STANDARDS DEPARTMENT OF HEALTH AND SANITATION yNITED STATES SHIPPING BOARD EMERGENCY FLEET CORPORATION 1918 LIEUT- COL. PHILIP S. DOANE DIRECTOR CONTENTS IXTRODUCTIOX 5 HEALTH OF WORKERS GENERAL 7 EXAMINATION OF WORKERS. 7 DISEASES Communicable Diseases 9 \'enereal Diseases 9 \'accination for Smallpox and Typhoid 9 MEDICAL TREATMENT Prevention of Infection 9 Treatment of Wounds 9 STAFF First Aid Attendants and Doctors on Call 10 Resident Physician 10 TREATMENT FACILITIES First Aid Station 10 Dispensary 10 Hospital 10 Stretchers 11 Ambulance 11 Heat Prostration 11 Municipal and Private Hospitals.. 11 FIRST AID STATION Location 11 Plans 11 Equipment 12 Supplies 12 DISPEXSARY Location 13 Plans 13 Equipment , 13 Supplies 13 YARD HOSPITAL Location 13 Plans and Equipment 13 SANITATION WATER SUPPLY Source 14 Quality 14 Pressure 15 Distribution 15 Dual Connections 15 TOILETS General 16 Water Closets and Urinals 17 Privies 17 SEWAGE DISPOSAL 17 WASH ROOMS 17 DRESSING ROOMS 19 CLEANING AND DISINFECT- ANT 19 GARBAGE DISPOSAL 19 MANURE DISPOSAL 20 AHSCELLANEOUS REFUSE .... 20 INSECTS Mosquitoes 20 Flies 21 RESTAURANTS AND LUNCH- ROOMS GENERAL DESIGN 22 HEALTH OF FOOD HANDLERS 22 KITCHEN 23 FOODS 2i LUNCH-ROOM FACILITIES ... 24 LUNCH PERIOD 24 HOUSING GENERAL DFSIG.X 24 SANITARY EQUIPMENT 25 RECREATIOX FACILITIES .... 25 LAUXDRY 25 JAXITOR SER\ICE 25 APPROVAL OF PLAXS 25 736459 INTRODUCTION A healthy and energetic force of workmen is as essential to the speedy constrnction of the ships as a welMai(l-(»ut yard, prompt de- livery of materials, labor-saving machinery or e!ticient methods of work. The building and operation of ships l)y the V. S. Shipjiiug Board Emergency Fleet Corporation is the greatest industrial task ever undertaken, and being a governmental activity, the hygienic and sanitary standards under which this work is carried (»n should be worthy of adoption by private industry. The liealth of the workers also has a very direct influence upon the cost of building ships, for a dollar's worth of work should be ob- tained for every dollar paid in wages. This is not ]!(tssil)le with em- ployees in ill health or with lowered vitality. To obtain such conditions it is necessary that the principles of industrial sanitation as established by actual j)ractice sliall be clearly understood and strictly conformed to. This requires tlie expenditure of funds. l»ut experience has clearly demonstrated that the investment pays dividends. The enormous increase in the shi])]iuilding industry to meet war needs has caused a constant influx of workmen into tlie slii])yards wiio are unu.sed to the rigor and exiiosure of shipltuihliiig. This condition demands unusual care to safeguard their vitality. The above conditions liave been the guiding i»rincii>les in the prep- aration of this bulletin, and it^is hoped tliat the closest ]»ossible co- operation may be obtained between the sliipyard managers and the Department of Health and Sanitatiitn (»r the Tnited States Shipping Board Emergency Fleet Corjtoration. whereby these problems may be met and worked out in a mutual sj)irit of imrjtose to speedily build ships. HEALTH OF WORKERS GENERAL 1. The health of the worker may l>e considered from two staud- X)oiiits: (1) That which considers the hygiene of the workman, the sanitation of the plant at which he is employed and the habitation in which lie is honsed. ( 2 1 That which considers the adoption of selectiye measures, whereby only persons fitted for their work are per- mitted to enter the employ of the shipyard and who, through medical care, are enabled to keep themselyes in a condition of bodily yigor. EXAMINATION OF WORKERS 2. Many employers haye found it adyisable to determine the con- dition of health of a worker at the time he enters the employ of the company and at iuteryals afterwards. This procedure benefits both the employer and the workman. Physical examinations properly car- ried out will bring to the attention of the examining physician any communicable disease with which the applicant might be afflicted and which might be communicated to his fellow-workmen. Applicants for employment sutferiug from minor ailments or condition of ill health should not necessarily be excluded from emi)loyment, but should be given work for which they are best suited. Physical examination of workers provides also for the early de- tection of conditions which, untreated, might become serious, and the examiner is given the opportunity to indicate to those persons in which these conditions are found the remedy which will restore them to a condition of health. Whenever physical examinations are carried on it is advisable to provide and maintain especially arranged quarters for this purjiose. Such arrangement should include individual dressing rooms for appli- cants and other facilities necessary for the i)roper conduct of this work. The Department of Ilealtli and Sanitation will upon recpiest send to yard authorities a floor jilau showing the convenient arrangement of rooms and facilities for the proper carrying out of ])hysical exami- nations in an industrial establishment. The adoption of the following examination form is strongly recommended, which should be i)rinted on an S l»y 10t4-inch card and ruled conveniently: ' CORPORATION PHYSICAL EXAMINATION FOR EMPLOYMENT Name Check Xo. Xationality Address Dept. Color Date Age CHECK ITEMS APPLICANT HAS HAD MEDICAL HLSTUKY Scarlet Fever, Diphtheria, Typlioid, Malaria, Pneu- monia,Tonsilitis, Rupture, Asthma, Habitual Cough, Pleurisy, Spitting of Blood, Dizziness, Epilepsy, Paralysis, Discharge of Bladder, Kidney Disease, Syphilis, Gonorrhea, Cancer. Remarks: GENERAL EXAMIX ATIOX Height AVeight EYES Vision Distance 20 ft. Eye Diseases Right Vision Distance Right Left 1 ft. Left EARS NOSE Hear Watch Tick Right Left ft. Disease ft. THROAT TONGUE TEETH XECK SKIN Identification Marks Disease CIRCULATION Blood Examination if necessary Blood Pressure HEART Defects Compensation CHEST Girth Full Insp. Full Exp LUNGS Right Left ABDOMEN- -Girth Stomach Liver INGUINAL REGION Intestines Kidneys Bladder GENATALIA URINE Color React. Sp. (irav. Albumin Sugar SEVERE INJURIES OR OPERATIONS NERVOUS SYSTEM GENERAL INTELLIGENCE ALCOHOLISM OR DRUG HABITS ACCEPTED RECOMMENDED FOR REJECTED Examining Physician DISEASES COMMUNICABLE DISEASE o. The iiiauajiemeiit of the shipvanl should laiiiiliai-ize ilsell' with the regulations of the local and State healtli authorities which con- cern the control of communicable disease, that no employee wlio has been ill with communicable disease shall return to his w<»rk until the danger of convovinji' infection lias passed. VENEREAL DISEASE 4. The Department of Health and Sanitation is prepared to give active assistance to any shipyard management desiring to control the prevalence of venereal disease among their employees. An mquiry into the amount of disal)llity duo to venereal disease shouhl ]»rompt em- ployers of lal)or at shipyards to take all possible means to minimize the appearance of these diseases among their employees. VACCINATION FOR SMALLPOX AND TYPHOID 5. Compulsory vaccination for smallpox and optional vaccina- tion for typhoid and para-typhoid should be carried out. Typhoid vac- cine can be secured from the Army Medical School, Washington. D. C, at" five cents a cubic centimeter, and should be ordered direct. MEDICAL TREATMENT 6. The neglect of minor ailments l>y workmen often leads to pro- tracted sickness. In yards having a full-time physician, or where a physician regularly visits the yard, the worker should be given the opportunity to bring his ailment to the physician's attention. Im- mediate attention given these ailments should result in the saving of many working hours otherwise lost. PREVENTION OF INFECTION 7. Workmen should be reipiired to report for treatment all abra- sions, cuts and scratches, no matter how slight. Too great stress cannot be placed upon the necessity of keeping infected hands, hand- kerchiefs and mouth away from wounds and abrasions. Injured per- sons should be taken to First Aid Station without touching wound unless bleeding is dangerous to life! Much unnecessaiw illness and loss of time can l)e jirevented by the immediate treatment of injuries, whether serious or slight. The passage of infection and ccuitagion from one person to another can l)e largely ]>revented liy the installation of sanitary toilets, lavatories and drinking fountains. TREATMENT OF WOUNDS 8. The surgical treatment of wounds with Dichloramine-T and Chlorcosane to prevent and remove infection and reduce the period of disability is strongly recommended. Technic outlined by Dr.--Edward Martin, of Philadeliihia. is given in Appendix "A." STAFF The following are coussidered ininiiiiuni lequirenients tor the proper treatment and care of employees in the shipyard plants. FIRST AID ATTENDANTS AND DOCTORS ON CALL 9. Plants employing under one thousand men should have a first aid attendant or trained nurse for each shift and two doctors on call. First aid attendant should have taken a regular course in First Aid, and should have passed examination in same satisfactory to attending doctor. RESIDENT PHYSICIAN 10. In plants emplojiug over one thousand men a resident physi- cian should be employed and should be furnished with such assistance as the size of the plant and work to be done demands. In plants where a dispensary is required it is desirable to have a physician resi- dent in the dispensary. Plant physicians must have a license to prac- tice medicine in the State in which the plant is located. First aid treatments may be rendered by nurses or attendants. All redressings should be overseen by licensed jthysician and first aid treatment should be whenever possible. TREATMENT FACILITIES Three types of facilities for the treatment of injuries and illness at shipyards are discussed in this bulletin : FIRST AID STATION 11. The First Aid Station is the unit recommended for plants employing up to one thousand men. In no case should first aid treatment be given in the yard office. A specially assigned room should always be provided for first aid treatment. DISPENSARY 12. A dispensary is necessary for plants employing from 1,000 to 2,500 men. A First Aid Station located at a convenient point within the grounds should supplement the dispensary for each 2,500 men employed. HOSPITAL 13. The need of a i)lant hospital depends largely upon available hospital facilities in the vicinity. A plant employing a relatively small number of men, and in a situation remote from adequate hospital facilities w^ould be much more dependent upon its own resources than a plant employing many more men, but with nearby hospital facilities immediately available. With this consideration in mind each plant should make adequate provision for the hospital care of its injured employees. 10 STRETCHERS 14. Stretchers should he jtlaced in various j»arts of the yard to insure the rapid renu)val and innuediate care of the injured. AMBULANCE 15. Plants should own or have at their dis]»osal a sufficient num- ber of ambulances to insure quick transportation of patients to dis- pensary or hos])ital. HEAT PROSTRATION IG. Arrangements should be made on or near the shipways in advance for the treatment of heat prostration. A tent with tiy in which is kept a tub of cold water, ice, etc., is recommendeped with resuscitating apjiaratus, and one or more such pieces of api>aratus should be close to the shipways. Several men should be available who have been trained in the jtrone-pressure method of resuscitation. PLANS 1*J. First Aid Stations with two rooms and with four rooms are described. The two-room station combines the waiting with the office and record rooms, and the emergency with the dressing room, shown in plans for four-room stations. The two-room station is recommended for plants employing from L*()(» to 500 men; the four-room station for plants employing 500 to 1,000 men. The equijiment of the two- room station shouhl include as much as space will ixMinit-'Of that outlined for the four-room station. 11 The following floor plans are recommended for the four-room station : /^-/RS-T A/O STAT/ ON 0£fT 0/=^ HSy^LTH AA/O SAA//TATfON EQUIPMENT 20. The following eiinlpment is snggested as the miuimnm de- sired : Waiting room should contain eight chairs or efpiivalent, wash bowl and closet for stretchers. Attendant's supply room and office should contain one desk, one wardrobe, two chairs, one tiling cabinet, one typewriter with stand and adequate shelving for supplies. Emer- gency room should contain one toilet, one bed, one examining table and one glass-top stand. Treatment room should contain two di'ess- ing tables, one lavatory or sink, one small sterilizer, one cabinet, one three-basin stand, one sanitary waste can, two small glass-top tables, three chairs and two stools. SUPPLIES 21. A list of instruments, dressings, drugs and other supplies that are considered adequate will be furnished on application. 12 <»■% k\-i-\ DISPENSARY LOCATION i!2. The building in which the dispensary is located should be inside the yard and of convenient access. Where plants make physical examinations of their employees, a dispensary should be conveniently located with reference to the service or em[doyment department of the plant. PLANS 23. The dispensary should contain adecjuate facilities for first aid and emergency work and should, in general, include the provisions shown in the following diagram : EQUIPMENT 24. The completeness of disi)ensary equipment should be gov- erned considerably by available hospital accommodations. The physical examination section should consist of a waiting room, a toilet room, wdth wash bowl, six to ten dressing booths, two shower baths, an examining room, and a physician's living room with bath adjoining. The dispensary proper should include a waiting room, a physician's office, a ward of from two to ten beds, a diet kitchen, if patients are to be retained in the ward, a bath room for patients, a clerk's record and supply room, a treatment room, a preparation room, an operating room, an X-ray room and a dark room. The complete equipment recommended for any or all of the above rooms will be furnished upon request to the Department of Health and Sanitation. SUPPLIES 25. Complete drug, dressing and laboratory sui»ply lists will be furnished upon re(iuest to the Department of Health and Sanitation. YARD HOSPITAL LOCATION. 26. Whenever it is considered necessary to build hospitals they should be located outside of the plants. PLANS AND EQUIPMENT 27. Plans for hosjiitals of all sizes can be furnished by the Department of Health and Sanitation, as well as complete lists of equipment needed and estimate on cost of the same. Sample plans of hospital already constructed are available. 13 DISPENSARY LOCATION L'l'. The hiiildiii^ in whicli the dispensary is located should be inside the yard and of convenient access. Where plants make physical examinations of their emjiloyees, a dispensary should be conveniently located with reference to the service or employment department of the plant. PLANS 2o. The dispensary should contain adequate facilities for first aid and emergency work and should, in general, include the provisions shown in the following diagram : EQUIPMENT 24. The completeness of dispensary equipment should be gov- erned considerably by available hospital accommodations. The physical examination section should consist of a waiting room, a toilet room, with wash bowl, six to ten dressing booths, two shower baths, an examining room, and a physician's living room with bath adjoining. The dispensary proper should include a waiting room, a physician's office, a ward of from two to ten beds, a diet kitchen, if patients are to be retained in the ward, a bath room for patients, a clerk's record and supply room, a treatment room, a preparation room, an operating room, an X-ray room and a dark room. The complete equipment recommended for any or all of the above rooms will be furnished upon request to the Department of Health and Sanitation. SUPPLIES 25. Complete drug, dressing and laboratory supply lists will be furnished upon reijuest to the Department of Health and Sanitation. YARD HOSPITAL LOCATION 20. Whenever it is considered necessary to build hospitals they should be located outside of the plants. PLANS AND EQUIPMENT 27. Plans for hospitals of all sizes can be furnished by the Department of Health and Sanitation, as well as complete lists of equii>ment needed and estimate on cost of the same. Sample ]>lans of hospital already constructed are available. 13 SANITATION WATER SUPPLY An ample supply of clean pure water properly distributed throughout the yard for drinking and washing purposes is absolutely essential to the maintenance of health. SOURCE 28. Surface water from streams or lakes should never be used without thorough purification, except from uninhabited drainage areas. When shipyards are near a town or city having a water supply ©f established purity, and it is practical to obtain connections from the public mains, it is advisable to do so. Where it is necessary for the yard to provide a new or additional water supply, local conditions will govern the selection of the best source, and upon request the Department of Health and Sanitation will furnish advice as to the best and most economical procedure to be adopted. If shallow wells are used as the source of water supply a location should be selected where there is a positive assurance that there is no danger of soil or surface contamination within influence upon the well. The upper part of the well should be lined with tight walls which should be carried above the surface of the ground, Avhich should be graded to carry surface water away from the well. The well should be protected with a water-tight cover. If artesian wells are used, they should be driven to a sufficient depth to insure a supply of uncontaminated ground water. Artesian wells may become contaminated through soil pollution of the drift overlying the water-bearing rock, or by pollution entering the well along the exterior surface of the well-casing. These conditions should be protected against in an adequate manner. If purified water from streams or lakes be determined upon as the source of water supply, the Department of Health and Sanitation will furnish advice upon request, as to the best type of purification plant to install in each particular instance. QUALITY 29. The water should at all times be free from contamination (presence of disease germs), pollution (presence of organic matter), or not contain an undue amount of mineral matter ( such as "hard- ness," sulphur, iron or mineral salts). This condition may be obtained by selection of a projter source of supply and exercising eternal vigilance in every process of purifica- tion used and in piping the water direct to the point where it is actually used. The quality of the water should be determined at regular intervals by bacteriological and chemical analyses made by reputalde laVtora- tories. 14 Ill many cases state or local Boards of Health are able to do this work. Copies of analyses should be sent to the Department of Health and Sanitation of the United States Slii])])iii2. As the i)urity of the water sujqdy is absolutely essential to health, there should not be any connection between the mains^or pii)es carrying drinking water and those carrying nni)uritieIDISI9 t\^A<^ "Si a-A'^ N«^ q, ?vv\^ \^^ •^ '<^- Qi k ^>aW^ ^^Vli A-.- <\ '\. ViAsN .s.^r-i x; •V-^^^ •i\\^\N^ 'TOD aoiviiaa 35111 a3V05n^ ;HD3HD '\M7\ 3qYr'0WT D'/[iau kji^TUM YSfOTDA^ oaTAIDoeeA '. an A HTJASH 'HO TM3MTsrAq3a \K ^Vteb n t^ \ kkk^^^m^yrwrr ) v.- ■'\ \ \ A .^^Si ^•\>s^"?i'!ir^ f\^ ^■oo*^ ^V^"^ ' ",^' ^ '.• ^ :-A .*■■" i^ .^•A "^ ■ \-. <^- ."a- A' HOUOSTHT HOITDSe A.^n old Out >^ ^>il rVJAV "HO MA^DAia TH3M3c)MAirsrA .£ WATER CLOSETS AND URINALS 154. In toilets con tain in j;' A\ait'i- closcis and niiiials ihcrc should be at least 10 square feet of Hooi- space and (i"^Ti ^iK a\\iTi PK <^ ^-A-^^V \»-»X rV^AV -HO MA^-iDAia n^H3M3c)HA5r5J-A .CDI'^ WATER CLOSETS AND URINALS oJ:. lu toilets coiitaiiHiiiiucipaily from the restaurant or lunch rooms, and from dwelling houses if they are provided for em])loyees with families. It should be collected in covered impervious containers to avoid fly-breeding and odor nuisance and collected at frequent intervals. If the yard is near enough to a town or city haying municipal collection arrangements may be made for disposal by municipal au- thorities. 19 MANURE DISPOSAL 41. A stable ou or adjacent to the shipyard makes the sanitary care and disposition of the manure a matter of importance to prevent the development of dies with accompaming danger of disease trans- mission by them. When this condition is fonud outside the shipyard, the Department of Health and Sanitation will endeavor through proper channels to cause abatement of the nuisance. Flies are bred in decomposing materials, such as manure, and not only feed upon that material, but also upon food stuffs for human consumption. This direct connection is not only revolting to the sense of decency, but by means of their hairy legs and mouth parts they convey disease germs from the excrement to the food. Cleanliness in stables is, therefore, essential. The floors should be impervious to moisture. The manure should be frequently removed from the stalls and kept in fly-proof pits until final disposition. Such a pit should preferably be constructed with concrete bottoms and side walls and covered with fly-tight doors, so made as to exclude rain water, but so constructed as to facilitate filling and emptying the pit. Each time manure is placed in the pit, it should be sprinkled with a solution of powdered hellebore made with one-half pound of helle- bore in ten gallons of water and applied in proportion of one gallon per one cubic foot of manure; or other approved insecticide. Such solutions will largely destroy fly larvae in the manure, but will not injure its fertilizing value. The vessel in which the hellebore solution is kept should be covered to prevent horses drinking it, as it is poisonous. The manure should be removed from the pit at least twice a week in the summer time, and may be used as fertilizer, preferably applying it to land in thin layers. After removal, the pit should be thoroughly cleaned and sprinkled with the hellebore solution or other approved insecticide to kill any eggs or larvae of flies remaining therein. MISCELLANEOUS REFUSE 42. In the conduct of shipyards more or less refuse and rubbish accumulates. Such general refuse should be systematically collected and disposed of. If by burning, at locations not creating any fire hazard. MOSQUITOES INSECTS 4:5. It is an established fact that mosquitoes are the means of transmission of malaria, yellow fever, dengue and other diseases. The elimination of their breeding places and their exclusion from buildings are, therefore, essential to maintain workmen in a state of efficiency at shipyards, where mosquitoes are liable to be present. While some- 20 k times breediug places aiv entirely loeal, it is generally found that extensive areas are involved as tiie cause of the trouble. The Depart- ment of Health and ^Sanitation will use its best efforts to enlist other officials and bodies to co-operate in plans for mosquito elimination in the territory about the shipyard and the dwellings of employees. Low land on which water collects in stagnant pools should be filled in with ashes, earth excavated from adjacent high ground, ma- terial dredged from in front of the ways or other suitable inorganic material. This materially minimizes the menace. ^yhere not i)ractical to fill in Ioav land, drainage ditches should be made to carry the water away or connected with tide water to induce currents in the water in the ditches. The surface of quiet water may also be oiled, which, if done efficiently and continuously will destroy the mosquitoes during their larva stage. Sufficient oil should be applied to cover the entire sur- face with a thin film. As the oil is volatile it Avill disappear in a few days or wind may destroy its elficacy. Frequent api)lications of oil are therefore necessary. No body of water is too small for mosquito breeding. Street ditches with flat or uneven bottom form favorable breeding places for mosquitoes and should be avoided where possible. Rain water collecting in depressions in the ground or in empty cans, inlets to sewers, etc., and water stored in cisterns or barrels all form a mosquito menace. Water tanks should be protected with mosquito- tight covers or contents covered with oil. To prevent mosquitoes gaining access to buildings all doors, win- dows and other openings should be thoroughly screened with at least No. 16 (16 meshes per inch) wire netting, excepting where the yellow fever mosquito may appear in which case at least No. 18 screens should be used, FLIES 44. As has been stated above under "stable refuse," the fly is a serious menace to health. It affords a direct means of communication from excrement and other filth to food stuff's. The principal measure required for fly elimination is cleanliness. All garbage, manure, and other decomposable matter should be pro- tected from flies until final disposal in a sanitary manner. Even where care is exercised to prevent fly breeding it is ditficult to entirely eliminate them anosed industrial villaues. 25 APPENDIX "A" TECHNIC OF THE TREATMENT OF INFECTIONS AND INFECTED WOUNDS WITH DICHLORAMINE-T-CHLORCOSANE PREPARED BY DK. ED^yAKD MARTIN University of Pennsylvaxia, Philadelphia THESE ARE THE CHARACTERISTICS OF A GOOD SURGICAL DRESSING: 1. It i8 easily, quickly and painlessly applied. 2. It is easily and painlessly removed, without causing bleeding. 3. Its removal is not followed by discharge of retained exudates. The following technic is suggested by a group of surgeons who have been intensively studying Dichloramine-T and who have clinically used it on more than fifteen thousand patients. The re- sults are habitually better than those following the use of any other antiseptic agent. DICHLORAMINE-T AND CHLORCOSANE ARE SOLD SEPARATELY, IN BULK BY The Abbott Laboratories, Chicago, New York. E. R. Squibb & Sons, New York. Monsanto Chemical Co., St. Louis. Robert McNeil, Philadelphia. BooTS^ London, England. To the surface of wounds to prevent sticking either Parresined Lace-Mesh (Abbott), or wide meshed, good quality paraffined mos- quito netting may be applied. The mosquito netting is cut in strips two inches wide and six inches long. Without removing the starch or sizing, it is sterilized ; is then steeped in hot paraffine wax (melting point 45 degrees C. ) , is drained out so that the meshes are open ; cooled; and wrapped, six in a ])ackage, in sterile, waxeu (paraffined) paper, then in sterile gauze and so kept ready for use. 27 The pieliminarv washing of the skin is by sterile five per cent. Castile t^oap Solution, or sterile neutral socliiim soap solution. (Abbott 1. PREPARATION OF DICHLORAMINE-T-CHLORCOSANE SOLUTION: Put the Dichloramine-T in a perfectly dry mortar and add suf- ficient Chlorcosane, constantly triturating, to form a pasty mess. Then add the balance of Chlorcosane (with constant stirring) to complete mixture. When this is done, transfer to an amber colored, glass stoppered bottle, occasionally shaking, until a clear solution" results. It is then ready for use. (Several hours). Dispense in perfcctl/j dry dark amber bottles, glass-stoppered and bearing the date of preparation on the label. Avoid exposure to direct sunlight. Providing it be kept in the dark, and does not come in contact with anything except the glass of the container in which it is dispensed, this solution may be kept for two months. If a heavy white precipitate has formed at the bottom of the bottle, discard the contents, thoroughly cleanse the bottle with Chloroform, dry, and refill with fresh solution. A slight precipitate need not be considered, but may well be removed by filtration through dry filter paper. A chilled solution may become turbid, but clears on warming to 80 degrees C. ; if the cloudiness and the deposit remain after this heating it denotes a decomposition and loss of strength of th-e Dichloramine. Solutions poured out into open vessels for immediate use must not be returned to the stock bottle; nor should swabs, pipettes, or nozzles be introduced into any stock container. Decomposition once started progresses rapidly. Water and an excess of light or of heat are fatal to slock solutions. SURFACE APPLICATION The oily soluli(»n max be swabbed, dropped from medicine drop- per or small bottle, or squirted from an all-glass syringe. If a spray be used it must be all-glass and to vaporize the heavy oily solution must be especially constructed. It is usually out of order. All these implements must be strictly dry before being used and must be cleaned after use with chloroform. Eaw and granulating surfaces treated by Dichloramine-T-Chlor- cosane are covered with strips of jiarresined lace-mesh or paraffined mosquito netting overlapping the surrounding sound skin. Over these strips is placed a thin gauze dressing held in place with as few turns of gauze bandage as will suffice to retain it. and make even moderate pressure. 28 DEEP APPLICATION The solution may he s\\al»l»('(l. iiouicd. dropped, or in the ease of sinuses, injected l»y means of an all-glass syringe litted to a 16 F. soft iiibliei- catheter, oi- to a hmg glass ])ii)ette or nozzle. If the wound be infected it should be kei)t open by a strip or strips of parresiued lace-mesh or i)arariiued niopquito netting. This is cut to appropriate width and folded once cross-wise. The angle made by this fold is pressed to the deepest part of the wound, thus lining all raw surfaces. In the space enclosed by this lining is loosely laid sterile gauze, well soaked in Dichloramine-Chhncosane. In this way the wound is kei)t widely open by a dressing which thoroughly drains and comes away without causing pain or bleeding. All wounds call for: (fl) Cleanliness. (&) An Abundant Supply of Constantly CHANciiNG Blood. (c) Eest. (A) CLEANLINESS This is most essential in the deepest part of the wound, and is impossible to secure or maintain in the presence of dead tissue or foreign bodies. A fresh wound (within six hours) is cleansed in the following manner: It is tightly packed with gauze soaked in Dichloramine- Chlorcosane; the surrounding skin is then rapidly and vigorously rubbed clean with gauze wet with sterile Castile (or neutral sodium soaj)) solution. This, in turn is scrubbed away with gauze wet with ether, a moment Is allowed for this to evaporate, when the skin is tinally swabbed with Dichloramine-Chlorcosane and wiped dry again with sterile gauze. The tight Dichloramine-Chlorcosane packing is then removed from the wound and the latter is cleansed by swabbing with Dichlo- ramine-Chlorcosane both before and after the removal of obvious dirt, and the excision of badly bruised or dead tissues. Incised icomids, after cleansing, are closed by w idely interrupted sutures going to the depth of the wound, and scniiring ai)itosition of raAv surfaces without suture tension. A blanched skin about a sutvire j)ractically assui-es death. Pressure Necrosis. Contused and lacerated, wounds, after (deansing with Dichlo- ramine-Chlorcosane, and resection of (hnilalized skin and deei>er tis- sues (freely bleeding and clean, healthy surfaces being the signs of vitality) are also closed l»y widely placed, interrui>ted s\itures going to the bottom of the wouiul. or by catgut layer sutures. 29 Such woundts are closed only when this can be accomplished without tension ; otherwise they are kept open wholly or in part by a strip or strips of lace-mesh or of paraffined mosquito netting folded crosswise, the fold being carried to the deepest part of the wound and the angle made by it being lightly filled with the gauze soaked in Dichloramine-Chlorcosane. Infections (boils, abscesses, carbuncles, etc.) are treated, after surface cleansing with sterile soap suds, ether and Dichloramine- Chlorcosane, by oi»enings so placed and so free that more than twice the access deemed desirable is atforded. (An infection treated by too large an incision is a surgical rarity; one treated by too small a cut is the rule ) . These incisions should not include tlexure creases of the palm and fingers. The cavity is then flushed with Dichloramine-Chlorcosane and drainage provided by means of folded strips of parresined lace-mesh, or of paraffined mosquito netting, carried to the deepest part of the wound, the folds being lightly filled with gauze soaked in Dichlora- mine-Chlorcosane. Large granulatin