milk toast. Crackers in milk. Eggs: Coddled, poached, soft-boiled, soft-scrambled. Custard: Baked or boiled. Puddings: Blanc mange, tapioca, simple cream puddings, plain gelatin desserts. Junket. (h) Sample menu. Breakfast Orange juice. Cream of Wheat. Soft-boiled eggs. Coffee. Dinner Broth. Milk toast. Baked custard. Tea. Supper Strained vegetable soup. Crackers in milk. Junket. Cocoa. 10:00 AM Malted milk. 2:30 PM Ginger ale with ice cream. 8:00 PM Milk. (3) Soft diet.— (a) Foods.—Give small, attractive servings. The following foods may be added to the above lists: Fruits: Oranges, stewed fruits (without seeds), baked apple, canned peaches or pears. Cereals: Prepared (not high in roughage). Toast: Zwieback, rusks, toasted white bread. Chicken: White meat (sliced, scalloped, creamed, etc.). Eggs; Any way except fried or hard-boiled. Crackers: Soda. Brains: Creamed, scalloped (plain or with eggs). Sweetbreads: Creamed, scalloped, or broiled. Fish: White (baked, boiled, broiled). Oysters: Broiled, creamed, scalloped, stewed. Potatoes: Baked, mashed, riced. Macaroni; Spaghetti, noodles, and rice. 411 TM 8-220 336 MEDICAL DEPARTMENT Asparagus tips. Celery: Creamed or stewed. Vegetable purees: Beets, carrots, lima beans, peas, squash, spinach, string beans. Cheese: Cream and cottage. Fruit whips. (h) Sample menu. Breakfast Sliced orange. Cream of Wheat. Poached egg on toast. Coffee. Dinner Strained cream of celery soup. Sliced white meat of chicken. Mashed potatoes. Puree peas. Toast and butter. Prune whip with cus tard sauce. Milk. Supper St r a i n e d vegetable soup. Buttered asparagus on toast. Baked potato. Puree carrots. Toast and butter. Junket. Cocoa. (4) Light diet—(a) Foods.—ln addition to all foods listed above the following may be given : Fruits: Fresh (except bananas and melons) and canned or stewed fruits. Cereals: All except very coarse cereals. (See semi-soft diet list.) Crisp bacon. Scraped beef. Lamb chops. Liver, scalloped or souffleed. Poultry. Fish (except pickled or fried). Vegetables: Raw or cooked. Coarse or strong vegetables must be omitted. Bread: White, graham, whole wheat. Simple puddings. Sponge cake. Wafers. Simple salads. 412 TM 8-220 SOLDIER S HANDBOOK 336 Breafast Sliced orange. Cream of Wheat. Poached egg on toast. Crisp bacon. Coffee. (&) Sample menu. Pinner Cream of celery soup. Scraped beef cakes. Mashed potatoes. Buttered peas. Bread and butter. Prune whip witli cus- tard sauce. Milk. Supper Vegetable soup. Buttered asparagus on toast. Baked potato. Lettuce salad with mayonnaise. Bread and butter. Junket. Cocoa. b. Surgical diets.— (1) Preoperative treatment.—As prescribed by the surgeon. (2) Postoperative treatment.—The surgeon may prescribe the following: (a) Abdominal cases (except stomach and small and large intestines). I. First day.—After 8 hours, if there is no nausea, allow the patient tea and tap water. S3. Second day.—Give four 8-ounce feedings of tea, tap water, and broth. 3. Third day.—Give a surgical liquid diet after the oil is effective. J. Fourth day.—Soft diet. After this period a regular diet is allowed at the discretion of the ward officer. (&) Stomach cases (small intestines and colon). I. First, second, and third days.—Give the patient nothing by mouth. Use the Murphy drip 2 hours on and 2 hours off (except in colon cases). S3. Fourth day.—Allow 1-ounce quantities of tea, tap water, whey, and strained orange-juice every half hour. 3. Fifth day.—lncrease the same liquids as above to I ounces every 2 hours. J. Sixth day.—Add orange, albumin, and clear, nonirritating broths. 5. Seventh day.—Add cereal gruels to the diet. Malted milk and junket are given only when ordered by the doctor. Gall bladder cases. 1. First, second, and third days.—Follow the routine of abdominal cases. 2. Fourth day.—Semi-soft diet is given. Milk, cream, and lemon must be restricted. 413 TM 8-220 336 MEDICAL DEPARTMENT 3. Fifth day.—Give a soft diet, gradually introducing butter and cream. Restrict milk, cream soups, cocoa, and eggnogs. After the fifth day additional diet orders should be given by the ward surgeon. On a regular gall bladder diet restrict gravies, fried foods, pastries, gaseous vegetables, and all salads. (d) Liquids. Broths. Bouillon. Beef tea. Beef juice. Tea. Coffee. Whey. Albumin. Fruit juices. Ginger ale. Avoid milk in any form. Liquid diet should be administered every 2 hours from 7 AM to 8 PM. (e) Semi-soft. 1. Foods.—Useful in transferring ill cases from liquid to solid foods. Feedings six times daily. From 500 to 600 grams at meal time with 200 cubic centimeters between meals may be allowed. Liquids of all sorts. Broth: Thickened, strained. Soups: Thickened, strained. Eggs: Poached, coddled, soft-boiled. Poultry and beef jellies. Cottage cheese. Plain gelatins. Fine cereals. Oatmeal: Strained. Tapioca. Junket. Custards. Blanc manges. Plain sherbets. Plain ice cream. 2. Sample menu. Breakfast Orange juice. Cream of Wheat. Coffee. Dinner Broth. Baked custard. Tea. Supper Broth. Jello. Tea. 10:00 AM Eggnog. 3:00 PM Lemonade. 8: 00 PM Milk. 414 SOLDIER S HANDBOOK TM 8-220 336 (/) Soft. 1. Foods.—Food six times daily. Carefully guard total amounts. Any liquid or semi-soft foods. Cream of Wheat, Quick oats. Cerevim, Pablum (cooked cereals). Toast. Butter. Apples: Stewed or baked (no skin). Puree stewed fruits. 2. Sample menu. v Breakfast Puree prunes. Cream of Wheat. Toast and butter. Coffee. Dinner Broth. Cottage cheese. Toast and butter. Baked custard. Tea. Supper Broth. Poached egg on toast. Jello. Tea. 10: 00 AM Orange juice. 3: 00 PM Lemonade. 8: 00 PM Fruit juice. iff) Light. 1. Foods. Potatoes: Mashed or baked. Stewed celery. Asparagus tips. Spinach. Beets. Carrots. String beans. Peas. Macaroni, spaghetti, noodles. Brains. Bacon: Broiled. Chicken. Sweetbreads. Lamb chops. White fish. Oysters. Stewed and canned fruits (except pineapple, figs, and raisins). Oranges. No salads, raw vegetables, or raw fruits (except oranges). 415 TM 8-220 336-337 MEDICAL DEPARTMENT Breakfast Stewed prunes. Cream of Wheat. Poached egg on toast. Broiled bacon. Coffee. 2. Sample menu. Dinner Chicken broth. Broiled lamb chop. Mashed potatoes. Buttered string beans. Toast and butter. Baked custard. Milk. Supper Cream celery soup. Buttered asparagus with toast points. Baked potato. Buttered carrots. Toast and butter. Fruit Jello. Milk. Section V DENTAL REPORTS AND RETURNS Paragraph Dental reports and returns s 337 337. Dental reports and returns. W. D., M. D. Form No. Title and description 18b Statement of Expenditure of Special Dental Materials.—Rendered monthly from every military station or separate command where a dental clinic with laboratory facilities is established and a dental officer is in attendance. If post is under the immediate control of the War Department, report is sent directly to The Surgeon Gen- eral, one copy to the station medical supply officer, and one copy retained. If forwarded through the corps area surgeon, two copies are sent forward, one copy to the medical supply officer of the sta- tion, and one copy is retained. (See AR 40--1010.) 18b-L Statement of Expenditure of Special Dental Materials.—Rendered monthly from every central dental laboratory. If the laboratory js under the immediate control of the War Department, report is sent directly to The Surgeon General, one copy is sent to the medical supply officer of the station, and one copy retained. If forwarded through corps area surgeon, two copies are sent, one copy to the medical supply officer of the station, and one copy retained. 57 Report of Dental iSeratce.—Rendered monthly from every station and separate command where a dental officer has been on duty during the month. If post is under the immediate control of the War Departriient, report is sent directly to The Surgeon General; one copy retained. If forwarded through the corps area surgeon, two copies are sent and one retained. (See AR 40-1010.) 65 Dental Engagement Slip.—It should be made out for all appointments given for dental treatment. In the case of the enlisted man, it is a request for his relief from other duty so that he may obtain dental treatment at the designated time. 79 Register of Dental Patients (card).—Prepared for every person receiving dental treatment. (See AR 40-1010.) 416 TM 8-220 337-338 SOLDIER’S HANDBOOK W. D„ M. D. Form No. Title and description 123 Label Penalty.—This form to be placed on the outside of all cartons used in mailing dental appliances. (See Circular Letter No. 1, compilation of Circular Letters, Surgeon General’s Office, January 2, 1940, par. 11.) 124 Prosthetic Case Record.—Two copies made at dental clinic and for- warded to central dental laboratory, which retains one copy and returns the other to the dental clinic along with the completed prosthetic appliance. 125 Caution Slip.—This form to be placed on all mailing cartons contain- ing dental appliances. 126 Report of Central Denial Laboratory.—Case record of all dental appli- ances constructed at central dental laboratory during the month. One copy is forwarded to The Surgeon General and one copy retained. Section VI VETERINARY REPORTS, RETURNS. AND RECORDS Tabulation of reports and returns : : 338 Responsibility for veterinary reports and returns 339 Disposition of records and reports on abandonment of station 340 Disposition of old records 341 Mobile units temporarily at stations 342 Special reports and articles for publication 343 Correspondence records 344 Veterinary history of station 345 Clinical record 340 Report of veterinary personnel 1 347 Paragraph 338. Tabulation of reports and returns.—The following tables include only the reports and returns required by Army Regulations pertaining to the veterinary service: a. Daily. , Title W. D., M. D. Form No. Reference and remark Veterinarian’s morning re- ports of sick animals. 71 V_ AR 40 2035. Made after veterinary sick calls. Sent to commanding offi- cer. Returned by adjutant to vet- erinary hospital. Morning report of ward 72 AR 40-2065. Forwarded to hospital office. 417 TM 8-220 338 MEDICAL DEPARTMENT Title W. D. M. D. Form No. Reference and remark Record and report physical 109 ... AR 40-2265. Filed in office until end examination of animals for of month. On days that no examina- purchase. tions are made, no report is required. Report of veterinary meat 110 AR 40-2260. Filed in office. On days and dairy hygiene and that no inspections are made, no forage inspection. report is required. b. Monthly. Title W. D„ M. D. Form No. Reference and remark Statistical report, third section (personnel and transportation). 86c Section IV, AR 40-2245. Original to The Surgeon General direct; copy to corps area surgeon; copy retained. For rendition and trans- mission in time of war see Section IV, A R 40-2245. Report sheet; report of, and register card for, sick and wounded ani- mals. 102 and 115 AR 40-2245. Original to The Surgeon General through corps area surgeon; copy to corps area surgeon; copy retained for file. Record and report phys- ical examination of animals for purchase. 109 AR 40-2265. Made by assembling chronologically daily reports of examinations. Original to The Surgeon General through military channels; copy to headquarters veterinarian; copy retained. Report of veterinary meat and dairy hy- giene and forage in- spection. 110 AR 40-2260. Prepared by compiling data from daily reports. Original to commanding officer through the surgeon; copy to quartermaster; copy retained. c. Quarterly. Title Form Reference and remark Veterinary sanitary re- port. Letter AR 40-2255, AR 40-2090. Original and copy to commanding officer; one copy to station surgeon; one copy retained. 418 TM 8-220 SOLDIER S HANDBOOK 338 Title ' Form Reference and remark Report of corps area veterinarian. Report of veterinary activities at labora- tories. Report of veterinarian, purchasing. Letter . AR 40-2015. Original to corps area surgeon for transmission to The Surgeon General; one copy retained. AR 40-2140. Original to corps area surgeon for transmission to The Surgeon General; one copy retained. AR 40-2045. Original to The Surgeon General through military channels; one copy retained. Letter Letter d. Annually. e. Occasionally. Title W. D., M. D. Form No. Reference and remark Veterinary health certi- ficate. 101 ... AR 40-2270. Prepared by the veterinarian of the issuing sta- tion. Original and copy to the receiving veterinarian; one copy to shipping officer; one copy retained. Veterinary health certi- ficate (memorandum section). 101 AR 40-2270. Memorandum sec- tion completed by receiving veterinarian. Original com- pleted and forwarded to The Surgeon General through mili- tary channels. One completed copy retained. Veterinary sanitary re- port of animal trans- port. 103a AR 40-2055. Prepared by port veterinarian. Original to The Surgeon General through mili- tary channels; copy retained. Trip report, veterinary transport service. 113 AR 40-2060. Prepared by trans- port veterinarian. Original forwarded to officer in charge; copy retained. Special report of trans- port veterinarian. Letter. AR 40-2060. Original to port veterinarian; copy retained. Report of personnel ac- companying shipment of animals. Letter AR 40-2035. Original to The Surgeon General through mili- tary channels; copy retained. 419 TM 8-220 338 MEDICAL DEPARTMENT Title W. D., M. D. Form No. Reference and remark Report of appearance of first case of serious communicable disease. Letter AR 40-2090. One to corps area surgeon; one to The Surgeon General (from units within continental United States); one to issuing veterinarian (if among animals received from another station); one to receiv- ing veterinarian (if contact animals have been shipped); one to commanding officer; one retained. Notification of commu- Letter or such form AR 40-2090. Original to civiL •nicable disease to civil- ian authorities. as desired . by civil authorities. authorities; copy retained. Special professional re- ports epizootic diseases and other interesting cases. Letter _ __ AR 40-2090. Original to The Surgeon General through med- ical channels; copy retained. Certificate of examina- Letter AR 40-2075. Original to officer tion of officer’s mount. requesting examination; copy retained. Veterinary opinion on hospital buildings. Letter AR 40-2065. One to the com- manding officer; one to The Surgeon General through mil- itary channels; copy retained. Request for alteration or addition to hospital. Letter AR 40-2065. Original to The Surgeon General through mil- itary channels: copy retained. Chart of tuberculin test__ Letter AR 40-2230. Original attached to report of meat and dairy hygiene (W. D., M. D. Form No. 110) and forwarded; copy retained. Autopsy protocols Letter AR 40-410. Original to curator, Army Medical Museum through medical channels; one copy retained. Clinical record 55-series Paragraph 8, AR 40-2235, and paragraph 26, AR 40-2065. Filed in hospital office. Receipt for animals 116 ... Paragraph 34, AR 40-2065 Original furnished organiza- tion presenting patient; dupli- cate filed. 420 TM 8-220 SOLDIER S HANDBOOK 338-341 Title W. D., M. D. Form No. Reference and remark Emergency veterinary 115b_ _ Paragraph 39, AR 40-2245. For tag. use in the field; original at- tached to patient; upon final disposition in theater of opera- tions, duplicate will be com- pleted and signed by responsi- ble officer and forwarded with next report on W. D., M. D. Form No. 102; triplicate re- tained. Index card register of 115a Paragraph 5, AR 40-2245. Filed animal patients. at station. 339. Responsibility for veterinary reports and returns.—a. The senior veterinary officer of a station or other command is re- sponsible for the preparation, authentication, transmission, and safe- keeping of the reports, returns, and records prescribed for the use of the veterinary service (AR 40-2235). b. In the absence of a veterinary officer, the surgeon will take charge of veterinary property and will render all reports pertaining to the veterinary service unless otherwise specifically excepted. c. An attending veterinarian or a civilian veterinarian rendering professional service to a command will, in. the absence of a veterinary officer, sign or initial (if name is typed) register and report cards of sick and wounded animals. 340. Disposition of records and reports on abandonment of station.—a. When a post is abandoned or a detachment is broken up the veterinary officer will report the fact through the commanding officer to the corps area surgeon and after completing all current re- ports will forward them, through channels with a letter of trans- mittal, to The Surgeon General (AR 40—2235). h. In case all commissioned personnel, Veterinary Corps, are relieved or go on leave from a station or command at which a surgeon remains, the latter will take charge of all veterinary records. If all medical department personnel is relieved, the veterinary records will be disposed of as prescribed in a above. 341. Disposition of old records.—Registers of sick and wounded animals and the veterinary history of a station will be permanently preserved at such station. Other records and retained copies of 421 TM 8-220 341-345 MEDICAL DEPARTMENT reports and returns will, in the absence of specific regulations and or- ders governing their disposition, be salvaged after 8 years from their date (AR 40-2235). 342. Mobile units temporarily at stations.—For purposes of administration, mobile units arriving at a station for maneuvers, summer training, etc., automatically become a part of such station, and all reports and returns will be consolidated and forwarded as a station record by the senior veterinarian on duty at the station (AR 40-2235). 343. Special reports and articles for publication.—a. When a medical or surgical case presents unusual or interesting features, a special report of the same will be forwarded by the veterinarian, through channels, to The Surgeon General. b. Veterinary officers will not publish professional papers requiring reference to official records or to experience gained in the discharge of their official duties without the previous authority of the Secretary of War (AR 40-^2235). 344. Correspondence records.—a. The War Department decimal system will be used for recording and filing the correspondence of veterinary general hospitals, convalescent hospitals, and such other offices as may be especially authorized (AR 40-2235 J. b. The correspondence book system as prescribed by the War De- partment will be used for recording and filing the correspondence of all veterinary station hospitals and other veterinary formations ex- cept those for which some other system is specially prescribed. c. The correspondence of veterinary officers on duty at the head- quarters of a corps area will be considered a part of the correspondence of the office of the surgeon. d. Correspondence books are furnished by The Adjutant General’s Department and materials for the decimal system are furnished by the Quartermaster Corps. 345. Veterinary history of station.—A veterinary history of every permanent station will be kept by the veterinarian in a loose leaf binder. A copy of the veterinary sanitary report (AR 40-2255), the meat and dairy hygiene report (AR 40-2260), the forage inspection report (AR 40-2085), and the veterinary report of sick and wounded animals (AR 40-2245) will be filed therein in a single chronological sequence. Additional sheets measuring about 13 by 8 inches for noting the occurrence of epizootic diseases and other data of general and veterinary interest will be inserted as occasion requires at their proper chronological places. The prescribed record of the official endorse- ments on sanitary reports and W. D., M. D. Form No. 110 (Report of 422 SOLDIER'S HANDBOOK TM 8-22 C 345-347 Veterinary Meat and Dairy Hygiene and Forage Inspection) will invariably be made on the copy filed in the veterinary history (AR 40-2235). 346. Clinical record.—a. A clinical record will be kept for every patient in a veterinary hospital establishment. W. D., M. D. Form No. 55aV (Clinical Record Brief, Veterinary) and W. D., M. D. Form No. 55j (Clinical Record, Treatment) will be used in every case; the other lettered blanks of W. D., M. D. Form No. 55 will be used as the nature or importance of the case may warrant (AR 40-2235). h. Upon transfer of a patient from one ward of the hospital to another or to a new station, the clinical record will be sent with him. The fact of transfer will be noted on W. D., M. D. Form No. 55g (Clinical Record, Progress). c. Upon the completion of the case, all the sheets of the clinical record will be arranged in their proper order, fastened together at the top, all entries completed, and the record signed by the ward veter- inarian. Tne record as completed and signed will be sent to the hospital office with the next morning report of the ward and will be filed according to the register number thereon. ? 347. Report of veterinary personnel.—A monthly report of veterinary personnel will be rendered on W. D., M. I). Form No. BCc (Statistical Report, Third Section—Personnel and Transportation), in accordance with section IV, AR 40-2245 (AR 40-2235). TM 8-220 348-350 MEDICAL DEPARTMENT Chapter 7 MEDICAL SIDE OF CHEMICAL WARFARE Section I. Chemical agents 348-356 11. Individual protection 357-368 111. Collective protection 369-375 IV. Medical care of chemical casualties 376-383 Paragraphs Section I CHEMICAL AGENTS Paragraph Use in war : 348 Definition ! 349 Kinds 350 Physical state 351 Concentration 352 Recognition in field 353 Basic rules for identification by odor 354 lihportance of ability to recognize 355 Distinguishing between mustard and lewisite 350 348. Use in war.—The United States is a party to the Geneva Gas Protocol of 1925. The terms of this international agreement forbid the use of poisonous gases in warfare. However, in the event of war with a country not party to the Geneva Gas Protocol or wdiich disregards that agreement, it is necessary for all soldiers, but more particularly medical soldiers, to understand certain fundamentals. These fundamentals pertain partly to the soldier’s self-protection and partly to knowing how to care for a patient who has been injured or disabled by one or more chemical agents. 349. Definition,—A chemical agent is a substance which, by its ordinary chemical action, produces— a. A toxic effect on the body. b. An irritant effect on the body. c. A screening smoke. d. An incendiary action (lire). 350. Kinds.—The following types of chemical agents may be used in warfare. Each group includes several substances of widely dif- ferent chemical composition, but which act on the human body in the same general manner, and are therefore placed in the same group. TM 8-220 SOLDIER S HANDBOOK 350-356 a. Tear gas. b. Nose irritant gases. c. Lung irritant gases. d. Blister gases. e. Gases which paralyze. f. Incendiary agents (those which set fire to flammable objects). 351. Physical state.—A chemical agent is not always a gas. The term “gas” is used because it is convenient and has become sanctioned by long use. Some chemical agents are gases, some are liquids, and some are solids. 352. Concentration.—The amount of chemical agent in. air (that is, the concentration) influences the effect produced by an exposure to such agent. The higher the concentration, the greater is the effect upon exposure to any chemical agent for any period of time. 353. Recognition in field.—Chemical agents in the field may be recognized by their odor and other immediate effects on the body. See table 11, page 439. See section II for description of effects of chemical agents. 354. Basic rules for identification by odor: a. No. 1.—Do not inhale deeply. Sniff. b. No. 2.—Sniff only once. Repeated sniffing dulls the sense of smell. c. No. 3.—First sniff, then think. The memory of odors can be trained by practice. d. No. 4-—Every perception of odor must be named. Learn odors by memory of the thing sniffed, rather than by the name of some- thing else. A thing is odorless only when no perception of odor is obtained. e. No. s.—After each test, breathe out strongly through the nose several times. Do not sniff a new sample until the old perception has vanished. f. No. 6.—Do not smoke while sniffing. Smoking dulls the sense of smell. 355. Importance of ability to recognize.—Every soldier should, for his own protection, be able to recognize the odors of chemical agents. The medical soldier, in addition, must recognize them so that he may the better protect a disabled or other wounded man in his care. 356. Distinguishing between mustard and lewisite.—The two chief blister gases are mustard and lewisite. Both of them possess the general characteristics of the group as a whole, but differ in the following important details: 425 TM 8-220 356 Mustard Lewisite 1. Entirely insidious; presence hard to detect. Presence easily detected. 2. Has a feeble and not very definite Has a strong and definite smell of gera- smell. niums. 3. Produces no immediately detectable The vapor, if breathed for a few minutes effect on the body (unless a drop produces a. severe sensation of burning gets into the eye, when a mild irri- and irritation of the nose; the liquid tation may be felt). produces a sharp tingling in contact with the skin, and immediately severe pain if a drop falls into the eye. 4. Cold or warm water has practically Contact with water at any temperature no effect except after long periods of time, such as days or weeks, but boiling water destroys fairly rapidly. rapidly destroys. 5. Immediate application of the paste Immediate application of the paste made made of bleaching powder and of bleaching powder and water is water is effective in preventing effective in preventing skin burns, but burns. Bleach ointment is also effective. bleach ointment is not effective. 6. Extremely persistent. . Not so persistent, largely because of the action of water. 7. Effects are local and no general When the skin has been heavily con- poisoning is caused. taminated, symptoms of arsenical poisoning may accompany those caused by the burning. 8. Blisters should not be broken _ _ Blisters should be opened because they contain arsenic. MEDICAL DEPARTMENT Section II INDIVIDUAL PEOTECTION Gas mask , 357 Solutions : 358 Other articles 359 Tear gas 360 Nose irritants 361 Lung irritants 362 Blister gases 363 Effects of blister gases 364 Death rate from blister gases 365 P'irst-aid treatment of patients injured by blister gases 366 Paralyzing gases 367 Incendiary agents 368 Paragraph 426 TM 8-220 SOLDIER’S HANDBOOK 357-361 357. Gas mask.—The Army gas mask is the best individual pro- tection against chemical agents and is entirely satisfactory for this purpose. The Army service gas mash will not 'protect against carbon monoxide or ammonia gas and is not suitable for use in fighting fires or in industrial accidents where ammonia fumes are present. It is important to learn by practice how to put on and take off the mask quickly. 358. Solutions.—ln the absence of a gas mask breathe through a handkerchief saturated with a solution of cooking soda (sodium bicarbonate) or soap suds. Use urine to wet the cloth if no soda or soap suds are available. Tear off a piece of shirt for this use if no handkerchief is at hand. 359. Other articles.—Obviously the gas mask cannot protect the individual’s body against chemical agents. Since gas passes through the ordinary uniform, only a complete gasproof suit can protect the whole body. It is ordinarily impracticable to use such suits. Protection, therefore, depends on destroying chemical agents, pro- tective covers for material, use of gasproof shelters, etc. 360. Tear gas.—Tear gas, or lachrymator gas, maj7 be any one or more of chemical compounds which act upon the eyes. They produce acute pain, profuse outpouring of tears, and spasm of the eyelids. a. Effect on, eyes.—Tear gases do not usually do permanent damage to the eyes, for the effect is generally of comparatively short duration. But they cause an almost complete inability to see for the time being. b. Effect on sympathetic nerves.—Tear gases sometimes cause vom- iting. c. First-aid treatment.—Since the damage is usually only of short duration, first-aid treatment is not so necessary as in other chemical injuries. The eyes should be protected from the gas and when the gas is no longer present, the eyes should be exposed to fresh air. The patient should be warned not to rub his eyes, as this increases the irritation. The eyes should be bathed with warm water, normal saline solution (1 teaspoonful of salt dissolved in a pint of water), or a weak solution of bicarbonate of soda (cooking soda). It is not necessary to evacuate patients whose only injury is from tear gas. d. Mental effects.—Tear gas, like all other warfare chemicals, has another effect on human beings. It produces fear if its actual nature is not understood. 361. Nose irritants.—Nose irritants (sternutators) cause irrita- tion of the nose and throat and a watery discharge from the nose. There is also coughing, pain at the base of the nose, severe headache, 427 TM 8-220 361-362 MEDICAL DEPARTMENT and nausea. Mental depression is a characteristic effect of this group of chemicals. a.. Damage.—Usually little or no permanent damage is caused, though there is at the time very real distress. The effect of nose irritants may be either immediate or delayed for as much as 30 minutes or longer. h. First-aid treatment.—The patient should be put at rest and his clothing loosened. The nose and throat should be bathed with warm, weak solutions of sodium bicarbonate (cooking soda), 10 grains to 1 pint of water. Keep the patient away from heat. If vomiting has resulted from this gas, copious drafts of the weak sodium bicarbonate solution will help to relieve him. It is usually not necessary to evacuate patients whose only injury is from a nose irritant gas. However, the more serious cases of this kind may have to be evacuated. c. Mental effects.—Besides the mental depression caused by nose irritant gases, the effect on morale must be considered. If the patient does not understand that his condition is not serious his fear may be very great. Medical soldiers should understand the condition and therefore be able to reassure patients. 362. Lung irritants,—Lung irritant gases are very dangerous chemical agents which may cause death if the patient is exposed to them for a long period. However, slight or brief exposures are not likely to cause such serious results. Lung irritants affect the patient’s ability to breathe. a. Symptoms produced.—These vary considerably with the particu- lar gas encountered and with its concentration. They are usually irritation of the nose and throat with coughing, difficulty in breath- ing, pains in the chest, vomiting, and a blue pallor of the lips and ear lobes. The face takes on a grayish pallor. h. Appearcmce of symptoms.—The symptoms of damage to the lung do not as a rule come at once. Usually about 2 hours elapse before such symptoms appear. There is sometimes what is called “de- layed action”—that is, the effect of the gas seems to be absent at first, only appearing after some time has elapsed. It is important to re- member that even though the symptoms seem slight, more serious effects may come on later. c. Treatment of casualties.—Patients suspected of being injured by lung irritant gases should not be allowed to walk. All casualties known or even suspected to have been seriously exposed to one of these gases should be treated as litter cases from the start. 428 TM 8-220 SOLDIER'S HANDBOOK 362-363 d. First-aid treatment.—Remove the patient from the gas atmos- phere if possible. The gas mask must not be removed until the patient has been removed to a place where the air is free from gas. Loosen the clothing and keep the patient at absolute rest. Do not allow him to walk. Keep him warm with blankets, hot water bottles, etc. Give such nonalcoholic stimulants as hot coffee or tea. The administration of oxygen is required in extreme cases. Such patients should be evacuated to aid stations as soon as possible. e. Danger period.—The most dangerous period for the patient who has been exposed to lung irritant gas is the first 48 hours. Most deaths occur within this time. Therefore, exercise great care when patients are first seen. /. Precaution against artificial respiration.—Artificial respiration is not to be performed on lung irritant gas casualties. The lungs are seriously damaged and likely in a waterlogged condition. Artificial respiration would probably do more harm than good and might even cause sudden death. 363. Blister gases.—This group of gases produces special and peculiar characteristics which are so important individually and which cause so many different problems that their five principal effects are considered separately below: a. Persistence and power.— (1) Persistence.—Members of this group are normally liquids of a somewhat oily consistency. Under normal weather conditions in temperate climates they persist up to 3 weeks if the original contamination was heavy and if the area affected is sheltered from direct action of wind and sunlight. (2) Power.—The power of these chemicals is so great that a drop the size of the head of a small pin can produce a blister the size of a quarter. The exposure to a vapor of one part per million parts of air for an hour is capable of producing a casualty. The action on the eyes is particularly marked. h. Penetration of materials and of the human hody.—The ability of blister gases to penetrate is one of their characteristics. They “soak in” just as ink soaks into a blotter. This is not the same as “eating in” as when an acid acts on a metal. In other words the “soaking in” takes place without any damage to the material (cloth- ing, etc.). These chemicals also “soak into” the body. About the only substances which withstand this power of penetration are metal, glass, and highly glazed resistant materials such as tiles or porcelain. c. Insidious character.—By this is meant that the presence of such a gas (for example, mustard gas) may not be very obvious, either by smell or by producing any particular sensation such as burning. On 429 TM 8-220 363-364 MEDICAL DEPARTMENT the other hand, lewisite, another of the chemicals of this group, has a characteristic smell (like geraniums). d. Delayed action.—One of the important peculiarities of this group, and one which makes them very dangerous, is that while the actual damage takes place rapidly the recognizable signs of such dam- age do not appear for a considerable time. Thus a patient may be contaminated without knowing it (insidious character) and yet may show no signs of damage for 24 hours. However, the average time of the development of clinical signs or symptoms is about 4 to 8 hours for mustard gas, and even sooner for lewisite. e. Universal action.—Unlike the agents of the other groups, the effects of this group are not confined to any one area of the body. The blister gases have the power to burn and blister any area with which they come in contact, either as a liquid or as a vapor. This is equally true of areas within the body. 364. Effects of blister gases.—The damage caused by this group of chemicals varies somewhat with the area affected. The various parts of the body affected by the blister gases are considered below: a. Eyes.—The eyes are very liable to injury, whether from liquid or vapor. Though there may be some delay in appearance of signs, such delay is less than in other areas of the body. A few hours after exposure, inflammation (conjunctivitis) sets in, with smarting, water- ing, and finally closure from swelling of the eyelids. Conditions rapidly get worse and there is much pain, especially on exposure to light (photophobia), with discharge coming from between the swollen lids. Actual destruction of the eye and consequent blindness is rare, but there may be some impairment of vision due to scars. h. Respiratory system.—lnflammation of the throat and windpipe (trachea) as a result of breathing air contaminated by the vapor of these liquids is fairly common. It produces dry and burning mouth and throat, with harsh, ringing cough. This cough is very character- istic and very distressing. Partial loss of the voice due to inflamma- tion of the throat (laryngitis) is common. In most severe cases burning of the lungs may produce pneumonia. c. Digestive system.—lnflammation of the stomach, with pain and vomiting may occur. This is the result of swallowing contaminated saliva, or the swallowing of contaminated food or drink. It is not serious as a rule. d. Skin.—lnjury to the skin develops in three stages: Reddening (erythema) with a fine rash not unlike “hives”, blistering, and finally ulceration. How far the casualty progresses toward the final stage depends on the original concentration of the chemical agent and the 430 TM 8-220 SOLDIER’S HANDBOOK 364—366 length of the patient’s exposure to the poison. In case of contamina- tion by liquid, blistering always occurs if steps are not taken at once to counteract the effects. The areas of skin most likely to suffer from exposures to vapor are those which are normally moist, such as the bend of the elbows and knees, the armpit (axilla), the crotch, and the inner side of the thighs. The genitals are particularly liable to attack. 365. Death rate from blister gases.—lt is encouraging to re- member that while the number of casualties due to these agents is high, chiefly due to their persistence and insidiousness, the death rate is low. It was only about 2 percent in the World War. 366. First-aid treatment of patients injured by blister gases.—lt must be remembered that preventive treatment is very important. First-aid must take into consideration the “insidious- ness” and the “delayed action” of this group. a. Eyes.—The only first-aid for blister gas in the eyes is free wash- ing either with plain, warm water, normal saline solution (1 tea- spoonful of salt in a pint of water), or sodium bicarbonate (cooking soda) solution of about 10 grains to a pint of water. This washing should be carried out as soon as possible after exposure. The solu- tion should be run directly to the eyes by means of a rubber tube from an enema can or similar container. A little vaseline on the edges of the eyelids will prevent their sticking together. h. Breathing passages.—Cases in which signs of damage to the breathing passages have developed, including the mouth and throat, have evidently been exposed to relatively high concentrations of va- por for a considerable period of time. Such cases are likely to be serious. Most of the deaths caused by blister gases are due to this. The hard, dry, “brassy” cough is very characteristic of this condi- tion. One of the earlier symptoms is loss of voice fjrom inflamma- tion of the throat (laryngitis). First-aid cannot cope with this condition. The patient must be hospitalized as soon as possible. c. Digestive system.—The pain in the stomach and vomiting can be temporarily relieved by draughts of warm sodium bicarbonate (cooking soda), 10 grains to 1 pint of water. Such cases should be hospitalized as soon as possible. d. Skin—lt is important to remember that there is a delay of some hours between the time that the chemical agent comes into actual contact with the individual and the time at which he develops recognizable signs or symptoms of damage. Yet, as a matter of fact, the damage has already begun almost immediately, and the delay is only in the development or the signs that we recognize. 431 TM 8-330 366-367 MEDICAL DEPARTMENT There are two measures which may be taken in first-aid treatment. The chemical agent may be removed by washing or wiping, and it may be neutralized. If the actual liquid has reached the skin, treat- ment must be begun in less than 5 minutes to be satisfactory. If only the vapor has reached the individual, the time is longer. The only efficient agent to neutralize blister gases is chloride of lime (bleaching powder). This neutralizing agent is itself irritating and must be removed by subsequent washing. If bleaching powder is not available, immediate soap and water baths may remove some of the poisonous agent. If the liquid chemical agent, such as mustard, has reached the skin, much of it may be removed by wiping with a clean cloth moistened with kerosene (coal oil) or straight gasoline (but not gasoline containing lead). When bleaching powder is used, the most effective method of its application is to make a paste of a small quantity of the bleaching powder with water, the mixture being carefully stirred while being prepared. Usually equal volumes of water and of bleaching powder are used. The contaminated area of skin, is covered as well as the immediately surrounding area. The paste is rubbed in well for about 1 minute and then removed by wiping with a dry rag or by flushing off with a large quantity of water, if available. A subsequent bath with soap and water is de- sirable. Care must be taken not to get the bleaching powder paste into the eyes. If the skin has already begun to show definite redness or blisters, the bleaching powder should not be used, as it is irritating. 367. Paralyzing1 gases.—a. General.—Gases which cause pa- ralysis have been used in warfare, but without much success. There are three gases which may be used for their paralyzing effect: (1) Hydrocyanic (prussic) acid. (2) Sulfureted hydrogen (hydrogen sulfide). (3) Carbon monoxide (called fire damp by miners). Such gases are very dangerous and some of them may result from the explosion of projectiles. Hydrocyanic acid has the faint odor of bitter almonds (peach kernels). Hydrogen sulfide has definitely the smell of rotten eggs. Carbon monoxide has no odor. It is the gas that results from incomplete combustion, such as from charcoal flames or automobile exhausts. b. Symptoms.—These begin with uneasiness, dizziness, and rapid heart beat and breathing. Unconsciousness and convulsions follow rapidly, and death occurs through paralysis of the part of the nervous system which controls the breathing (respiratory center). c. First-aid treatment.— treatment must be immediate. Prompt removal from the poisonous atmosphere, artificial respiration, and ad- 432 SOLDIER S HANDBOOK TM 8-220 367-371 ministration of oxygen. A valuable addition to the oxygen is sto 7 percent of carbon dioxide. This last stimulates and increases respiration and helps flood the lungs with oxygen and wash out the poison in the blood. The patient must be kept warm. 368. Incendiary agents.—a. General.—lncendiary agents are chemical agents which cause fires. The more common forms are white phosphorus and thermite. h. First-aid treatment.—The treatment is essentially that of ordinary burns. Particles of white phosphorus may be adhering to the skin and hence have to be picked off. The chief use of white phosphorus in warfare is as a smoke-producing material. Section 111 COLLECTIVE PROTECTION Paragraph Small areas ___ 369 Large areas 370 Food = 371 Water 372 Clothing 373 Precautions against enemy’s chemical agents_ 374 Evacuation of gas casualties 375 369. Small areas.—lt is possible to remove contaminating chemi- cal agents from the areas involved, provided the area is not too extensive. Extensive areas cannot be decontaminated because such a large amount of the neutralizing agent is required. Chloride of lime (bleaching powder), standard article of issue for this purpose, can be used under field conditions to neutralize a small mustardized area. 370. Large areas.—When large areas in the field cannot be de- contaminated such areas are evacuated if possible. Warning signs should be posted on all avenues of approach. Remember that high vapor concentrations will be found in the areas immediately down- wind from mustardized areas. They should be treated the same way as the mustardized areas themselves. 371. Food .—a. Protection.—All food supplies at the front should be kept in airtight containers until required for use. Ration carts and kitchens should be covered by paulins for protection against chemical spray. h. G ontaminated foods.—Food having a peculiar odor or taste, and suspected or known to have been exposed to a chemical agent should be discarded. 433 TM 8-220 371-374 MEDICAL DEPARTMENT c. Susceptibility to contamination.—Some foodstuffs absorb chem- ical vapors more quickly than others. Fatty and oily substances, such as meat and butter, and meal and flour, are quickly contam- inated by vapors. Green vegetables are less readily affected by vapors. 372. Water.—Water contaminated by mustard gas should be avoided. If necessary, however, such water may be rendered safe for use by settling or chlorination. When such water stands, the liquid mustard sinks to the bottom. Allow the water to settle for not less than 4 hours. Siphon off the top portion, leaving a layer 10 or 12 inches in a container of the dimensions of a barrel. This lower layer should be thrown away. Chloride of lime (bleaching pow- der) in the proportion of one-fifth of a pound to the gallon of water, should then be added and the water should be boiled for at least X hour. Contaminated water in shell holes should be avoided. Water contaminated by lewisite, irritant smokes, or white phosphorus can- not be purified by this method. 373. Clothing.—a. Removal.—Only rarely does the actual liquid chemical agent pass through the clothing. That only takes place when the clothing is soaked with it. On the other hand the vapor readily passes through clothing. Therefore, remove all of the patient’s clothing and treat his whole body by washing with soap and water. Remember that the clothing after removal from the patient’s body is still contaminated. Men have been seriously burned by picking up contaminated clothing. h. Decontamination.—Contaminated clothing should be collected into receptacles, preferably metal ones with close-fitting lids (such as G. I. cans). These cans should be turned over to the details whose duty it is to do this work. Men of the Chemical Warfare Service when available are assigned these duties. 374. Precautions against enemy’s chemical agents.—a. In the ■field.—All chemical agents are heavier than air and settle in shell holes, depressions in the earth, dugouts, trenches, etc. Therefore, seek high ground and open spaces which are free from gases insofar as the military situation permits. h. Precautions in 'presence of gas cloud.—Move out of the gas cloud as quickly as possible. Proceed cross-wind, if possible. If a gas cloud envelops a building, close all doors and windows tightly, put out all fires, plug all chimneys, and go to the upper floors of the building. c. Procedure during gas attack.—As soon as it has been established that a gas attack is in progress, the alarm should be given by all 434 TM 8-220 SOLDIER'S HANDBOOK 374-375 means available. Masks are adjusted, doors of gasproof shelters are lowered, fires are put out in such shelters, materiel is protected, and, in general, all routine measures of individual and collective protection are carried out. Casualties are removed from the gassed area as soon as possible and first-aid treatment given. 375. Evacuation of gas casualties.—ln the evacuation of a patient who has been injured by chemical agents, the following measures should be employed: a. At aid stations.—Examine gas mask and if gas is still present in the surrounding air, leave it on the patient. Remove the equipment and loosen the clothing. Remove the clothing if it is contaminated with blister gas (mustard or lewisite) and wrap the patient in a clean blanket. If affected by mustard gas, wash the patient’s eyes with 2 percent sodium bicarbonate (cooking soda) solution. Apply dressings to wounds caused by other war weapons. See that the patient avoids unnecessary movement if suffering from a lung irritant. Keep him quiet. Produce vomiting by giving the patient tepid salt water, if safe to remove the mask. Inspect the emergency medical tag and make the proper notation thereon. Expedite evacuation to the col- lecting station. b. At collecting stations.—Change the patient’s clothing and thor- oughly bathe all individuals who have been affected by blister gases. Completely demustardize all clothing and materiel where time and facilities permit. Adjust dressings. Give special treatment as in- dicated, including administration of oxygen if available in cases of lung damage. Prepare the patient for evacuation. c. At special degassing stations.—Administer neutralizing chemi- cals and degas clothing by the group method. d. At clearing stations.—Sort and* classify the patients, separating them according to the nature of the chemical agent that injured them. Bathe. Retain critical cases for observation. Demustardize if this has not been previously and thoroughly done. Administer oxygen if available when indicated. When patient is fit for transportation, evacuate to the rear. 435 TM 8-220 376-381 MEDICAL DEPARTMENT Section IV MEDICAL CARE OF CHEMICAL CASUALTIES Cases requiring hospital care 376 General nursing care 377 Treatment of shock 378 Clothing 379 Position of patient 380 Observation 381 Diet 382 Nursing of cases 383 Paragraph 376. Cases requiring hospital care.-—Any patient suffering from disability due to the action of a chemical agent should be treated in hospital whenever and as soon as possible. This is particularly true if the patient is also suffering from a wound. 377. General nursing care.—Patients suffering from injury from chemical agents are usually both physically and mentally depressed. They must be handled with both gentleness and firmness. All ordi- nary nursing cares must be intensified. All precautions must be taken to prevent infection and pressure sores (bed sores, etc.). The eyes must receive earliest possible attention. Pure air and rest are essen- tials. All strain on the heart and lungs must be avoided or relieved. In general, the treatment must be carried out in accordance with the patient’s condition. It is impossible to give specific directions cover- ing all cases. Common sense is needed. 378. Treatment of shock.—As all patients of this kind are suf- fering from some degree of shock, the first essentials are warmth, complete rest, and fresh air. They should be reassured as soon as possible that their troubles, however trying, are temporary; above all, they must be encouraged to be hdpeful. 379. Clothing.—Both the clothing worn by the patient and the bed clothing should be light, loose, and warm. Pillows should be arranged according to the degree of shock and the comfort of the patient. 380. Position of patient.—See paragraph 379. In order to allow the escape of fluid from the mouth, the patient’s head and shoulders should be supported and turned to one side. There should be hot-water bottlfes, back rests, rubber sheeting, etc., according to the needs of the individual. 381. Observation.—Each case requires constant observation be- cause of the necessity of reporting immediately any alarming or new symptoms. 436 TM 8-220 SOLDIER’S HANDBOOK 382-383 382. Diet.—The diet should be liquid, warm, and nourishing. If the patient vomits, there should be copious draughts of warm water and sodium bicarbonate (cooking soda) (a level teaspoonful to 1 pint of water). Thirst is not an outstanding feature. Patients must therefore be encouraged to take sufficient fluid. 383. Nursing of cases.—a. Tear gas.—These cases are unlikely to be admitted to hospital, and even if admitted the effects of the tear gas are so transient that usually no nursing problem arises. The pa- tient can usually bathe his own eyes with plain warm water. Where time permits, a drop of olive oil, mineral oil, or castor oil may be dropped into the eyes. h. Nose irritant.— (1) Such cases are usually so slightly severe that they do not reach the hospital. However, if the exposure to the gas has been abnormally long or severe, there may be such complications as mental depression, occasionally leading to suicidal tendencies. (2) The initial coughing and sneezing may be followed by dizziness, occasionally merging into unconsciousness. Patients are often men- tally dulled, indifferent, and disinclined to exert themselves. (3) A possible early complication is a temporary paralysis of the limbs. This soon passes off. The weight of tile bed clothes should be supported by bed cradles. (4) Later, sometimes after about 4 days, there may be numbness or shooting pains in the arms and legs. Such symptoms may cause alarm because one may think that they arise from injuries other than poisoning by nose irritants. (5) In addition to ordinary nursing care, some patients are relieved by nasal douching with a weak solution of sodium bicarbonate (cook- ing soda), a level teaspoonful to a pint of water. The same solution may be used as a gargle or may be administered internally. (6) Symptoms of arsenic poisoning may be suspected. They in- clude restlessness, irritation of the skin or mucous membrane, pain in the throat and abdomen, nausea, etc. c. Lung irritant.— (1) All such cases must be admitted as litter cases, and require complete rest, with sparing of all exertion, extreme gentleness in handling, and constant attention. The condition of the patient on admission depends on the degree of lung damage already developed. This damage, as it develops, causes difficulty in breathing and heart strain, (2) The clinical picture depends upon the degree of the edema of the lungs that has been produced. In an advanced case the face and neck are flushed and blue (cyanosed) and the respiration appears forced and difficult. Patients with such symptoms are sometimes called the 437 TM 8-220 383 MEDICAL DEPARTMENT “blue type.” Unless this condition is checked, heart failure results. This is indicated by an increased pallor. This stage is sometimes described as the “grey type.” (3) The administration of oxygen is always indicated. Venesection (blood letting) followed by intravenous adminis- tration of saline solution may be indicated. (5) Sedatives may be ordered, but morphine is contra-indicated since it may tend to depress the respiratory center (the area of the brain that controls breathing). (6) Heart stimulants, such as hypodermic injections of camphor or pituitrin, may be ordered. (7) "Raising the foot of the bed, a few minutes at a time, sometimes relieves the “waterlogging” of the lungs by assisting the patient to get rid of the exudate. d. Blister gas.—(1) First-aid measures.—See paragraph 366, (2) Objects.—The nursing of such cases has three main objects: (a) The prevention of secondary infection. (b) The healing of actual injury. (c) Suggestion and tactful firmness to combat the patient’s tendency to mental depression. • (3) Delayed action.—Remember that the effects of blister gases are delayed for periods varying from 2 to 48 hours. (4) Eyes.—(a) The patient must be reassured that his sight will not be lost. Severe inflammation results from contamination, either by the vapor or the liquid chemical agent, the latter being more serious. The conjunctivae may be so swollen as to protrude between the swollen and edematous eyelids. The discharge soon becomes pussy. (b) Treatment should be immediate. It consists of frequent and copious irrigation with a warm solution of sodium bicarbonate (cook- ing soda), a level teaspoonful to a pint of water. This is followed by the instillation of a few drops of olive oil, mineral oil, or castor oil. The eyes should not be bandaged, but an eyeshade may help. Drops of a 2 percent solution of argyrol or protargol may be ordered. Fre- quent bathing or hot applications outside the lids may help to relieve the pain. (5) Nose and throat.—{a) Sneezing, coughing, and hoarseness may be eased by gargling and douching with any bland solution, spraying with any suitable antiseptic solution, or by inhaling steam from a pint of boiling water containing a teaspoonful of a mixture of menthol (10 grains) in compound tincture of benzoin (1 ounce). Patients should breathe through a perforated mask (pad of gauze 438 TM 8-220 SOLDIER S HANDBOOK 383 moistened with an antiseptic and pain-deadening mixture prescribed by a medical officer). {h) Secondary bronchitis or broncho-pneumonia may occur in cases showing damage to the respiratory tract. Therefore, when practi- cable, treat such cases in a separate' ward. Table II.—Identification of chemical agents Chemical agent Symbol Odor Other immediate effect Chlorine CL Disagreeable; pun- gent. Choking; coughing; dis- comfort in chest; smart- ing of eyes. Mustard gas HS Garlic; horseradish _ _ None. Ethyldichlorarsine ED Biting; irritating Nasal irritation. Phosgene CG Silage; fresh cut hay_ Coughing; tightness in chest; eye irritation. Chlorpicrin PS Sweetish; flypaper Flow of tears; nose and throat irritation; vomit- ing. Adamsite DM No pronounced odor. Headache; vomiting. Diphenylchlorarsine _ _ DA No pronounced odor. Sneezing; vomiting; head- ache. Chloracetophenone CN Locust or apple blos- soms; ripe fruit. Flow of tears; irritation of skin in hot weather. CN solution _ CNS Sweetish; flypaper Flow of tears; irritation of skin. Brombenzylcyanide __ CA Sour fruit _i__ Flow of tears; nasal irrita- tion. White phosphorus WP Matches Glow from burning par- incendiary effect. HH mixture HC Acrid__ Slight suffocating feeling. Prickly sensation on skin; Sulfur trioxide in FS Acrid (strong) _ chlorsulfonic acid. > eye irritation. Titanium tetra- chloride. FM Acrid (mild) Very slight irritation of eyes. (6) Skin.—(a) Skin should be cleansed gently with soap and warm water, and the hair on the affected areas clipped. Erythema (redness) is frequently followed by blisters which may result in ul- ceration. Every effort must be made to prevent secondary infection of these raw surfaces. (h) The itching of the early inflammation may be relieved by the application of calamine or other alkaline lotions, dusting powders, or ointments, as prescribed by a medical officer. Blisters must be 439 TM 8-220 383 MEDICAL DEPARTMENT opened under antiseptic precautions, and the blister fluid carefully removed. Dressings of old sterile linen are better than those of gauze, since the latter tends to stick. The use of oiled silk or other material that retains discharges must be avoided. The resulting scars are weak and must be protected even after healing. (7) Lewisite injuries.—Lewisite has greater rapidity of action than mustard. Penetration of the skin is much quicker, and irritation is intense. The serum from the blisters must be evacuated aseptically, the epithelium (top layer of the skin) removed, and the raw surfaces irrigated. This is done to lessen the absorption of arsenic compounds (lewisite contains arsenic). The patient’s eyes must be irrigated and the same general measures taken as described above. 440 TM 8-220 SOLDIER’S HANDBOOK 384-385 Chapter 8 VETERINARY FOOD INSPECTION Paragraphs Section I. Meat and meat products 384^389 11. Dairy and dairy products 390-395 111. Miscellaneous food products 390-401 Section I MEAT AND MEAT PRODUCTS Paragraph General : 384 Purpose of inspection 385 Scope 1 380 Inspection agencies 387 Fresh meats 388 Inspection 389 384. General.—The terms “meat” and “meat food products” as used in Army publications imply all foods of animal origin, and in- clude such products as beef, pork, lamb, poultry, eggs, fish, milk, butter, cheese, and ice cream. 385. Purpose of inspection.—a. The primary purpose of all meat food inspection is to conserve human health. The animals from which meat is obtained are subject to many diseases which are di- rectly transmissible to man (for example, tuberculosis, trichinosis, and undulant fever). During its preparation the meat may become contaminated and act as an indirect carrier of such diseases as ty- phoid fever or septic sore throat. Meats, being perishable, may de- teriorate and form toxins which are harmful to health. h. Adequate inspection insures that the meat comes from healthy animals; that it is prepared in a sanitary establishment and protected from contamination; that harmful ingredients are not added; that it is not misbranded; and that at the time of delivery (to the mess sergeant) it is sound, healthful, and fit for human consumption. These various inspection procedures are known as “sanitary inspec- tions.” c. The secondary purpose of meat inspection (in the Army) is to insure that the quality of the product complies with the contract specifications. This is known as “inspection for quality.” 441 TM 8-220 386-388 MEDICAL DEPARTMENT 386. Scope.—lt is obvious that a given piece of meat will have had a number of sanitary inspections throughout the process of its manu- facture, but only one inspection for quality is necessary and this is made at the time of acceptance from the contractor. 387. Inspection agencies.—a. Various health laws provide for the sanitary inspection of meat products. They may be Federal, State, or municipal. The Army unconditionally recognizes only the Federal inspection which is operated by the Department of Agri- culture through its Bureau of Animal Industry, Other agencies may be recognized, but only after investigation by the Veterinary Corps as to their adequacy and competency. h. A Federal law, Meat Inspection Act of 1906, requires that all meat produced from cattle, sheep, swine, or goats and which enters into interstate or foreign commerce must be inspected and passed by the Department of Agriculture. Such meat can be identified by the inspection legend which may be stamped with blue ink directly on the carcass of the animal or printed on the wrapper or embossed on the can of processed meats. Examples of this legend are shown in figure 110. c. This legend insures that, at the time of leaving the establish- ment, the meat was sound and healthful. It has no reference to quality. And it will be found only on meats made from cattle, sheep, swine, or goats. d. All meat products, as defined in paragraph 384, intended for Army use, are inspected both for quality and sanitation by the Veterinary Corps. 388. Fresh meats.—A large part of our meat requirements are used in the fresh state and preserved by refrigeration, either as chilled or frozen meat. Chilled meat is held at a temperature of 32° to 36° F., while frozen products are held at zero to —lo°. Fresh meat includes— a. Beef.—(1) Beef is the flesh of mature cattle, marketed in quarters (fore and hind) or in various wholesale cuts, such as loins, rounds, and ribs. Beef is classified, according to sex, as steer, heifer, cow, bull, and stag. The Army buys only steer beef, A steer is a bovine animal which has been castrated prior to sexual maturity. The grade of beef is determined by its conformation, finish, and quality. {a) Conformation refers to the general form of the carcass. (b) Finish is the amount, color, texture, and distribution of the fat. 442 tjvt 8-320 SOLDIER’S HANDBOOK 388 Figure 110.—Inspection legends. 443 TM 8—220 388 MEDICAL DEPARTMENT (