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LECTURES

Military Sanitation and Manage*
ment of the Sanitary Service

— ^

ARMY SERVICE SCHOOLS

SPECIAL REPRINT FOR OFFICERS' TRAINING CAMPS

GOVERNMENT PRINTING OFHCE

WASHINGTON

1917

LECTURES

Military Sanitation and Manage-
ment of the Sanitary Service

U . ^ ARMY SERVICE SCHOOLS

SPECIAL REPRINT FOR OFFICERS' TRAINING CAMPS

GOVERNMENT PRINTING OFHCE

WASHINGTON

1917

u^^

?'0L06Y

CONTENTS,

Lecture I. [Military hygiene 5

II. Militarj' hygiene 23

III. Military hygiene 37

IV. The sanitary service of the march in campaign 56

V. Sanitary service of the camp 69

VI. Sanitaiy service in combat 84

VII. Sanitary service in combat, station for slightly -vrounded 97

3631G2

LECTUEE I.

MILITARY HYGIENE.

Hygiene is a science which deals with the preservation of the health.
Its existence depends on past scientific discoveries. Sanitation is
the method which is adopted to carry out the principles of hygiene.
Stinitary methods may differ, but yet be effective, m the same way
that many problems m geometry may be solved by different methods.
Sanitation, therefore, is the application of scientific discoveries to
prevent disease. "IMihtary sanitation'' should be used instead of the
words ''military hygiene "'as hygiene covers all principles to insure
health and the application of these principles in the mihtary service
is the method of deahng with men livmg under conditions somewhat
foreign to those that civihzation has caused to exist.

A medical officer has many duties to perform. There is hardly
anythhig pertauiuig to a soldier that he is not in some way required
to make recommendations or act on his own initiative, but his prin-
cipal duty in time of war is to initiate the proper sanitary measures,
and without your intelUgent help as officers he will not be entirely
successful. The greatest achievements toward mihtary efficiency
in our Army so far have been accomphshed by the Medical Corps by
scientific discoveries and theh* appHcation, and the officer who is
now in command of men, and who does not give this subject the
proper attention must necessarily be a failure.

In all the wars that history records (possibly with the exceptions
of the Russo-Japanese War, and the present disturbance abroad)
much more disabihty and many more deaths have resulted from
disease than from wounds. The failures of armies on account of
preventable diseases are not few. Arnold in 1775 was unsuccessful
because smallpox and dysentery incapacitated the command. In
1802, 15,000 of Napoleon's aimy perished in Santo Domingo of
yellow fever and other preventable tropical diseases. The British
in the Crimea lost twenty-five times more men from disease than from
womids. In the Spanish- American War there were seven times more
deaths from sickness than was caused by the enemy. During the
Balkan wars cholera in the Bulgarian Army and typhus fever in Ser-
bia during the present war greatly influenced the results of the attack
in the former, and the defense of the latter.

8 MILITARY SANITATION AND SANITARY SERYICE.

Height, weight, chest. — In the absence of actual diseased condi-
tions the physical attributes which chiefly determine the acceptance
or rejection of an applicant for enlistment are the height, the weight,
and the chest measurements. In normal individuals these bear a
fairly definite relation to each other, which relation is set down in
official tables. Men whose chest circumference, at rest, is below 32
inches should not be accepted, for such a chest has not sufficient air
capacity. The present minimum of height is 5 feet 4 inches. The
question of height is not quite so important now as in the days of
shock action. Other things being relatively equal, the smaller man
is generally quicker in his movements and has more endurance. In
these days of specialism we might well accept vigorous men who are
a little shorter than the present requirement for special service, thus
releasing others of standard height for the fighting line. With respect
to weight, men of the 'Viry" type may be accepted when they are
but a few pounds under the standard, but the mistake must not be
made of confusing these with cases of defective or arrested develop-
ment. Li these latter, deficiency in weight, pallor, flabby muscles,
a flat chest, sloping shoulders, and generally poor physique denote a
feeble constitution.

Records. — It is essential, for the protection of the Government,
that careful records be made (a) of aU departures from the normal,
including minor ones which are not considered disqualifying, and (b)
of means of identification. The fii"st is needed as a defense agamst
unjust claims for pension. The second leads to the detection of crim-
inals, deserters, bomity jumpers, and dishonorably discharged men
who enlist fraudulently.

Depots. — Owing to the widespread derivation of recruits, depots
for their coUection and training are frequently afflicted with one or
more kinds of contagious diseases, brought by some who have con-
tracted them elsewhere. It has sometimes happened that measles,
mumps, or some other commmiicable disease has developed in parties
of men sent from depots during the trip or shortly after arrival at
their destination. Ai'my posts have thus been frequently infected,
whfle the health of the traveling public has been endangered. If,
therefore, such a disease exists at depots, the men who have been
exposed to contagion should be isolated, in separate squads, until the
period of incubation of that particular disease is past If a case
develops in any one squad, none but members of that squad have
been exposed to it and the othei"s may safely be forwarded. A similar
procedure is advisable in camps.

Vaccination. — One of the first requirements after the enlistment
of a man is to have him vaccinated against smallpox and typhoid
fever. This is a very important procedure, lookmg to his future
health and that of the Ai-my.

MILITARY HYGIENE. 9

PERSONAL HYGIENE.

Nature and importance. — Personal hygiene means preserva-
tion of health by attention to the care of the body. It is obvious
that such care is essential to keep the physical character of the soldier
up to the proper standard. Napoleon is reported to have said: "The
most important quality of the soldier is his ability to support fatigue
and privation; physical courage is only second." Whether or not
this be true, it must be apparent to any thinking individual that
personal merits, includmg courage, are of little avail to the military
man if he has not bodily vigor.

Formation of correct habits. — Military efficiency in an indi-
vidual, then, rests upon certain considerations, chief among which
are health, strength, and activity. To secure and keep these qualities
it is essential for every man to form such habits as experience has
shown to be necessary. These habits are: Personal cleanliness; regu-
lation of diet; avoidance of excesses (particularly in eating, drinking,
and sexual matters); wear^g suitable clothing; keepmg the bodUy
processes at work (kidneys, bowels, skin) ; taking sufficient exercise,
preferably in the open air; devoting a proper part of each day to rest
of the body and mind, with recreation for the latter; maintaining the
surroundings in which one fives in a cleanly state.

Personal cleanliness. — The maintenance of personal cleanli-
ness is even more necessary in the military service than in civil fife.
Tliis is due in part to the violent exercises requh'ed of the soldier,
with the resultant dirt and sweat, but especially because so many
five together within a small space.

Baths and bathing. — The most important requirement to insure
cleanliness is bathing. Baths are necessary partly to rid the skin of
external impurities, but chiefly to keep open the pores, which are the
mouths of the sweat glands, whose product carries away large amounts
of waste and poisonous matters from the blood. Each man has a
preference for a certain temperature of the water in which he takes
his bath; this varies from freezmg to hot, A cold bath is stimulating
and is to be preferred for a vigorous man, provided he "reacts" well
and feels a glow on emerging from the bath and rubbing down.
The cold bath is not suited to elderly men nor to those whose circula-
tion is poor. The proper time for cold bathing is on arising in the
mornmg, not at bedtime, as sometimes indidged m.

It is worthy of mention that the practice of cold bathing often
breaks up the habit of "taking cold," to which certain people are
liable.

Hot and warm baths are soothing and best remove surface dirt;
they are grateful means of reducing muscular soreness after exertion,
and will often induce sleep in a restless, wakeful person.

10 MILITARY SANITATION AND SANITARY SERVICE.

The most desirable means of batliiiig is perhaps in a tub in which
he whole body may be immersed ; in default of this, and particularly
in barracks, the shower bath is very satisfactory. If means for com-
plete bathing are not available, careful attention should, in any event
be given to the daily cleansing of the armpits, crotch and feet, as well
as the hands and face. The hands should be washed after defeca-
tion and urination, lest they convey disease germs. The nails must
be well kept and clean. On the march, if no water is available,
a vigorous "dry rub" with a coarse towel will be found refreshing as
well as cleansing. The scalp should be washed at least once or twice
a month and should be stimulated daily by brisk rubbing with a
brush or the fingers.

Care of the teeth. — Every man should own a good toothbrush
and use it with a tooth powder or mild antiseptic (listerine, for in-
stance) at least twice a day. If no tooth powder is available, wood
ashes or wood charcoal make efficient substitutes.

Clothing. — Since clothing (especially the underwear) when soiled
with sweat and dust is irritating to the skin and gives off disagree-
able odors, it is necessary to keep this as clean as the body. The
soldier can not keep his person clean if his garments are filthy. There-
fore, whenever possible, the soiled clothing should be washed (and
with soap if it can be had). If the articles are of wool, they should be
washed in cold water and dried without wringing. On the march
a man should have two suits of underclothes to wear on alternate
days, thus insuring cleanhness if the garments are regularly washed.
If, at the end of the day's march, water is not available for this pur-
pose, the gamients should be dried, then beaten or well rubbed, and
hung up in the air.

Skin diseases. — In campaign, skin diseases due to animal para-
sites, especially lice and the itch mite, usually make their appearance
and cause much disgust and discomfort. They must be watched for
and report of their presence promptly made to the medical officer.

Diet. — In the soldier's life the diet is, of course, regulated as far
as possible by the authorities who design and issue the ration and
train the cooks by whom the articles composing it are prepared. In
campaign, mifitary considerations may necessitate cutting away from
the base of supply, so that soldiers are obliged to five on the resom'ces
of the country in which they are operating or even to subsist for a
few days upon the emergency ration. Every soldier should bo re-
quired to learn how to prepare his individual field ration, since the
necessity for this frequently occurs in field service.

The character of the food taken should vary in accordance with
the conditions of bodily vigor, occupation, chmate, and food values.
A vigorous man, doing heavy work, requires more nourislunent than
one of delicate physique following a sedentary pursuit. Climate is

MILITARY HYGIENE. 11

an important factor. Mon serving in Alaska need a large amount of
fats to serve as fuel in maintenance of the temperature balance.
Those on duty in the PhiUppines require a large proportion of
sugars and starches.

Dietary don'ts. — A few general dietary principles follow, which
may perhaps best be expressed in the form of prohibitions :

Don't eat hurriedly.

Don't swallow a morsel till it is thoroughly broken up and mixed
with the saliva by chewing.

Don't overload your stomach, but get up from the table feeling
that you could eat a little more with relish.

Don't eat unripe or overripe fruit.

Don't eat anything, while away from camp or barracks, whose ma-
terials or mode of preparation may seem questionable.

Don't bring worry or a "grouch" to table with you.

Excess in eating. — ^Overeating gives rise to biliousness and other
forms of dyspepsia and overloads the body tissues with waste mat-
ters. These wastes are irritant substances and are just as likely as
alcohol to cause kidney disease, gout, obesity, and hardening of the
arteries. Beefy, overfed men are especially liable to apoplexy.

Excess in drinking means, to us all, overuse of drinks containing
alcohol in some form. You will learn that the great majority of
violations of discipline, trials by courts-martial, and subsequent
punishment in our Army result from this particular excess. Habitual
indulgence in alcohol brings, as certain rewards, a host of physical
and mental ailments. Besides weakening men physically, alcohol
tampers with their will power and makes them less trustworthy even
when sober.

Sexual indulgence. — It is the popular idea that a yoimg man
must exercise the sexual function to some extent in order that he may
retain his vigor. This belief is not founded on fact, for the sexual
act is not necessary to preserve the health or powers of a man. Not
only is this true, but it is equally true that sexual indulgence by
yomig unmarried men is responsible for an immense amount of dis-
ease and suffering. This disease and suffering is borne not only by
the men themselves, but, in a large proportion of cases, by the inno-
cent women whom they afterwards marry and by their children.
The wives may be, and often are, infected years after an apparent cure
has resulted and the children are bom diseased.

Clothing. — The prime purpose for which clothing is worn (other
than that of decency) is to afford protection to the body against ex-
tremes of cold and heat. The materials used should, therefore, be
such as to conserve the natural warmth of the body or to aUow it to
escape freely, in accordance with weather conditions. Clothing

12 MILITARY SANITATION AND SANITARY SERVICE.

should not bo permitted to interfere with the circulation of the
blood, nor with the normal movements of the body.

Excretory functions. — Our bodies, in the work their various
parts must perform, manufacture certain waste products which we
call excretions. Now, it is evident that if we do not get rid of these
substances, they will clog up the body or even act as poisons. Nature
has, therefore, designed certain avenues of escape for these excretions,
and the chief of these are the skin, the kidneys, the bowels, and the
hmgs. The importance of the skin has already been dwelt upon.
The kidneys can best be kept in good condition by drinking plenty
of water (at least 6 or 8 glasses a day), which flushes these organs and
dilutes the solid impurities of the urine. Constipation induces a
variety of uncomfortable conditions, among which piles, headache,
the state often called "biliousness," and mental depression are fre-
quent. Therefore, remember to keep your bowels open.

Lungs. — Tlie lungs are an important avenue of escape for jcertain
waste products, cliief of which is carbon dioxide. The ventilation of
living rooms thus becomes desirable to dilute or carry off these wastes,
to renew that most vital element, oxygen, and to prevent overheated
and undue moisture of the atmosphere, which latter are important
f actoi-s tending to the diminution of vitality. The germs of diseases
which affect the respiratory tract are thi*own off into the air and are
hkely to be breathed by healthy individuals, who are thus in turn
infected. "Colds" result more often from overheated, poorly venti-
lated rooms than as the result of drafts and chilhng. Such colds are
often- contagious. The transmission of tuberculosis and such acute
infectious diseases as measles, scarlet fever, influenza, and whooping
cough is favored by poor ventilation.

Exercise. — A sufficient amount of exercise to maintain health is
ordinarily provided by military drills and other duties requiring active
movement. Nevertheless, the physical condition is f ui'ther improved,
muscular size and strength greatly increased, and the mental outlook
rendered more cheerful by athletic exercises, whether in the open air
or the gymnasium. A proper appreciation of the benefits of physical
exercise may be gained by a mental comparison between the rugged
condition of a man who exercises regularly and the poorly-developed
muscles and shallow skin of another who has some occupation which
keeps hira indoors at work of a light sort. The improvement is
brought about by the increased activity not merely of the muscles,
but of every part of the body, including the heart, lungs, skin, digestive
apparatus, etc. Like all good things, however, exercise may be over-
done; excessive rapidity or irregularity of the heart's action and la-
bored breathing are warnings to stop and rest. Soldiers in campaign
especially immature boys, who are sometimes enlisted are very liable
to heart strain and an "irritable" condition of that organ.

MILITARY HYGIENE. 13

Artekies. — "A man is as old as his arteries," and some men grow
old in this respect much sooner than the average, so care must be
taken to suit the exercise to their condition.

The amount and kind of exercise best suited to each must be deter-
mined, as these vary widely in different individuals. There are men
who require the equivalent of a brisk 15-mile daily walk to keep in a
satisfactory physical state, while the ordinary occupation of others
sullices to maintain them in excellent health.

Rest. — For the repair of damaged tissues and the relief of fatigue
a certain amount of rest for both mind and body is necessary. Differ-
ent people vary considerably in their requirements, but it may be
set down as a fair average that 8 hours of sleep in each 24 hours are
needed to keep the faculties at their best. In addition work of any
sort, physical or mental, must be intermitted by brief period of relaxa-
tion. Mental overwork is very common in these days of complex
civihzation, and exhaustion of the nervous system (neurasthenia)
takes a long time for its recovery.

Recreation. — The risk of overtaxing the mind is greatly lessened
by measures of recreation, which may take any proper form most
agreeable to the individual. The cultivation of a fad is of especial
value. The habit of worry, of ''crossing bridges before one comes to
them," must be avoided. Fits of ''the blues," if yielded to, tend to
increase in number and length and finally to unfit one for work. In
garrison, on transports, and particularly in winter camps during war
time we must make provision for measures of recreation. These are
essential to promote cheerfulness and contentment and to lessen the
tendency to abuse of alcohol and tobacco, gambling, and perversion
of the generative function. Entertainments of aU sorts, but more
particularly those participated in by the men themselves, compe-
titions and contests, reading rooms, and opportunities for following
and learning mechanical trades must be provided.

Cleanliness of surroundings. — It is not sufficient merely to
keep our bodies in a state of cleanliness by the measures previously
outhned. We must also keep our surroundings — the house and
grounds in which we live — ^well "poUced," as the expression goes in
our mihtary service. It is self-evident that where people five — ■
especially where many people are congregated in a small space —
there much dirt wiU collect. This refers not so much to earthly
particles as to the so-caUed organic materials which are derived
from animal and vegetable sources. Under this head faU the body
discharges, refuse from the kitchen, decaying flowers and weeds,
cigar stubs, floor and stable sweepings, and the hke. These must be
received in vessels specially kept for them and frequently removed,
or they give off foul odors, poUute the ground, attract hosts of flies,
and act as breeding places for the germs of chsease.

14 MILITARY SANITATION AND SANITARY SERVICE.

PREVENTABLE DISEASES.

In the first place, the fact must be recognized that there are no
diseases peculiar to soldiers. There is not, by reason of their occu-
pation or mode of life, any abnormal physical condition engendered
which has not its counterpart among civihans. On the other hand,
there are certain departures from a state of health to which soldiers
are especially hable because of their work and envii'onment. Newly
raised troops and recruits^ generally have the highest disease rates.
Old soldiers are inured to service and have learned how to care for
themselves.

Dependency of soldiers. — ^''The men who compose an army are
drawn from civil hfe, in which each individual has, to a greater or
less extent, independent control of his time, choice of occupation,
selection of food and dwelling place, and general sanitary care.
After erdistment, soldiers lose most of this independence; they are
housed, clothed, fed, and exercised under regulations which it is be-
yond their power to amend; they are moved from one point to an-
other, differing perhaps very widely in climatic and other conditions,
under orders which they may not presmne to question; their hours
for sleep, meals, work, and recreation are fixed for them without
consultation with them or without regard to individual or com-
munal preference." (Harrington.)

Inexperienced soldiers. — ^In our mihtary system the absolute
dependence on the wiU or neglect of a superior is especially prone to
result in disease conditions, because of the ignorance and inexperi-
ence of mihtia and volunteers suddenly called into active service.
The officers have Httle or no knowledge of the care of troops, while
the men exhibit a recklessness and disregard for the laws of health
peculiarly national. The American volunteer, unless firmly com-
manded, displays the utmost incUfference to the ordinary rules of
decency. He deposits his excrement where he happens to be; he
drinks of any hquid he encounters which may be dignified by the
name of water; he thi-ows his wastes indiscriminately upon the camp
ground, heedless of the fact that putrefactive changes wiU shortly
make them offensive; he gleefully seeks opportunities for alcohohc
and sexual excesses; and, in defense of his heaven-born liberties, he
often declines to mend his ways because he enlisted to fight and not
to perform menial occupations. The necessity on the part of fine
officers for familiarity with the preventable diseases to which the
soldier is Hable and with the fundamental sanitary principles neces-
sary for their prevention thus becomes apparent.

Venereal disease. — Of all the ills from which the soldier suffers,
those consequent upon venery affect his efficiency to the greatest
extent. Om- Army is made up mainly of young, unmarried men
freed from the moral restraints of home, often without opportmiity

MILITARY HYGIENE. 15

for association with decent women and susceptible to the suggestion
of the vicious. There must be some outlet for their siu-plus energies.
They visit places of amusement, many of which are maintained with
the sole object of pandermg to vice, where strong hquor and the
advances of lewd women combine to break down such moral defenses
as they may possess. Unless prevented by legal enactment the low-
est kinds of "dives" cluster round the entrances to Army posts.
The soldier has a right to his amusements, and we must strive to
furnish such as will attract him more than evil resorts, to secure the
passage of laws preventing the estabhshment of low brothels at our
gates, and to build up the moral stamina of our men by education.

Statistics show that at least a third of all women who give their
bodies for immoral purposes are suffering from some form of venereal
disease. This includes not merely the professional prostitute, but
the chorus girl, "saleslady," or mill hand, who, to satisfy her love
for finery or for other reasons, may eke out a scanty income by
occasional lapses from virtue. It is a medical axiom that every
prostitute becomes infected with syphihs inside of two or three years.
It is therefore easy to see that the risks of contagion are very great.

Tlie American people have, xmtil recently, shunned pubhc discus-
sion of venereal matters through what may now seem to have been
mistaken prudery. A great movement has lately been instituted,
through the American Association for Sex Hygiene and allied societies,
looking to the awakening of the pubhc conscience and the moral
education of the youth of the land.

Prevalence in the Army. — Venereal infections are responsible
for an enormous amount of sickness in the Army— vastly more than
any other cause — and constitute the most important health problem
with which we have to deal. There are constantly on the sick report
from this cause a number of men which more than equal the strength
of a regiment of Infantry. Our Army has the unenviable distinction
of having much greater amount of sickness of this nature than any
foreign army. Moreover, since the Spanish-American War the ratio
of such cases has rapidly increased, until it is now twice as much as
in 1898. The situation must therefore be fairly faced and every
effort put forth to determine the causes for the prevalence of venereal
diseases and to devise measures for their prevention.

That the Army has a greater percentage of such disease than has
an equal number of vigorous young unmarried men drawn from hke
source in civil hfe is not behoved. Such infections cause the largest
proportion of rejections of apphcants for enhstment. They honey-
comb oiu- social structm-e. In point of prevalence they vastly out-
number aU other infectious diseases, both acute and chronic combined.

Causes. — These are not far to seek. In the first place, sexual
desire is implanted in man as a compelling factor for the perpetuation

16 MILITARY SANITATION AND SANITAEY SERVICE.

of the race. This desn-e is strong, especially when, by previous exer-
cise of the function, the habit has been formed. Next, the demand
for partners in the sexual relation has always created a supply, and
prostitution is as ancient as history. Of late this supply has been
elevated to the dignity (?) of a business, and a hideous traffic, with
an mtricate system for procuring young girls and suborning those
who legally should prevent such traffic, is now strongly intrenched.

Preventive measures. — How, then, shall we set about to mini-
mize, as far as possible, the incidence and effects of these loathsome
diseases, largely dependent, as they are, upon causes inlierent in the
nature of mankind ? From a sanitary standpoint it is plain that we
must apply the ordinary principles of sanitation. That is, we must
recognize their contagious character and apply such preventive
measures as are effective in other transmissible diseases. The most
important measure of this character is the isolation of infected indi-
viduals until the danger of transmission is past. In the Ai-my we can
and do control our infected soldiers, but the women from whom their
disabifities were derived, as well as infected male civifians, are still at
large to spread the contagion further. It is obvious, therefore, that,
if we hope for success, sentimentalism and prudery must give way,
and that diseased pubhc women must be admitted to hospitals or
otherwise placed under restraint tiU the infectious stage of the disease
is over. For the diseased male, it should be made a crime knowingly
to spread a venereal disease.

Education. — The measures above outlined do not conform with
the yet uneducated pubhc feeling that it is immoral to openly recog-
nize diseases of this class and their chief transmitter, the prostitute.
On the other hand, the measures themselves are certainly not immoral,
while they are practical. On the moral side, the camj^aign of educa-
tion already begun should be extended and a flood of fight poured
upon the subject, that all may clearly understand sex matters, the
dangers as well as the immorafity of iUicit intercourse and the methods
of spread of diseases transmitted thereby. With such education, the
veil of ignorance, misiriformation, and prudery will be lifted and the
tendency to secret vices among children will be lessened. Havard
says truly: '' It is in the conscience of the young man that prophylaxis
shoidd begin." The knowledge of sexual matters acquu'ed bj^ a child
is from bad sources and of a perverted kind. Such knowledge, secretly
acquired and brooded over in secret, hastens the awakening of sexual
feclmg and leads to vice.

Action by tue War Department. — Our War Department has
acted with courage and vigor in attacking this problem. Orders were
issued in 1912 directing procedures as foUows:

I. That physical inspections of enlisted men should be made twice
each month for the detection of venereal disease.

MILITARY HYGIENE. 17

II. That any soldier who exposes himself to infection shall report
for cleansmg and preventive treatment immediately upon return to
camp or garrison.

III. That any soldier who fails to so report, if found to be suffering
from a venereal infection, shall be brought to trial by court-martial
for neglect of duty.

IV. That men so diseased shall be confined strictly to the limits
of the post during the infectious stages of the disease.

V. That all officers servuig with troops shaU do their utmost to
encourage healtliful exercises and physical recreation and to supply
opportmiities for cleanly social and interesting mental occupations
for the men under their command.

VI. That company and mecUcal officers shall take advantage of
favorable opportunities to point out the misery and disaster which
follow upon moral uncleanliness and the fact that venereal disease
is never a trivial affaii*.

Action by Congress. — Congress, too, has taken a decided stand,
by an enactment providing that no officer or enfisted man who shall
be absent from duty on account of disease resulting from his own
intemperate use of drugs, or alcohofic Hquors, or other misconduct,
shall receive pay for the period of such absence.

It will be seen from the foregomg that the Army now has an
excellent plan for the discouragement of vice and the control of
cUsease resulting therefrom. To add to the effectiveness of this plan,
efforts are being made to induce Congress to repeal the anticanteen
legislation, thus again permitting the sale of beer and light wines
in the soldiers' clubs and cooperative stores officially known as post
exchanges. It is not here argued that the canteen is an unmixed
good nor that drinking should be encouraged. It is, however, in
the highest degree desirable to keep the men away from more evil
influences, and it is notorious that the saloon, prostitution, and pro-
fessional gambling go hand in hand. The close relation betw^een
alcohofic excess and sexual indulgence is an interesting fact. A
man's passions are inflamed by licjuor, his wiU power and his judgment
are afike weakened, and he yields to conditions which in his sober
moments might be positively offensive to Mm.

Syphilis. — There are three kinds of venereal disease. The most
serious to man is, perhaps, syphilis (sometimes called the ''pox,"
and referred to in the newspaper advertisements of charlatans as
"blood disease"). This is due to a very active, corkscrew-shaped
protozoal germ. Its first apparent result is an open sore at the point
of infection. This sore, known as a hard chancre, does not appear
for several weeks after exposure, but is then very resistant to treat-
ment and remains for a month or more. The body is soon infected
98756°— 17 2

18 MILITARY SANITATION AND SANITARY SERVICE.

throughout, and symptoms of this condition appear most often in
the form of skin eruptions and glandular swellings.

Syphilis is an infection of the entire system and its manifestations
are practically innumerable. We may expect it to appear in any
conceivable form, and where a chronic case of disease is obscure,
tests often reveal its presence. Certain of these manifestations may
(and do) appear many years after the disease was contracted. Among
these are paresis (softening of the brain) and locomotor ataxia.

Syphihs is extremely difficult to cure, and, in a certain proportion
of cases, never is cured. The new remedy — ^^'606" or salvarsan — is
stiU in the experimental stage, but it is at least certain that its use
is not followed by permanent recovery, and that the older and more
prolonged forms of treatment must still be employed. Syphihs is
the disease which is so often transmitted to the children — ^''even unto
the third and fourth generation," as the Good Book informs us —
as well as to the wife. It may be transmitted to others not only by
sexual contact, but also by means of articles (such as towels, eating
and drinking utensils, a comrade's pipe) used in common. Cases
also are frequently met which have been innocently acquired
through kissing, surgical or dental operations, the ministrations of a
nurse, and numerous other blameless ways.

The danger of transmission of the disease from father to cliild
(hereditary syphilis) is very considerable. Many childi-en are born
dead; others die soon after birth; still others (who, though diseased,
may survive) show characteristic deformities or unmistakable
syphihtic lesions.

Marriage. — ' 'Marriage of a syphilitic is permissible only after five
years, during the last two of which he has been without symptoms
and without treatment" (Keyes).

Gonorrhea, or "clap," is the result of infection with the bacterial
germ known as the gonococcus, and is characterized by a profuse
pm-ulent discharge from the affected part. This is usually the canal
of the penis (the urethra) in the male, although any mucous or serous
membrane may be involved. Thus if, by carelessness or misfortune,
a little of the pus is transfen-ed to the eye, a most violent inflamma-
tion ensues and the sight is in grave danger of -destruction. Gonor-
rheal rheumatism is a common and intractable affection. Heart
disease is an occasional sequel.

Gonorrhea is even more frequently conveyed to the wife than
syphilis, and with most serious results, as thousands of deaths and
tens of thousands of chronic invalids attest; 60 to 80 per cent of pelvic
suppm-ations in women are due to this affection. The eyes of babies
become infected during birth. It is estimated that 25 per cent of
blind people owe their infirmity to this cause.

MILITARY HYGIENE. 19

Gonorrhea is popularly regarded as something of a joke, an affec-
tion but little more harmful than a cold in the head; but many sur-
geons look upon it as more serious than syphilis in its results, for the
infection has a way of traveling along the various routes to the
bladder, kidneys, and testicles, leaving a man permanently injured
and often greatly shortening his life. Gonorrhea is transmitted to
innocent people — wife, child, comrade — with extreme ease, so, if
thus affected, one can not be too careful to make sure that none of the
discharge is brought in contact with a healthy individual. Cotton or
other material soiled with the discharge should be burned or otherwise
safely disposed of.

Chancroid. — The third venereal disease— chancroid or soft
chancre — is a contagious ulcer. It is always local, never constitu-
tional, and has no relation to syphilis (although it is frequently nec-
essary to wait for weeks before one can be sure it is not the latter).
Its cause is a special bacillus. While it may occur elsewhere, it is
practically always found about the genitals. Though less serious
than the other diseases of this class, it is a painful and repulsive
affection. In about one-third of the cases it is accompanied by an
abscess m the groin known as a bubo.

Personal prophylaxis. — Reference has been made earlier in this
lecture to the War Department requirement that enlisted men who
have exposed themselves to venereal infection shall report at hospital
or dispensary for cleansing and preventive treatment, but it may be
said that the procedures used are very successful in the prevention of
infection. Objection has been made that such prevention, by making
licentiousness safe, encourages the latter. As already shown, our
problem is to keep om' soldiers physically fit, and purely sentimental
considerations are of secondary importance. Moreover, our Navy-
has given the system a fair trial, and finds an actual diminution in
percentage of exposures as the result of the campaign of education.

In the absence of legitimate intercourse (that is, married fife)
natm'e will relieve the situation by an occasional nocturnal emission,
which is in no sense harmful. The cultivation of pure thought, the
avoidance of temptation, cold baths, simple, nonstimulating diet,
vigorous physical exercise, and alcohohc abstinence will prove effi-
cacious in overcoming desire.

TYPHOID FEVER.

Typhoid fever (or enteric, as the Enghsh call it) has for many years
been known as " the scourge of armies." In our Civil War the Union
Army had over 80,000 cases recognized as such, and there were
probably as many more which, because of imperfect means of diag-
nosis, were thought to be malaria and other infections.

20 MILITARY SANITATION AND SANITARY SERVICE.

War of 1870. — The Germans, in tlie war with France in 1870, had
over 73,000 cases and nearly 7,000 deaths, although active hostihties
lasted but six months.

Boer War. — ^The British Army in South Africa, while fighting
with the Boers, had 57,000 cases and 8,000 deaths.

War of 1898. — ^In our war with Spain we had 20,738 cases, with
1,580 deaths, among 108,000 men, all occurring within three and a
half months; 1 man in every 6 had the chsease, while this proportion
was increased to 1 in 5 among those regiments which never left the
United States. Typhoid fever caused nine-tenths of all deaths occur-
ring among troops encamped in the United States in 1898.

Such instances might be multiphed indefinitely, but enough has
been said to show what an immense amount of sickness and mihtary
inefficiency — ^to say nothing of the suffering and death of individuals,
with economic loss — ^this dreaded disease causes.

How spread. — Typhoid baciUi find the most favorable soil for
growth and increase in the bowels of human beings; they are usually
found also in the lu'ine of infected individuals. The disease is spread,
therefore, by the discharges of such individuals gaioing access to the
intestinal canals of others through swallowing substances contami-
nated with the germ. This may happen directly by contact with a
diseased person or indirectly through infected water, nulk, uncooked
fruit and vegetables, dust, flies, soiled hands, garments, bedding, or
tentage.

If we had a perfect method of disposal of these waste products of
the body, it would not be long before typhoid fever would cease to
appear in epidemic form, and only an occasional case would be en-
countered as the result of direct contact with an infected inchvidual.
But, under the imperfect sanitary conditions of modern existence, it
will be a long time before this is reahzed, and in the meanwhile we
must employ such measures as will reduce to a minimmu the risks of
contact with infectious material.

Army epidemics. — ^Typhoid fever is more hkely to become epi-
demic in mditary than in civil life because of the greater difficulty in
cUsposing of wastes and the close crowding and intimate contact of
yomig men under the conditions of camp and barrack life. A man
affected with typhoid may scatter the germs of the disease widely
before its existence is recognized in himself, since it frequently hap-
pens that mild cases are not detected for a week or two from their
onset. Moreover, 3 to 4 persons in every 100 who have recovered
from attacks continue to breed the germs in their bodies and to dis-
charge them with their excretions. We call such chronically infected
inchviduals carriei'S. Such a man, by defecating in the nearest brush,
step])ing just outside his tent at night to urinate, or fafling to cover
his chscharges in the sink (whereby ffies may have access to them, to

MILITARY HYGIENE. 21

convey the filth to food in near-by kitchens a httle later) may he
sowing the seeds of the scourge broadcast. Each man who thus
oflfends seems to think he is the only one who does such a trick and so
it won't do any harm. Unfortunately, many of hLs comrades are
looking at the matter from the same point of view. And fhes are not
necessarily the agents in this matter. Let us again assume one in-
fected individual in camp. His habits as to cleanliness may be bad
or his opportunities therefor poor. At any rate, his hands are sure
to be soiled with infectious material, which he transfers to everything
he touches — <lothing. bedding, towel, the cigars or matches he proffers
to a comrade, and even the food of others which he handles — ^for he
may be company cook or cook's police. His saliva is infectious and
he fouls the common drinking cup or a pipe which another may use.
Or, again, a solchers shoes may be soiled with the filth deposited upon

le ground by a careless comrade. This material is carried about the
V amp and into the tents, and. since the typhoid bacillus may live for
a time in the earth, a puff of wind of a friendly scuffle whirls the
infected dust in the air. whence it is likely to be blown upon food and
thus swallowed. By such means not one but dozens of men are
infected, and with each new case the risks grow in geometric progres-
- >n. In the multitude of cases during the Spanish- American War
impure water played little or no part. The three factors almost wholly
responsible for these cases were uncovered excreta, flies attracted
t-iereby. and personal contact with infected individuals.

Peevextiox. — Xow, what is the ''ounce of prevention'' in this

-e '. It consists, first, in the preliminary antityphoid vaccination
uf men beUeved to be susceptible; second, in a campaign of educa-
tion (which must be shared by line and medical oflS-cers alike) in the
facts just related; third, in the protection of the water supply;
fourth, in the systematic and thorough disposal of excreta and or-
ganic wastes generally: and fifth, in sharp punishment for violations
of sanitary regulations.

AxTTTTPHOED VACCiXATiox. — ^In antityphoid injections we now
have a method of protection against this disease which is quite as
efficacious as is vaccination against smallpox. It is well known that
an attack of typhoid usually protects a man against a subsequent
attack. Only 1 case in 143 has typhoid a second time, and the
method of protection referred to is found to confer immunity in a
similar way and, it is thought, to an equal degree.

It is in our own service that the procedure has been most thor-
oughly tested and its value definitely proved. Vaccinations of offi-
cers and men who volunteered for the purpose were commenced in
1909. The results were so good that in 1911 the procedure was made

mpulsory for all imder -1-5 years of age who had never had the dis-
ease. The Navy followed suit, and immunization of both services

MILITARY SANITATION AND SANITARY SERVICE.

is now practically complete. A single instance of the value of the
prophylactic measure to our service will suffice. This takes the form
of a comparison between an Army division in Florida during the
Spanish War in 1898 and a division in Texas during the border trou-
bles in 1911. Conditions as to strength of command, chmate, sea-
son, purity of water supply, and duration of camp were approxi-
mately equal. The disposal of wastes was much superior in the
latter camp, but the complete immunization of the Texas command
by means of the antityphoid prophylactic constituted the conspicu-
ous difference.

Year.

Mean
strength.

Cases of

typhoid

(certain

and

probable).

Deaths

from

typhoid.

1898....
1911....

10,759
12,801

2,693
2

248

LECTURE II.
MILITARY HYGIENE.

DYSENTERY.

Dysentery remains the most serious of the diseases to which our
people in tlie Phihppines are hable. Broadly speaking, dysentery
is any inflammatory disease of the bowels in wliieh blood and mucus
appear in the stools. Based upon their causative factors there are
two types, the one due to animal (protozoal), the other to vegetable
(bacterial) parasites.

Amebec type. — The prmcipal form of dysentery under the first
head is caused by an ameba, a minute animal consisting of a single
cell. This is the type which causes most trouble in the Phihppine
Islands; it is also met with in our Southern States. The amebse
enter the body with food or water and produce inflammations and
ulcerations of the large intestine, which are sometimes complicated
by abscesses of the liver. Their natural home appears to be the
human intestine, and from this source they contaminate foods
(especially fruits and green vegetables) and drinking water.

Bacillary type. — The bacterial type of dysentery is caused by
the baciUus dysenterise. Bacillary dysentery can only be told from
the amebic form by an expert, but for our purposes this fact is unim-
portant, since our preventive measures are the same for both. This
type is very widely distributed over temperate as weU as hot chmates,
and is the one which is responsible whenever epidemic outbreaks
occur in an army. The baciUi are conveyed from fecal matter to
the mouth by contaminated food or drink. Flies are common agents
of transference and personal contact plays as large a part as in typhoid.
As a result of their presence in the bowel and the development of
poisons (toxins) resulting from their activities, ulcerations of the
large intestine, hem^orrhages therefrom, and great prostration result.
This form is usually more active and dangerous than the amebic,
being sometimes almost as rapidly fatal as cholera.

Camp diarrheas. — Diarrheas are very common in field service
and may result from a variety of causes, such as bad food, certain
kinds of water, poor cooking, or abdominal chilling. There is also
an epidemic form (heretofore referred to as camp diarrhea) which
attacks large numbers of men at one time and is severe in character.
One cause of epidemic diarrhea is the dysentery bacillus, which

24 MILITARY SANITATION AND SANITAEY SEEVICE.

occasionall}' manifests its activities thus, but any form of diarrhea
is bad, since it not only rapidly weakens a man, but, by irritating
the intestines, it increases the habihty to attack by the more serious
affections, typhoid fever and dysentery. Under conditions of active
service the importance of "carriers" of typhoid, dysentery, and epi-
demic diarrheas is greater than in civil life. Indeed, these probably
constitute the most important of all factoids.

Prevention. — Preventive measures for all forms of dysenteries
and camp diarrheas are identical with those for typhoid fever save
in the matter of vaccination, for which we do not as yet possess an
efficient agent. The water supply should be carefully protected
from fouling ; the feces of men sick with these diseases should be disin-
fected or otherwise safely disposed of; the sick should be separated
from the well; and all sources of irritation of the intestinal tract
should be avoided.

MALARIA.

The malarial fevers constitute an important class of diseases.
Other names by which they are known are ague; chiUs and fever;
remittent fever; intermittent fever. The dreaded Chagres fever of
Panama is a form of pernicious malaria. There are three types of
these fevers, each due to a different minute animal parasite which
attacks the blood of man, but it is sufficient for our purpose here to
know that all have a similar origin, namely, the bite of an infected
mosquito. The method of transmission was discovered as recently
as 1898 by a British Army surgeon.

Anopheles mosquitoes. — Only one variety of mosquito (the
anopheles) which, however, has rather numerous species is capable
of transmitting the germs responsible for the disease. The mos-
quitoes may be recognized, in their adult or even larval forms, by
peculiarities in their attitudes when at rest. The larvae (popularly
called "wigglers") of harmless (culex) mosquitoes lie head down-
ward in the water in which they are developing, with only their
breathing tubes in contact with the sm-face. Those of the anoph-
eles lie parallel -w^th the water's ' surface and just beneath it.
Mosquitoes themselves, when resting, show opposite peculiarities;
that is, the common forms lie parallel with the surface to which they
chng, while the anopheles rest with their heads near the surface
and their bodies anghng away from it. Another point of difference is
that the common form is humpbacked, while the anopheles is nearly
straight from proboscis to tail. It is worthy of remark that only
females are bloodsuckers and thus transmitters of malaria. The
male may readily be recognized by the feathery tuft on his head.

Mode of transmission.— The transference of the infection from
one man to another is accomplished in the following inamier: A
certain individual has malaria, which means that he has in his blood

MILITARY HYGIENE. 25

tlie germs which cause the disease. An anopheles mosquito bites
him and draws into her stomach, along with the blood, a number of
these germs, which undergo a peculiar form of development witliin
her body. After this development is complete, this mosquito bites
a healthy man, and, injecting a little saliva through her hollow
proboscis in order to make the blood more fluid, she thus presents
this second man with a number of undesirable guests in the shape
of malarial parasites. These promptly attack such of the red cor-
puscles of his blood as are most available, and the cycle is complete.
Thus, the conditions which must exist to favor the spread of malaria
are: First, an infected human being; second, anopheles mosquitoes;
third, healthy man; and fourth, opportunity afforded to the mos-
quitoes. The germ of the disease is a microscopic, single-celled
animal (protozoon). This germ was discovered in 1880 by a French
army surgeon.

Prevention. — Preventive measures are as follows: First, pre-
caution against moscjuito bites by the use of screens for doors and
'VA-indows, bars for beds, and head nets and gloves when necessary
at night; second, the killing of mosquitoes in houses by fumigation,
trapping, or other means; third, the destruction of their breeding
places (i. e., collections of standing water), associated ^-ith the cut-
ting of high grass and underbrush near human habitations; and
fourth, the routine administration (in malarious localities) of small
doses of quinine to officers and men and attached civilians. Wlien
an individual is known to be infected, he should be screened wdth
especial care to prevent access of mosquitoes to him. Gen. Gorgas
is of the opinion that when troops are marching through a malarious
country the only practical measure for their protection is the ad-
ministration of quinine. The theory of this procedure is that when
the malarial parasites are introduced into the blood, they find there
a substance hostile to them. He says fm-ther, that such anopheles
mosquitoes as may bite soldiers in campaign, would not likely be
infected unless the troops are quartered in or camped near some
town. If the camp is occupied for more than a day or two the
ground should, of course, be cleared and accumulations of water
di-ained away or oiled.

TUBERCULOSIS.

Tuberculosis is what is commonly known as ''consumption," be-
cause of the wasting away of the body, which is an invariable accom-
paniment. The tubercle bacillus, wliich is responsible for tliis disease,
may and does attack any part of the human body, but tuberculosis
of the lungs so greatly preponderates that when we apply the term the
pulmonary variety is generally meant. Tliough tliis affection may
result from food (especially milk) containing the tubercle bacillus,

26 MILITARY SANITATION AND SANITARY SERVICE.

the usual channel of infection is by way of the lungs, the germs being
carried in the air. A soldier with the disease may, before the condi-
tion is suspected, infect the air of his squad room to such a degree that
all other susceptible individuals therein may contract the disease.

Coughing and spitting. — The germs are coughed up from their
seat in the lungs ; the spitting habit, as we know, is one deeply en-
grafted upon the American male; the germs resist death by drying to
a remarkable degree. We are therefore, Ukely to have in barracks
the conditions best suited to the spread of this disease, namely, a num-
ber of susceptible individuals closely aggregated, an infected man
who scattere his sputum carelessly about, and close air, breathed over
and over because of the inadequate ventilation so dear to the average
crowd.

Prevention. — The information just given readily suggests the
means to be employed to prevent the spread of this affection, which
are: First, the exercise of great care in recruiting, to exclude those in
the early stages of the disease; second, the early recognition of such
cases in the mihtary service, with their removal to a special hospital;
to this end, noncommissioned officers should be required promptly to
report any man who has a persistent cough; third, ample air space
per man in barracks; fourth, adequate ventilation must be provided
for and its mechanism carefully guarded to insure its continuous
operation. In this connection it is well to state that in our service
the guardhouse is the place most commonly infected, since it is usually
overcrowded and the men of most careless habits are apt to be im-
mured therein.

TONSILITIS.

TonsiHtis and other throat affections are very common in barracks
during cold weather and frequently occur in company epidemics.
When such is the case, ventilation is at fault, and it will usually be
found that the men, for the sake of warmth, have stopped up the air
inlets. Such throat affections are often quite severe and prostrating
and may even resemble diphtheria at fu'st. They are not usually due
to any one specific germ, but rather to one or more varieties of ordi-
narily harmless bacteria residing in the tliroat, which have taken on
virulent properties by reason of the lowered vitahty of the tissues due
to bad air. Tlie sick should be isolated promptly and the tendency
on the part of fresh-air cowards to plug up ventilation shafts in cold
weather must be appreciated and combated.

INFLUENZA.

Influenza, commonly known as "the grip," occurs in epidemic
waves which affect the civilian population equally with the military,
but as this is clearly infectious, being due to a weU-knoAVu bacillus,

MILITARY HYGIENE. 27

and is transmitted chiefly if not wholly by contact with the sick,
such contact should be avoided as far as possible. Tlie influenzal
bacillus prefers to attack the respiratory system, but may affect the
digestive tract or the membranes surrounchng the brain and spinal
cord as pneumonia, meningitis, and ear suppurations are not unusual.
Marked 'depression of spirits is a frequent accompaniment. Many
people are cripples in health for years after an attack.

COLDS.

Though seldom serious in symptoms or results, common colds are
so frequent and temporarily disabhng that they deserve mention
here. Many of them are undoubtedly "catcliing, " and persons
suffering from them should take pains to avoid close contact with
others. A large percentage of cases is due to overcrowding and
faulty ventilation in barracks. Other causes are wet feet and chilling
following overheating of the body's surface.

MEASLES.

We are apt to underrate the importance of this highly contagious
disease, which, in time of war, when new levies of troops are brought
together, becomes a really serious condition. City-bred recruits have
usuaUy had an attack in childhood, but those from country districts
very hkely have not encountered the infection. The disease is much
more severe in its effects upon adults than upon children. In the
Union Army during the Civil War there were 76,000 cases, with more
than 5,000 deaths. Among the Confederates whole brigades were
temporarily disbanded on this account in the early part of the war.
No means of prevention other than isolation of the sick and their
attendants are at present known. Measles is due to a virus whose
exact nature is as yet unrecognized.

MUMPS.

•

Mumps is also a contagious disease, and, like measles, causes much
disabihty among newly raised troops. It is not so serious in its
results as measles, but is a painful and disabhng affection, especially
when, as frequently happens, it attacks the testicles. Its ordinary
characteristic is an inflammation of the sahvary glands located in the
neck near the angle of the jaw.'

CEREBROSPINAL FEVER.

Cerebrospinal fever (meningitis) occurs with considerable fre-
quency at recruiting depots, on transports, and in camps. Luckily,
though many inhale the micrococcus which is its cause, but few are
susceptible to the disease. Direct contact is responsible for the
transference of the infection and "carriers" play a large part in its

28 MILITARY SANITATION AND SANITARY SERVICE.

spread. It is a very deadly disease unless antimeningitic serum is
used promptly. Early recognition of its presence in the command,
rigid isolation of the sick and of such carriers as can be located, with
disinfection of all cUscharges from their throats and noses, are the
essentials in its prevention.

SCARLATINA.

Scarlatina (scarlet fever), though a highly contagious and dangerous
disease, fortunately attacks adults but seldom, so does not need ex-
tended discussion in this treatise, but a case of sore throat, associated
Avith a brilliant eruption on the skin, should be regarded as suspicious
of this disease and immediately isolated.

DIPHTHERIA.

Diphtheria, another very contagious and serious affection, is far
less feared since the discovery of its antitoxin. This substance has
great value in the prevention of the disease as well as in its cure. It
is given hypodermically to all persons exposed to the infection, as
well as to the sick man.

SMALLPOX.

Smallpox, the disease most dreaded by our forefathers because of
its repulsiveness, its mortality, and its disfigm-ing effects, has been
robbed of its terrors by the wonderful protection afforded by vacci-
nation, but if the antivaccinationists had then- way this loathsome
pest would reappear, deadly as ever, since it is kept alive in many
communities by those who evade the means of prevention.

Varioloid is simply a mild attack of smallpox.

HOOKWORM DISEASE.

Hookworm disease has recently been shown to be of great eco-
nomic importance in Porto Rico and our South. Curiously enough,
the animal source of this affection, though its home is the human
intestine, makes its way into the body of the person attacked through
the skin and not by way of the mouth. The eggs are passed out with
the feces and the larvae — which constitute the infective form — hatch
outside the body. The measures of prevention, therefore, consist of
two things, namely, the proper disposal of excreta and the wearing of

shoes.

DENGUE.

Dengue, better Imown as "breakbone fever," is a disease which
causes much sicloiess among our people in the Philippines, but which,
fortunately, does not termmate fatally. In common with malaria
and yellow fever, it is transmitted by the bite of a mosquito, so
measures directed against this pest receive an additional argument.

MILITARY HYGIENE. 29

YELLOW FEVER.

Thanks to the late and deeply lamented Maj. Walter Reed, of our
Army Medical Corps, who demonstrated the fact that yellow fever is
transmitted by the bite of a certain mosquito only, we have suc-
ceeded absolutel)^ in eradicating this terrible disease from Cuba and
Panama, wliere for centm'ies it had been prevalent. This has been
accomplished by antiraosquito measures alone. The insect con-
cerned in the transmission of this disease is known as the stegomyia
calopus or ' ' tiger mosquito," the latter name resulting from its striped
appearance, by which it may be recognized. It is peculiar in the
fact that it bites chiefly in the afternoon. It is a house mosquito,
residing in or near dwellings, and, since it finds favorable breeding
conditions in water tanks of ships, it is often carried about the world
in this way. Its larva, like that of the culex, floats head downward
in the water.

CHOLERA.

Cholera, whose normal home is the Tropics, is by no means con-
fined to warm chmates, but is frequently brought to our own shores.
Since we know its cause (the "comma" bacillus) and the fact that
the measures for its control are similar to those for typhoid fever,
we do not fear that it will affect a lodgment in the United States.
Cholera has given us much trouble in the Phihppines, but even there,
where sanitary measures are carried out with greater difficulty, its
invasions have been met and checked.

TYPHUS FEVER.

Typhus fever, the "febris belhca" of older writers, has been the
scourge of armies. Dm-ing the Crimean War it caused more deaths
than all other diseases combined. AU of you know what havoc it
has played in Servia. The great Von der Goltz, of whom you will
hear more about in the near future, recently died with typhus. As
it is quite prevalent m Mexico it is of great importance for you to
know that vermin transmit the disease from one person to another.
Tlie destruction of vermin will mpe out an epidemic.

PLAGUE.

Plague, the "black plague" of the Middle Ages, estabhshes itself
independently of chmate wherever it finds favorable conditions. It
has been demonstrated that rats are even more liable to this disease
than man, and it is well estabhshed that infection is usually incurred
through the bite of the rat flea, which after the death of its normal
host, foi-sakes the latter and attacks man. Rats should, therefore,
be rentlessly pm-sued, their haunts made inaccessible to them, and
opportunities for obtaining food cut off. Cousnis of the rat — such

30 MILITARY SANITATIOISr AND SANITARY SERVICE.

as the prairie dog of our Western plains and the ground squirrel
(tarbagan) of California and Manchuria — are subject to the disease
and may be agents in its transmission. In some epidemics a very
deadly form ("pneumonic" plague) attacks the lungs. Here the
germ is transmitted by breathing and the flea is not a factor.

BERffiERI.

Beriberi is of interest and importance for the reason that it has
attacked many of our PhiHpino scouts. No perfectly authenticated
instance of its occurrence in an American soldier is on record. This
does not mean that they are immune, but rather that their food
contains the essential preventive substances. Rice-eating peoples
are most often affected, and it has been found that some necessary
food substance resident in the husk of the grain has been removed
in the polishing process to which the higher grades of rice has been
subjected. By substituting an " undermilled " rice for the pohshed
varieties this disease has been entirely controlled among the scouts,
and its incidence much lessened among the Filipinos generally.
This is the latest instance of the beneficent effects upon the health
of the native populations of the occupation of tropical lands by the
American Army.

SCURVY.

Scurvy is a disease resulting from scant or improper diet and was
formerly common among armies and navies. It is now but seldom
encountered, although beleagured garrisons (as the Russians in Port
Arthur) and remote detachments (as in Alaska) are sometimes
affected. Its chief causative factor is the absence from the diet of
organic acids contained in fresh meats and vegetables. Potatoes,
onions, tomatoes (raw or canned), vinegar, the juices of rare meats,
lemon and hme juice are preventive and curative.

LEPROSY.

Leprosy is mentioned because of the popular interest in this
affection and not because of the risks of contact. Its germ is feebly
contagious and no apprehension need be felt if its victims are en-
countered.

EFFECTS OF HEAT.

Tlie effects of heat are frequently noted on the march in hot
weather. These effects are of two kinds, notably differing in
symptoms. In the severer type (heat stroke) the sick man is imcon-
scious, his face is scarlet, his pulses throb violently, and his skin
feels bui-ning hot. In the other condition (heat exhaustion) the
consciousness is retained, but the man feols exhausted, his face is pale,
his heart beats feebly, and his skin is cold and clammy. Heat stroke

MILITARY HYGIENE. 31

is most apt to occur when the air is not only very warm but is sur-
charged witli moisture as well. Evaporation from tlie skin is inter-
fered with, and as such evaporation is an important means whereby
excess heat is withdrawn from the body, the temperature may rise
to a dangerous degree. These heat effects can largely bo avoided
by timing the march, when possible, to take place during the rela-
tively cooler parts of the day. The head covering should have a
roomy air space and the crown should contain some light, moist
object, as a wet sponge or handkerchief or green leaves. Water
shoidd be sparingly drunk on the march; the man who empties his
canteen between halts is most often the man who is overcome by heat.

SKIN ERUPTIONS.

Skin eruptions are very common in campaign, for the reason that
men can not or do not keep their persons and clothing in a sufficiently
cleanly state. The affections which occur most often are those due
to the presence of small animal parasites. Of these, hce are the most
objectionable. The hirsute parts of the head and body should be
inspected for the eggs of these insects, which are readily seen as little
masses attached to the individual hairs. When insects or their eggs
are found, the man's underclothing should be boiled and the affected
parts of his body shaved or freely anointed with mercurial ointment.

BLISTERED FEET.

Large numbers of men are incapacitated — particularly at the onset
pf a campaign — by blistered feet. The two chief causes of bhsters on
the feet of the marching soldier are bad fitting shoes and imcleanhness.
The feet should be kept dry if possible; shoes, when wet, wrinkle and
lose their shape. To insure keeping the feet in good condition, their
daily washing, after getting into camp, is absolutely necessary. If
sufficient water is not at hand, wipe the feet carefully — especially
between the toes — ^with a wet rag.

Shoes. — The shoe is, at least for the infantryman, the most impor-
tant article of clothing. It is only after many years. of experiment
that a rational marchmg shoe has been developed for our service, and
the urgent necessity for exactness in the fitting of each soldier with
these articles and for their proper care, appreciated. Company com-
manders are now held responsible for undue injuries to the feet of their
men fjom ill-fitting footwear. Each man should have at least one
pair, weU broken in, for marching use. Men sliould be instructed in
the care of shoes and of feet, and frequent inspections of both should
be made.

Socks. — An Infantry soldier should carry two or three pairs of
socks, wliich ought to be soft, smooth, and imdarned. Those worn
on the day's march should be washed at the same time as the feet;

32 MILITARY SANITATION AND SANITARY SERVICE.

clean, dry socks are then put on and the wet ones hung up to dry.
In this way a clean pair may always be had. A woolen sock (hght or
heavy) is more comfortable when marching than a cotton one, because
it is softer and more yielding, while it absorbs the perspiration better.
If pei-spiration of feet is excessive, a thin cotton sock under one of
light wool does well.

Prevention of blisters. — To prevent blisters, foot baths of strong
brine or alum or alcohol, used for a week or more before the march,
are of great service in hardening the skin. Many experienced soldiers
of our Army soap the feet before puttmg on their socks. In the Ger-
man Army socks (or rags, which many wear for economy's sake) are
soaked in grease. An excellent powder, made up of starch, soap-
stone, and salicylic acid, is supplied by our medical department to
sift into the socks. These measures are used to diminish the friction
of the foot against the sock. The French have found that a small
strap buckled about the instep, over the shoe, diminishes friction and
lessens the tendency to the formation of blisters. If such form in
spite of our care, they must be opened to allow the serum to escape.

Treatment. — The opening is made at the lowest pouit of the
blister, with a clean needle, after the feet have been washed. The
raised skm must not bo disturbed, but is to be dressed with vaseline
or other ointment and protected from pressure by adhesive plaster.
Men afflicted with bunions or corns should be required to report
promptly to the surgeon for appropriate treatment.

CLOTHING. ,

Purposes. — Clothing protects the body against the changing con-
ditions of the weather, such as cold, heat, wind, and rain, sliields in a
measure from blows and bruises, and serves to adorn the person.
The materials used for this purpose are derived from a variety of
sources, animal and vegetable. The chief substances taken from the
animal world are wool, fur, leather, and skin; from the vegetable
Idngdom we obtain cotton, linen, and rubber, as well as a number of
less important materials. A good material for clothing purposes nmst
meet the followmg requirements :

1. It must afford proper protection against the weather.

2. It must not interfere with the natural f mictions of the skin.

3. It must exert no irritating effect upon the skin.

The characteristics and merits of the more important substances
wiU be considered briefly.

Wool is midoubtedly the most valuable of these substances used
by us. It has the merits (a) of being a poor heat conductor, tlms
retarding escape of warmth from the body and preventing the thermic
rays of the sun from passing freely. Tlu-ough its heat conservation
it is much warmer than cotton, and when loosely woven, so much that

MILITARY ITYOIENE. 33

air is entangled in tlie meshes of the fahric, its warmth is markedly
increased. This property makes it most valualjle in cold climates,
and even in hot ones it is not altogether undesirable. The olive-drab
flannel overshirt has been found to be a very valuable garment in
tropical field service. By day it keeps out heat and chemical rays,
and by night it prevents chiUing. (b) Wool is a great absorber of
water, a very important quality, as evaporation from the body's sur-
face during free perspiration is checked and the danger of chill les-
sened. Pei-spiration passes through linen and cotton freely and loss
of heat is rapid, (c) It does not absorb odors readily. A disadvan-
tage of wool is that its fibers become smaller and harder after wash-
ing, so that garments of which it is composed undergo marked shrink-
ing and stiffening. This tendency is minimized by washing as fol-
lows: Plunge garments, one at a time, in hot soapsuds and use gentle
friction to cleanse from dirt. Remove and rinse out all soap care-
fully with cold water. Hang up to dry without wringing. Stretch
into shape while drying if a tendency to shrink is observed.

Cotton is next to wool in value for purposes of clothing. It has
these merits: (a) Good wearing qualities; (b) cheapness; (c) non-
sluinkage in washing; (d) coolness. Its demerits are: (a) Rapid
heat conductivity; (6) poor water absorption; (c) free absorption and
release of odors.

Merino (a mixture of cotton and wool) is much used for underwear.

Linen (flax fiber) conducts heat even more rapidly than cotton
and is also a poor absorbent of moisture, besides being much more
expensive than cotton.

Paper. — It is useful to know that paper is of value in conserving
warmth, and the Japanese have utilized it in military clothing. A
paper vest affords marked protection against cold winds, while a
newspaper between blankets adds much to comfort on a cold night.

Warmth and coolness. — The warmth or coolness of clothuig de-
pends upon several factors; these are material, texture, and color.
We have seen that, according to heat conductivity the materials
named, in order of warmth, are wool, cotton, linen. Conversely,
hnen is coolest With respect to texture, the more loosely woven
the material the warmer the garment. Thus, a cotton or linen loose
mesh under shirt is much superior to one that is closely woven. The
same effect of warmth may be produced by wearing two or more
thin undergarments, one over the other, the advantage resulting
not so much from the increased thickness as from the layers of
warmed air. Color is of importance in this connection, in accordance
with its relative heat-absorbing properties. Thus, white absorbs
least heat; black, the most. Black clothes are, therefore, warmest;
98756°— 17 3

34 MILITARY SANITATION AND SANITARY SERVICE.

white, coolest; blue is next to black for warmth; ohve drab and khaki
are cooler than blue. OUve drab, being darker, is markedly warmer
than kliaki.

Socks are furnished in cotton and in hght and heavj^ wool. Those
of cotton are suitable for garrison wear, but not for marching. Those
of hght wool (wliich are really 50 per cent cotton) are used by the
majority of our men on field service. The heavy socks of pure wool
are quite bulky, but are superior for marching wear, except in the
rare cases in which they cause skin irritation. Wool absorbs per-
spiration better, stretches better, and fits more uniformly, so it is
less hkely to form creases and produce blisters, callouses, and corns.
Soclis should have a seamless foot, with reinforced toes and heels.
They should fit well and have no rough thread ends. It is of interest
to note that only two armies other than our own issue socks to their
soldiers. These are Great Britain and Japan. The great mihtary
nations of the European Continent expect their men to provide them-
selves somehow with these articles, which by us are deemed of such
importance. From motives of economy many German soldiers wrap
oil-soaked cloths about their feet in Heu of socks. A British mihtary
sanitarian (Col. Melville) estimates the life of a sock to be only 60
to 70 road miles. This is probably a fair mileage for our hght wool
sock, but it is beheved that the heavy woolen article will do con-
siderably better. Comfort and cleanliness as well as regulations re-
quire that socks shall be changed and washed daily on the march.
It is well to remember that a piece of soft cloth a foot square (wool
or part wool) will -make a better foot covering than a worn out or
poorly darned sock.

Shoes. — No one article of the soldier's clothing plays so large a
part in his efficiency as the shoe. Although Army commanders and
sanitarians of the past century have emphasized the importance of
good footwear, it is but very recently that the mihtary shoe hiis
received scientific study. The marching ability of armies is secoiul
to no other mihtary factor, yet, while enormous percentages of troo]>s
in campaign have been incapacitated by injuries to the feet due to
shoes badly made, shaped, or fitted, it has but lately been realized
that the conditions were preventable. A board of officers convened
for the purpose by our War Department has recently (1912) rendered
its report in the form of a truly admirable study of the foot and the
shoe. A number of important recommendations are made in this
report, among which are: (a) Tlie adoption of shoes made on a
rational last (one developed by the board); (b) careful fitting by
company officers personally; (c) full series of sizes carried in stock at
posts; (d) frequent inspections of feet by company and medical ofli-
cers. The War Department has adopted these recommendations and
has published them in the form of an order, in which occurs the fol-

MILITARY HYGIENE. 35

lowing sentence: "Hereafter an undue amount of injury and disabil-
ity from shoes will be regarded as evidence of inefEciency on the part
of the officers concerned and as cause for investigation." This places
the responsibihty where it belongs, and officers will do well to study
most carefully the foot and its coverings. This may best be done
by consulting the work "The Soldier's Foot and Military Shoe," by
Maj. Munson, Medical Corps, United States Army, president of the
Army shoe board above referred to. Maj. Munson lays down the
foUo^A^ing requirements for a good mihtary shoe :

(a) It must be of good materials and well made.

(h) It must be fairly flexible, with phable and porous uppers.

(d) The arch should be flexible and without metal shank or other
stiff enmg.

(e) It should have eyelets (not hooks) for fastening and the
tongue should lie smooth under the laces.

(/) The shoe should reach only a Uttle above the ankle; it should
be wide across the ball of the foot and should have high toe cap.

(g) It must be comfortable, neat looking, and light in weight.

(h) It must be easily put on and removed.

Civilian models. — The styles of shoes purchasable in the shops
are practically all defective in shape and unsuitable for marching.
The "toothpick" type and even broad-toed models produce a forced
outward angling at the junction of the great toe with the main
portion of the foot. This shifts the axis of the foot, which normally
should be directly to the front in marching. Shoes ordinarily pur-
chased are too small for the wearer, either in length, in breadth, or in
both these dimensions. It must be remembered that the soldier is
obhged to carry a load of clothing and eqyipment amounting to at
least 40 pounds. Under such a weight the foot, ifunconfined,
lengthens and broadens to a surprising degree. This may amount to
more than one-half an inch from heel to toe and nearly as much
across the ball. It is thus evident that, to avoid injury in march-
ing, the shoe must be roomy enough to allow all or a major part of
this normal expansion.

Supervision in fitting. — Soldiers can not be trusted to fit them-
selves with marching shoes, as, through ignorance or vanity (or,
perhaps, lack of proper size), tight-fitting footwear will usually be
chosen or accepted. Thus, the supervision of officers becomes neces-
sary.

How^ TO FIT SHOES. — Feet are measured and shoes fitted by com-
pany commanders in the following manner: The soldier stands with
bared foot upon a small, graduated measuring board, resting his en-
tire w^eight (augmented by a 40-pound burden on his back) upon

36 MILITARY SANITATION AND SANITARY SERVICE.

that foot. The length of the expanded foot is read off from the board
and the circumference around the ball is taken by means of a tape
applied at the base of the toes. An approximation to the correct
shoe length is then determined by adding 2 to the scale reading.
For width, the table of sizes given in the annual price Ust of clothing,
issued bjr the Quartermaster General, should be consulted. For ex-
ample, let us assume that a foot measures 6i on the scale and has a
circumference of 9J at the ball. Size 8^i D is found to be the shoe
which should approximate a fit; if this is not quite correct, others
will be tried on until a satisfactory fit is had. With each trial the shoe
should be snugly laced and the soldier will throw his augmented
weight upon the shod foot. The company commander personally
verifies the fit, assuring himself especially, by pressure with his
hand, that not less than two-thirds inch of vacant space exists in
front of the great toe and that no undue pressure or wrinkling exists
over the ball of the foot.

Breaking in. — New shoes should be adapted to the contours of
the feet by gradual wear and should on no occasion be used for march-
ing until broken in. If there is need for haste in the process, this
may be accomplished by having the soldier stand in water for a few
minutes until the leather is sodden. He should then walk about for
an hour or so on a level surface, lettmg the shoes dry on his feet. On
removal, a httle neat's-foot oil should be rubbed mto the leather to
prevent hardening and cracking. Shoes may be waterproofed by
rubbing a considerable amount of this oil into the dry leather.

It is beheved that with the adoption of the new shoe and its com-
plete supply to the Army, to the exclusion of other styles, our service
will have footwear superior to that of any other nation. The average
American has a foot rendered abnormal by long wear of shoes of bad
shape or improper size. But, taken m conjunction with the over-
sight m fitting and care of the feet now rendered obHgatory, we
should have a minimum of foot troubles. The high boots worn by
German and Russian foot troops furnish a striking contrast to our
own shoes in appearance, comfort, and efficiency. That men can
march at aU in such clumsy, misshapen footwear as that of the foreign
nations cited is surprising. The weight of such boots is 4 pounds,
which is twice that of our shoes.

Overshoes are desirable for garrison wear, but not usually practi-
ciible in field service. The "arctic" type is the only one officially
suppUed.

LECTURE III.

MILITARY HYGIENE.

CAMP SANITATION.

CAMPS.

There is no subject of more vital importance in the training of hne
officers than military hygiene. This applies mth especial force to the
uiihtaryhj'giene of field service. Why is this? Because when troops
arc in garrison their mode of life approximates in hygienic aiTange-
ments the lite of the better class of the civil population. Their
dwelhngs are constructed with a view to sanitary requirements.
Tlieir exercises and habits are simiiarly governed. Their sm-round-
ings, food supply, water supply, and other necessities of life are estab-
lished, regulated, and constantly watched by highly speciaHzed sani-
tary officere. In garrison the individual hne officer must concern
himself v.ith the habits and personal hygiene of his men and the
general pohce of the post ; but very rarely is it necessary for him to
concern himself directly with the sanitary arrangements for hving in
an established post. Moreover, in garrison it is extremely unusual
that the requirements of military necessity conflict with the prime
essentials of mihtary hygiene. The troops of garrison life are ordi-
narily disciplined men who have received training in sanitary matters ;
whereas in field service in our military forces a line officer of the
standing Army is very frequently placed in command of untrained
or insufficiently trained troops of the Organized Militia or Volunteers.
In the field, and especially in active service, the situation is completely
reversed. Life in the field, especially where very large bodies of men
are congregated, offers many problems in sanitary, as well as other
arrangements. When white men are assembled in large communities
they are in modern life accustomed to systematic arrangements for good
and sufficient suppfies of food and water; for systematic disposal of
wastes and all other sanitary apphances of like character. WTien men
are suddenly congregated in the field their oflficers at once find them-
selves face to face with the elementary problems of field sanitation.
Very often these sanitary problems must be solved by the line officer
individually. At times the requirements of mihtary necessity may
compel him to disregard the recommendations made to him by his san-
itary officer, even though he himself reahzes their full significance.
However, when we leave out of the question the factor of military

38 MILITARY SANITATION AND SANITARY SERVICE.

necessity the vital fact remains that sanitation in the field depends
upon the hne officer fully as much if not more than upon the medical
officer. By the Hne officer I mean the company or detachment com-
mander fully as much, if not more, than the regimental or division
commander. Tliis statement will admit of much explanation and
may demand much evidence for substantiation, which I have not the
opportunity to give here. I will merely cite the contrast between the
mobihzation camps of 1898 and 1916. In the former case the line
officers very frequently did not reahze the importance of camp sani-
tation; in the latter they were frequently as eager for sanitary con-
ditions as the medical officers. In this connection I wiU read the
following extract from a press dispatch dated San Antonio, Tex.,

November 28, 1916:

As a result of the scientific methods adopted by the Medical Corps and the steps
taken to insure absolute sanitation in border camps the big command of Regulars and
militia has set a new health record. From May 1 to October 31 there -were only 75
deaths from disease in the force of more than 150,000 men, and of this small number
only 21 deaths were due to infectious maladies.

Typhoid fever was formerly the worst scourge of camp, but it has no place among the
troops along the Mexican border. From May 1 to October 18 only 21 cases of tjiDhoid
developed and no deaths resulted from the disease. All of these cases were among the
National Guard organizations, where in some instances the men were not inoculated
with typhoid serum until after the regiments had come to the border. There was not
a-single case among the 42,000 troops of the Regular Army engaged in patrol duty and
stationed in Mexico with Gen. Pefshing's command.

In Spanish-American War days — over a period of eight months in 1898 — among
147,000 Regulars and Volunteers, the typhoid epidemic reached the enormous total
of 21,000 cases and there were 2,192 deaths from the disease.

Why is it that administrative officers now lend a ready ear to the
demands of field sanitation ? This question is answered in part by
the foregoing quotations. It wiU be emphasized by a statement of
the statistics of the deaths in battle or deaths as a result of battle
wounds and deaths from disease in a few modem wars.

Mexican War, 1846-47.

american regulars onl-y .

Per cent.

Died from sickness ^^

Invalided from sickness, additional to preceding 14

Killed in battle or died from wounds 5

American Civil War.

Killed in battle or died from wounds 93, 907

Died of disease 186, 216

Thus 2 deaths are recorded for disease to 1 for battle casualty.

Crimean War, 1854-56.

French forces 310, 000

Died from disease ^^' ^^

.Invalided 65, 000

Battle deaths 7, 500

MILITARY HYGIENE. 39

Spanish-American War.

Deaths from battle in all camps and fields 293

Deaths from disease in all camps and fields 3, 681

This is 1 death in battle to 12.5 from disease.

War Between China and Japan, 1894-95.

Japanese forces in the field 227, 000

Deaths from battle 1, 311

Deaths from disease 15, 850

The ratio here is 1 to 12.

That the Japanese were taught a lesson by this record is shown in
the following war :

Russo-Japanese War, 1904-5.

Total estimated Japanese strength in field of operations 700, 009

Deaths from battle 58, 887

Deaths from disease 27, 158

In the same war, Havard estimates the Russian casualties to hare
been approximately the following:

Deaths from battle 47, 608

Deaths from disease 27, 830

Thus it will be seen that even in modem wars untU the last decade
the deaths from sickness have totaled a larger figure than the deaths
from battle. The noneffectives from sickness are an even more
vital military factor in war than the deaths, because of the fact that
in effectives from sickness always number many times more than the
losses by death from sickness. For it may be safely assumed that if
a command has in a certain period 200 deaths from disease, its con-
stant noneffective rate from sickness will be many times that number
for the same period.

Before proceeding further the question arises: "What are the prin-
cipal camp diseases which produce the frightful mortahty and mor-
bidity of military campaigns?" The question is pertinent, because
we are far better able to cope with an enemy known than one con-
cealed.

In the European wars of the eighteenth century and Napoleonic
era typhus fever was an ubiquitous scourge. This disease has never
been absent in any of the prolonged wars of Europe so far as we have
record. It wiU be remembered by you that this pestilence has pre-
vailed in epidemic form on the eastern and Serbian fronts during the
present European struggle. The same disease is present in Mexico
to-day, and must be reckoned with by any troops who wage war in
the southern Republic. Typhus fever must not be confused in your
minds with typhoid fever, which it resembles in some respects. One
marked difference in the two diseases, and the only one which here

40 MILITARY SANITATION AND SANITARY SERVICE.

concerns us, is the method of transmission, typhus fever being con-
veyed by the bite of the body louse, whereas typhoid fever, as you
well know, is a disease ordinarily transmitted by infected water or
food supphes. This brings us to the triad of cholera, typhoid fever,
dj'senteries, and allied camp diarrheas, which are often termed the
\\^iter-borne or fly-borne diseases from the importance of these two
factors in their causation. In American miUtary campaigns these
have caused the greatest number of losses from disease. Other dis-
eases to be dreaded in mihtary campaigns on this continent are the
mosquito-borne malarial fevers — yellow fever and dengue. Venereal
and respiratory diseases, while not especially associated with camp
hfe in distinction from garrison life, are always factors in the sick rat«
of armies.

^Ye have briefly discussed the reasons for the importance of field
sanitation and have enumerated a few of the diseases which have
decimated the armies of all history. Before passing on to the details
of this subject, I shall pause to emphasize again the important and
responsible role which the line officer holds m relation to this subject.
The supreme commander of the nation's armies who would permit
his subordinates to neglect field sanitation of campaigning troops
could not with our present viewpoint be considered a wholly com-
petent commander, no matter what other mihtary quahfications he
might possess. In no less degree the efficiency of the division or regi-
mental commander who would slight the sanitary care of his troops
would be dmiinished, and his chances of military success would be
equally curtailed. Finally the company or detachment conunander
upon whom, after all, depends the execution of the prune requisites of
sanitation, who neglects or disregards the sanitary regimen of his
command, is morally responsible for the deaths and iUness from pre-
ventable diseases which occur among his men, is morally responsible
to his coimtry for the ineff ectives from the same sources in his com-
mand, and is directly and judicially responsible to his higher com-
manders for failure to enforce the weU-known laws of camp sanitation
or to adopt the proper and practicable recommendations of his medical
officers. The importance of your future position, gentlemen, as
executive officers in these mattere impresses me strongly with my
duty to you in this regard. Do not, as you go out in the service,
think lightly of the sanitation of your command. Do not neglect it
or disregard the advice of your surgeon. Do not permit petty per-
sonal or official differences to influence you in the matter of the care
of your command and its protection from disease and death. Do not
make the life of your sanitary inspector a burden by regarding him
as an iniquitous pest when he is in fact performing his proper mihtary
duty. Finally, do not modify or shelve or otherwise fail to take
proper action on his sanitary recommendations unless you are certain

MILITARY HYGIENE. 41

that the departmont will approve of your action in stacking up your
sanitary knowlodgo against that of the medical oflicor, or that the
law of military necessity compels you to disregard his advice, or,
finally, that his recommendations are wholly impracticable. In the
last event you may save yourself much difficulty by referring the
matter to higher authority with your indorsed expression of opinion.

|- CAMP SITES.

Field Service Regulations has the following sanitary requirements
for camp sites and other sanitary arrangements of camps:

Par. 236. The grounds should be easily drained, naturally healthful, and large
enough for depots, corrals, hospitals, etc., and the encampment of troops without
crowding, and with ample space for exercise and instruction.

The water supply should be excellent and abundant and not liable to contamination
from any source.

Pak. 238. Selection of site. — -There is often little choice in the selection of camp
sites in war. Troops may have to camp many nights on objectionable ground. Never-
theless, sanitary considerations are given all the weight possible consistent with the
tactical requirements.

When tactical questions are not involved, and especially when the camp is to be
occupied for some time, great care is exercised in selecting the site. Through no
fault of their own, troops occupying an unsanitary site may suffer greater losses than
in the battles of a long campaign. A medical officer assists in the selection of camp
sites.

The selection of camp sites while on the march or during active operations is governed
by the following conditions:

1. The ground should accommodate the command with as little crowding as possible,
be easily drained, and have no stagnant water within 300 yards.

2. The water supply should be sufficient, pure, and accessible.

3. There should be good roads to the camp and good interior communication.

4. Wood, grass, forage, and supplies must be at hand or obtainable.

Closely cropped turf with sandy or gravelly subsoil is best; high banks of rivers are
suitable, provided no marshes are near.

In hot summer months, the ground selected should be high, free from underbrush,
and shaded with trees if possible.

In cold weather, ground sloping to the south, with woods to break the north winds, is
desirable.

Old camp grounds and the vicinity of cemeteries are undesirable. Marshy ground
and stagnant water are objectionable on account of the damp atmosphere and the
annoyance and infection from mosquitoes. Ground near the foot of a hill range
generally has a damp subsoil and remains muddy for a long time. Thick forests, dense
vegetation, made ground, alluvial soil, punch-bowl depressions, inclosed ravines, and
dry beds of streams are unfavorable.

Camp sites should be selected so that troops of one unit need not pass through the
camp grounds of another.

As a protection against epidemics, temporary camp sites in the theater of operations
should be changed every two or three weeks.

Par. 240. Establishing the camp. — Camp is established pursuant to the halt
order. This order provides for the outpost, if necessary, and gives instructions for the
encampment of the main body. Wlien practicable, large commands are encamped by
brigades.

42 MILITARY SAN^ITATION AND SANITARY SERVICE.

The camping ground may be selected by the supreme commander, but in large
com raands is generally chosen by a staff officer sent forward for that purpose. This officer,
with a representative from each brigade and regiment and a medical officer, precedes
the command, selects the camping ground, assigns sections thereof to the larger frac-
tions of the command, and causes them to be conducted to their respective sections on
arrival. He also designates the place for obtaining drinking and cooking water, for
watering animals, for bathing, and for washing clothing, in the order named, from
upstream down.

On the arrival of the troops, guards are posted to enforce proper use of the water
supply: the interior camp guards proceed to their places, and after posting sentinels,
pitch their tents. The remaining troops pitch tents and secure animals and equip-
ment; kitchens are established and details made to procure fuel, water, forage, etc.,
and to prepare latrines and kitchen pits; if necessary, tents, company streets, and
picket lines are ditched.

In the presence of the enemy, places of assembly for the troops are designated and
directions given for their conduct in case of attack. Lines of information are estab-
lished with the outpost.

Par. 241. Billeting. — Unless the force is small, shelter of this character is usually
inadequate, and some of the troops must use shelter tents or bivouac. Villages and
large farms often afford facilities, such as wells and forage, which contribute to the
comfort of the troops; it is therefore advantageous to camp or bivouac near them.

Par. 232. In enemy territory public and private buildings may be used to shelter
troops and for other military purposes; but for sanitary reasons troops are seldom
quartered in private buildings.

Par. 242. Bivouacs. — On marches or in the presence of the enemy troops are
frequently forced to bivouac on account of lack of suitable ground or for tactical
reasons. On the other hand, in fine weather, in midsummer, or in the dry season in
the Tropics, the troops may bivouac from choice.

From the tactical point of view, bivouacs are very convenient, but for sanitary
reasons they are resorted to, as a rule, only when necessary. The general principles
governing the selection of camp sites apply to bivouacs. The ground should be dry
and protected against sun and wind. Light woods are nearly always good sites for
Infantry bivouacs, on account of the shelter and material a^^ailable.

Par. 244. Shelter During Sieges. — To guard against danger from epidemics in
the necessarily crowded camps or cantonments of the besiegers, the most careful atten-
tion is paid to the water supply and sanitation.

Par. 245. Care op troops. — Lack of sufficient rest renders troops unfit for hard
work and diminishes their power of resisting disease. Therefore commanders should
secure for the troops, whenever possible, their accustomed rest.

The rvdes of sanitation are enforced.

Men should not lie on camp ground. In temporary camps and in bivouac they raise
their beds if suitable material, such as straw, leaves, or boughs, can be obtained, or use
their ponchos or slickers. In cold weather and when fuel is plentiful the grousd may
be warmed by fires, the men making their beds after raking away the ashes.

When troops are to remain in camp for some time all underbrush is cleared away and
the camp made as comfortable as possible. Watering troughs, shelter in cold weather,
and shade in hot, are provided for the animals, if practicable.

In camps of some duration guard and other routine duties follow closely the custom
in garrison. The watering, feeding, and grooming of animals take place at regular
hours and under the supervision of officers.

The camp is policed daily after breakfast and all refuse matter burned.

Tent walls are raised and the bedding and clothing aired daily, weather permitting.

Arms and personal eciuipment are kept in the tents of the men. In the Cavalry,
horse equipments are usually kept in the tents, but in camps of some duration they

MILITARY HYGIENE. 43

may be placed on racks ontside and covered with slickers. In the Artillerj'', horse-
equipments and harness are placed on the poles of the carriages and covered with
paulins.

The water supply is carefully guarded. When several commands are encamped
along the same stream this matter is regulated by the senior officer. If the stream la
small the water supply may be increased by building dams. Small springs may be dug
out and lined ^vith stone, brick, or empty barrels. Surface drainage is kept off by a
curb of clay.

When sterilized water is not provided, or when there is doubt as to the purity of the
water, it is boiled 20 minutes, then cooled and areated.

Par. 246. * * * From latrines 50 yards to nearest occupied tent; but, when a
smaller camp is desired, the space between company latrines and the men's tenta
may be used to park carriages and animals. Latrine seats are provided at the rate of
one seat to about every 10 men; shower heads at one to every 50 to 100 men, depending
upon water pressure.

Thus, you see, the prime essentials of camp sites are definitely pre-
scribed in this manual, which is primarily compiled for the use of com-
batant troops. I have quoted them in detail, because your atten-
tion is thus directed to the fact that you always have at hand a guide
in these matters; and further because you can not go far wrong in
camp sanitation if you obey these simple rules. The War Depart-
ment has under date of September 11, 1916, seen fit to issue a General
Order (No. 45) governing sanitary regulation of camps. This order
should be in the possession of every ofiicer. I shall quote this fre-
quently in the subsequent discussion.

A few additional remarks will not be useless to you. Whenever
you are required to select a camp site, it is important to consider
the conditions in the neighborhood of the proposed camp. Other
things being equal it is always better from a sanitary standpoint to
place a camp away from fixed habitations such as villages or towns
than in or near such places. As a general principle also it is wiser to
place a camp above stream in preference to downstream from a
town when the camp site is to be along a watercourse. If you are
sent ahead of a marching command to select a site, do not regard
your work as satisfactorily done until you have endeavored to ascer-
tain some information concerning prevaihng diseases among the in-
habitants and domestic animals of the locahty. If any one of the
serious water-borne diseases, tyj^hoid, cholera, or dysentery is present;
if typhus fever or other serious contagious disease is present; if a
serious epidemic is present among horses or cattle, the community
should be avoided even for a temporary camp site. In the instance
of a temporary camp site for a small body of men it is often suffi-
cient, when you have selected a location which appears to meet all
requirements, that you cause inquiry to be made at all near-by
houses, or to the village doctor or some other weU-informod person
in the community as to the presence of contagious or communicable
disease. In selecting camp sites for large bodies of men, a medical

44 MILITARY SANITATION AND SANITARY SERVICE.

officer will assist his commander in this matter. His recommenda-
tions should in all cases bo given due consideration.

The following details are to be kept in view in considering the de-
sirability of a camp site from a hygienic viewpoint:

1. The site must be sufficiently extensive to accommodate the en-
tire command without crowding. For a bivouac or very temporary
camp, this feature is of much less moment than in camps of longer
duration, because in the latter it is a well-estabHshed law that the
more densely men are concentrated, the more liable they are to the
occurrence of communicable diseases. Havard considers that a
brigade should be the maximum for one camp.

2. The site should be high enough to secure a dry camp. An espe-
cially desirable site is a plateau or ridge with a gentle slope to secure
natural drainage; but a sharp slope from one camp to the next is
most undesirable for the reason that the pollution of one camp drains
into the next. In cold weather a slope to the south with woods or
other obstruction to protect from the winds is desirable. In sum-
mer or in tropical campaigns high grounds, breeze swept, and prefer-
ably shaded by trees are more agreeable camp sites. Grounds at the
foot of a ravine are subject to flooding and are exceedingly^ unheal th-
f ul and unsatisfactory.

3. Camps should not be placed in the vicinity of marshes or stag-
nant waters. These favor the prevalence of mosquitos, v/ith their
attendant mosquito-borne diseases as well as their constant annoy-
ance. These localities also favor rheumatic affections, tuberculosis,
and many similar affections, A camp site must be dry, well cleared,
and well swept by the sun and prevailing breeze. A camp site wliich
has been priorly used for the same purpose within three months
should be avoided.

4. The best soil for camp sites is a gravel or sand-gravel soil which
readily permits rain water to sink through it. On the contrary a
clay or clayey soil is the least satisfactory. The character of the
soil and subsoil has much to do with the comfort and health of a
permanent camp, and when there is opportunity to choose, this
factor deserves remembrance. It is quite important that the ground
water should not be nearer the surface than 8 feet. Twelve feet is a
safer figure. A pure sand soil is disadvantageous on account of the
glare, the constant blowing about of the surface sand, and the
mechanical difficulties of camping in sand.

5. The presence of occasional trees and shrubs is desirable because
of the protection during tlie heat of the day, the lessening of ground
dampness, and the restful effect upon the eyes. Heavy foliage or
imd(?rbrush is unhealthful and undesirable. A grass-covered soil
is a blessing in a camp and should be preserved as long as possible.

MILITARY HYGIENE. 45

WATER.

Notliing is of greater importance in the selection of a camp site
than an edeqiiate supply of potable water.

Wliat is an adequate supply of water? Manifestly a temporary
camp does not demand the same amount as a prolonged camp with
its shower baths, laimdering facihties, and even disposal of sewage by
a plumbing system. Again a mounted command requires a much
greater suppl}'' than a dismounted one. You will find on page 207,
Field Service Regulations, the following useful data on daily water
requirements.

Water.— Approximate daily requirements:

One gallon per man on march.
Five gallons per man in camp.
Six to ten gallons per animal on march and camp.

(The above figures apply to water taken from streams where
animals are watered at the streams and cooking water carried. In
estimating the daily supply for permanent or semipermanent camps,
where water is piped to kitchens, bath houses, etc., the requirements
wiU be 25 to 30 gallons per man and 10 to 15 gallons per animal,
depending on climatic conditions.)

Estimating quantity of water in stream :

BxDxVxlO, 800=gaUons in 24 hours. B=average width,
D=average depth, V=average velocity (all in feet).

What is potable water? The potability of water supply should
always be referred for decision to a medical ofTicer, when present
with the command. In case of doubt or suspicion as to the safety
of a water supply, you are directed by Field Service Regulations to
require that the water supply for your command be boiled for 20
minutes.

Water supplies are derived from three sources — the sky, the
surface of the earth, the depths of the earth. Rain water properly
collected in clean, impermeable cisterns is potable and above sus-
picion, but is rarely available for even a small body of troops. Sur-
face waters from rivers, streams, lakes, and ponds may be pure or
contaminated according to circumstances. The chief factor in the
matter is human pollution. A river or stream flowing through a
spai-sely inhabited coimtry is usually a reasonably safe water, pro-
Aided there is no pollution within several miles of camp. A flowing
body of water is self-purifying by dilution, by sedimentation, by
effect of sunlight, by the activities of animal and vegetable life.
Factors to be considered are size and rate of flow of stream and amomit
and proximity of pollution. A river or stream even 100 miles bclov,' a
large" community in which a waterborne disease is prevalent is an
unsafe water supply. A camp site on a very large lake, many miles

46 MILITARY SANITATION AND SANITARY SERVICE.

removed from a town, usually afiFords a safe water supply, provided
the camp is not permitted to pollute its own water supply. Small
lakes and ponds in thickly populated regions or near human dwellings
are a dangerous water supply. Springs are really outcroppings of
subsoil water and must be considered with reference to their source
and liability to pollution. This may often be approximately de-
termined from the surface configuration; more accurately by color
or bacterial tests.

Subsoil water supplies are generally classed for purposes of sani-
tarians as coming from deep or shallow wells. The distinction lies
not in any mathematical terms, but in the fact that deep wells pass
through one or more impermeable layers of the earth's surface,
whereas shallow wells do not. As you probably know, a layer of
water is encountered a few feet below the earth's surface. The depth
varies greatly in different localities from a few inches to many feet.
Similarly the height of this gromid water varies geratly in different
locahties. This is called subsoil water or ground water and is the
accumulated water from surface drainage of whatever description,
which is thus held at tliis level by reason of a supporting layer of the
earth's surface which is relatively or wholly impermeable. Any well
which does not penetrate at least one impermeable layer must then
of necessity draw upon this subsoil or ground water for supply.
You will readily understand then why it is that in thickly populated
communities we interdict the shallow well. You will readily see that
such water supplies in thickly populated places will receive con-
stantly pollution of every character; and even in sparsely settled
places be liable to sufficient contamination to be viewed with sus-
picion.

That is the point I desire to emphasize. Shallow wells are always
suspicious water supplies. It would be suicidal for large bodies of
troops to obtain their water supply from shallow or dry wells on or
very near a camp site of any but the briefest duration. Small
bodies of men may use water supplies from shallow wells, when such
have been carofuUy examined, and sources of pollution excluded. In
this connection two phases of military field life must bo considered.
Troops permanently or semipermanently encamped should not use
shallow wells for water supplies unless these supplies are treated as
suspicious water supplies and are kept mider constant medical sur-
veilance. Troops on the march or when campaigning may be
obliged to use water from those sources. In such cases how would
you, as an organization commander, determine the probability of the
purity of such wells ? In the first place, you must examine the sur-
face area drained directly by the well in question. This area is a
circle whoso radius is four times the depth of the well. This figure
is merley approximate. Contamination from surface pollution may,

MILITARY HYGIENE. 47

of course, proceed a much greater distance. But in this special area
no source of pollution is permissible. Such sources may be privies,
cesspools, pigstyes, manure piles, cattle sheds, stables, and, in fact,
any manifest organic pollution. When you come to examine the
wells of American villages and agricultural communities by this
simple test, you will be surprised to find how many of these derive
their water directly from such filthy sources. The second test is the
position of the well with reference to the slope of the land, ' Land slope
may or may not indicate the current of ground water depending en-
tirely upon the geology of the locality. On the other hand, a well
dug on the mid slope of a hill whose summit is crowned with a privy
would obviously be an unsafe water supply.

The third test for you to make is valuable in proportion to your
energy in its prosecution and the intelligence and honesty of the
response. Make inquiries among all households in the vicinity
who are using or have used this well for a drinking supply. Wliat
illness have they had in the past two years ? If typhoid, dysentery,
diarrheas, or other water-borne diseases, this water supply is higlily
suspicious and must be boiled before use for drinking. I have out-
lined briefly the means whereby you can judge rouglily of the purity
of shallow well-water. Do not take upon yourself the responsibihty
of passing upon such supply if you have a medical officer on whom
to bestow this, his proper responsibihty. In the absence of a medical
adviser, apply the foregoing tests, exercising such judgment as your
experience formulates. In case of doubt, always order water sup-
plies to be purified. So doing you free yoiu" conscience from the
possibility of having illness or death of your men placed upon it.
Deep wells penetrate at least one impermeable layer and if properly
constructed are usually safe for drinking. Havard says, "A well to
be above suspicion, must comply to the following requirements; it
should traverse the entire aqueous stratum and extend to the sub-
jacent impervious clay or rock; it should be fined throughout or at
least above the water with a weU-constructed masonry waU vaulted
at top with manhole in center and thoroughly cemented inside."
The safest rule in prolonged camps is to require that a competent
chemical and bacteriological examination of the water supply of
troops be made at frequent intervals.

FOOD.

Army Regulations are now quite brief in prescribing the field
ration as f oUows :

The field ration is the ration prescribed in orders. by the commander of the field
forces. It consists of the reserve ration in whole or in part, su]:)]ilemented by articles
of food requisitioned or purchased locally, or shipped from the rear, provided such
supplements or substitutes correspond generally with the component articles or
substitutive equivalents of the garrison ration.

48 MILITARY SANITATION AND SANITARY SERVICE.

RESERVE RATION.

Ounces.

iiacon 12

Or meat, canned 16

Hard bread 16

Coffee, roasted and ground 1. 12

Sugar 2. 4

Salt 16

I shall not enter into an orderly discussion of the relative values of
different articles of food, but confine myseK to a few remarks which
appear to me as practicable.

There are five essential elements in food supply as follows:

1. Proteids; examples of this class are flesh of animals and animal products.

Function, to replace tissue loss.

2. Fats; function, to produce body heat.

3. Carbohydrates; examples — sugars, starches, vegetable products.

Function, to produce energj\

4. Salts and extractives, obtained chiefly from fruits, vegetables, and flavoring

agents.
Function, chemical and biologic adjustment.

5. Water.

All of these elements must be represented in definite ratio in a
diet on which human beings are to subsist for any prolonged period.
Failure to furnish the minimum required amount of any one of these
elements will result in disease production. Some of the great
scourges of the world have resulted from disregard of this law of
nature, among them scurvy; beriberi; pellagra (probably); sprue
(probably) ; rickets. These are well recognized disease entities, in
addition to which are to be remembered the countless less definite
evidences of mal-nutrition seen in persons who are deprived of a
balanced diet. A dietary then must not only be sufficient in amount
but characterized by sufficient variety. Of the five elements of cfiet
which you as an organization commander must always be on your
guard to remember in the company ration, No. 4, listed as sidts and
extractives and obtainable chiefly from fruits and green vegetables,
is the one which is most frequently neglected with unfavorable
results. Remember, gentlemen, that a diet containing all of these
elements except element No. 4 will not be made complete for subsist-
ence by the addition of canned foods. The reason of this is that the
process of canning requires a very high degree of heat, which destroys a
certain element in the food. Tliis is called "vitamin." Its pro-
longed deprivation is very probably the causative agent in thi'ce of
the world's great plagues; beriberi, pellagra, and sprue. Remember
then, that a varied diet is equally as necessary as a hberal one, and
that fresh or dried fruits, and green vegetables, potatoes, and other
articles containing the essential salts or vitamines are necessary for
an adequate diet.

MILITARY HYGIENE. 49

Concerning the amount of food necessary for tlie subsistevco of
your men, you will quickly leani when you begm to handle a company
mess. Men marching or campaigning in a cold or stimulating climate
may be safely given a very liberal ration. On the contrary, men in
garrison or prolonged camp iu a hot country will be in better health
for a diet restricted especially in meats and fats. In the former case,
a wise commander will purchase with his ration allowance the greatest
possible amomit of real food utilizing the Government straight ration ;
whereas in the latter he will cut down on the beef and beans and
purchase more delicate and less heating foods. You will find that
time devoted to the conduct of your company msss is well spent.
A well-fed body of men is content, willing to work, and disinclined
to indulge in drunkenness. A weU-fed company becomes an organi-
zation which enlisted men desire to join and stay with. Consequently
it can build up a cadre of good men. Moreover, if you do not watch
your mess, you will not only find discontent and disciplinary troubles
but you will find financial frauds and dishonesty sooner or later
among the men to whom you leave the matter. General Orders 45,
1916, has the following on foods and drink in camps:

Food and drinks. — No food, drinks, or like commodities will be sold in camp
except in the authorized exchanges.

Attention is called to the use of the following foods, the elimination of which from
the messes will serve to prevent a variety of intestinal disorders:

(a) Canned milk and fish opened the day before. (Fish and milk poisoning.)

(6) Hashes of meats and potatoes prepared the night previous. (Ptomaine poison-
ing of severe type.)

The field cooking may be of any character from the individual
cooking of active campaign to the comparatively elaborate methods
of permanent camps. At the present time the field range is the
most usual means of field cooking. Time is lacking for details con-
cerning field paraphernalia for cooking. A few simple rules wUl
suffice.

1 . Kitchens, messes, and food-store tents must be located at oppo-
site end of company from latrines. (Field Service Regulations, par.
246.)

2. Kitchens should be sheltered in marching command by tent fly
and brush shelter when possible; in prolonged camp by a fly-proof
shack.

3. Kjtchen floors should be well tamped and sprinkled before each
sweeping, and should be well ditched.

4. Kitchens and all utensils must be clean at all times. Screened
kitchen shacks should have improvised flytraps.

98756°— 17 4

50 MILITARY SAlSriTATIOlSr AND SANITARY SERVICE.

5. All fresh food should be covered or protected from flies, dust, and
dirt at all times. Fresh food should be handled in a cleanly manner.

This includes bread.

6. Garbage and other refuse should not be collected m or about a
kitchen. Much, if not all of it, can be incinerated at once.

7. Men should not be permitted to sleep in kitchen or food-store
tents, nor to eat in their sleeping quarters.

8. Ice boxes and drinking-water barrels should not be sunk in the
earth.

9. Tinned meats and vegetables should be rejected if perforated
or bulging or otherwise evidencing contammation.

10. Not only the kitchen, food-store tent, and mess tent should
always be scrupulously clean and fly free but the earth surface around
and about these places.

11. Make it clear to your mess sergeants and cooks that you will
not be satisfied with anything less than absolute cleanliness in their
department.

12. Enforce your views by frequent personal inspection and dis-
ciplinary measures for neglect.

DISPOSAL OF WASTES.

Wastes may be classified as —

1. General refuse.

2. Human excrement.

3. Animal excrement.

4. Kitchen wastes.

5. Waste waters from kitchens, shower baths, etc.

Field Service Regulations provides for the disposal of general
refuse as follows : ' ' The camp is policed daily after breakfast and all
refuse matter burned."

Field Service Regulations provides for disposal of hiiman discharges
as follows :

Latrines for the men are always located on the opposite side of the camp from the
kitchens, generally one for each company unit and one for the officers of a battalion
or squadron. They are so placed that the drainage or overflow .can not pollute the
water supply or camp grounds.

When the camp is for one night only, straddle trenches suffice. In camp of longer-
duration, and when it is not possible to provide latrine boxes, as for permanent cam]7s,
deeper trenches should be dug. These may be used as straddle trenches or a seat
improA-ised. When open trenches are used the excrement must be kept covered at
all times with a layer of earth. In more permanent camps the trenches are not over
2 feet wide, 6 feet deep, and 12 feet long, and suitably screened. Seats with lids are
provided and covered to the ground to keep flies from reaching the deposits; urinal
troughs discharging into the trenches are provided. Each day the latrine boxes are
thoroughly cleaned, outside by scrul)bing and inside by applying when necessary a
coat of oil or whitewash. The pit is burned out daily with approximately 1 gallon of

MILITARY HYGIENE. 51

oil and 15 pounds of straw. When filled to within 2 feet of the surface such latrines
are discarded, filled \vith earth, and their position marked. All latrinea and kitchen
pits are filled in before the march is resumed. In permanent camps and cantonments,
urine tubs may be placed in the company street at night and emptied after reveille.

Tills paragraph briefly states the methods commonly employed
in our service. General Order 45, 1916, disposes of excreta as
follows :

Disposal op excreta. — ^ Where a water-carriage system is not feasible, the Havard
box will be used over the earth latrines. Daily inspection of this system is enjoined
on the part of the medical officer of the organization, who will see that the following
plan is carried out:

(a) The latrine will be burned out daily with crude oil and hay. (Each burning
1 gallon crude oil and 15 pounds of hay or straw.)

(b) The boxes will be at all times kept fly tight; this implies closure of all cracks,
care of the hinges and a back construction so that the lids drop automatically. The
latrine seats will be washed off twice weekly with a one one-hiindredths solution of
cresoline, or other disinfectant, and whitewashed inside twice weekly.

(c) When filled to within 2 feet of the top, latrines will be filled with dirt, their
positions marked, and new latrines constructed.

(d) Where water-carriage system is in vogue, either the automatic flush or trough
system will be installed.

In the foregoing order it is customary to have a noncommissioned
officer such as the noncommissioned officer in charge of quarters
take a squad and carry out the burning described under (a). For
the compUance with requirement (b) it is an excellent plan to require
the company artificer to visit the company latrine and daily repair
defects.

Animal excreta is always a difficult problem especially in a large
camp. Only the highest discipfine, and constant labor will dispose
of the mass of manure and picket line refuse. The reason that its
destruction is so imperative fies in the fact that manure is the natural
breeding place for flies. It is estimated that 90 per cent of ffies breed
in manure and horse di'oppings. The complete process requires
about 10 days. The fly larvae burrow into the depths of the manure
or the damp earth beneath until maturity is reached, so that an
apparently harmless manure pile niay harbor millions of flies. The
fly you must remember is just as much to be regarded as a danger
as the enemy's buUet, and may kiU off your men in much greater
number.

General Order 45 directs as foUows:

Disposal of manure and care of picket lines. — All manure will be hauled to
the camp dump. Picket lines will be kept broom swept, and all manure and straw
hauled off daily. A weekly incineration of the picket lines will be accomplished
with crude oil at the rate of 10 gallons to each line. Crude oil may be obtained from
the Quartermaster Corps on usual requisition.

The foregoing paragraph merely transfers the manure and with
it the responsibiUty for its disposition to another place, e. g. the camp
dump. A camp dump must be at least 1 mile from camp, and in

52 MILITARY SANITATION AND SANITARY SERVICE.

the opposite direction from prevailing winds when there are such.
At the camp dump, manure may be disposed of by burning in a
huge improvised incinerator; or by spreading out in this layers for
drying. The first way requires much constant labor, some fuel, and
the highest disciphne, especially in large commands. The second way
requires labor, disciphne, and constant official supervision, so much
so as to also prohibit complete success. Those of your number who
may have ever attempted to govern fatigue parties distributing
manure in a thin layer over the earth's surface wiU readily visuahze
the difhculty of so governing the same work for a division. One or
the other of these ways may be successful with a small body of
troops. The very best way for a large command such as a brigade
of mounted troops or an Infantry division is by arrangement with
some commercial parties to haul away by train or otherwise the
entire supply each day. If this can not be done, the best way is to
have the dump at least two miles from any part of the camp. Fhes
rarely travel so far unless carried by high winds. Carcasses of dead
animals should be carted to a spot selected by a sanitary officer and
there burned or buried. The latter is usually the more practical
plan.

General Order 45 prescribes the disposition of kitchen wastes, as

follows :

Disposal of garbage. — For detaclunents or companies in camps, or in isolated
location where other means are not available, the incinerator will be installed.

If wood is plentiful and medium-sized stones can be obtained, both liquid and
solid refuse can be disposed of by using incinerators improvised for each company aa
follows:

A pit is dug about 5 feet long, 2| feet wide, and 6 inches deep at one end and 12
inches at the other. The excavated earth is banked around the pit and the latter is
then filled with stones on which a fire is built. When the stones have become heated
liquid refuse is poured into the pit (shallow end), where it gradually evaporates; solid
matter is burned on the fire.

The efficiency of this type of incinerator depends largely upon the fact that porous
earth absorbs a A'ery large part of the liquid slops, but is not considered practicable
to destroy the usual accumulation of slops every day without using an extravagant
amount of fuel.

A type of incinerator ha\'ing a fire bed of rock 1 foot deep will not permit the heat
from the fire to penetrate beyond that depth. The rock wall on three sides of the
fire bed absorbs much heat that otherwise might l)e dissipated into space,' which
increases the evaporating capacity of the incinerator enormously, and requkes a
comparatively very small amount of fuel. Incinerators built of large rocks are con-
sidered to be most efficient.

About one-sixth of a cord of wood per day per company is considered more than
euflicient for the destruction of all slops and garbage if ordinary care and attention
are given the incinerator. Liquid slops should be evaporated by being poured slowly
along the vertical walls of the incinerator, not u]wn the fire bed. and the solid garbage
should be placed on top of the fuel. It has been determined that a skilled attendant
can destroy 100 gallons of liquids and 23 cubic feet of solid garbage in about 12 hours
by using one-sixth of a cord of wood.

MILITARY HYGIENE. 53

Where roclc is not available, material (brick 340, lime three-fourths bagi will be
obtained on requisition from the ([uartermaster. Whore disposal in a sanitary way
can be made l)y means oi carts, the garliage can may be used. The cans will l.e
thoroughly cleaned, scalded, and coated with crude petroleum after emptying.

KiTCHKNS AND MESS ROOJis. — Kitchens and mess rooms will be securely screened
and an eflicient fly trap provided for catching such flies as gain entrance thereto.
An effective fly trap consisting of a light wooden frame covered with wire gauze, extend-
ing to about one-eighth of an inch of the floor of the trap, is readily constructed . It has
been found that sweetened water slightly acidulated with vinegar is an excellent bait.

Ice boxes installed will be inspected daily and drip pans emptied and scalded out.

Garbage cans will be kept on wooden racks and elevated from the ground and cans
burned out daily with oU to prevent fouling, and kept clean outside with a coat of
whitewash.

There are, briefly, three ways of disposing of kitchen garbage — -
burning, carting off, and burying. In a general way their relative
sanitary value is as in the order named. Sometimes two methods
maybe combined ; thus, for example : Solids burned, liquids carted off or
burned. The principle involved is to leave no organic refuse in or about
camp to pollute water or food supplies or harbor and breed flies.

Waste waters from shower baths must be carried off by natural
or improvised watercourse so as not to be a source of mosquito
breeding or a nuisance to a camp.

SANITARY APPLIANCES.

THE LYSTER WATER BAG.

Hygiene of the march. — A few remarks must suffice. The health
as weU as the comfort of marching commands is influenced b}^ the
manner in which its details are arranged. A commander should
consider these when military necessity does not ride otherwise.
When a prolonged march extendmg over many days is undertaken,
especially by a command not inured to marching, it is wise to begin
the journey by short daily marches, gradually working the men up
to longer marches. In this way the men gradually harden up, their
feet toughen, and by the end of a week they are fit for the longer hikes.
He who gives very long hard marches on the first three days will
not hasten the ultimate time of arrival nor bring an equal number of
fit men to the goal. This rule applies to Regular troops as well as
others. An average day's march for commands not greater than a
brigade is for foot troops 15 miles, mounted troops 20 to 25 miles.
For divisions or larger bodies the journey must be cut down 20 per
cent. Troops hardened or spurred by necessity may, of course, cover
much more territory. Remember that a command that is soft may
much more readily march 20 miles on one day than 45 miles in three
days; in other words, the fatigue is cumulative for unseasoned men,
because they do not recover from one day of fatigue when the next
begins.

The time selected for marching has appreciable effect upon physical
condition of men and animals. Night marches or marches beginning
before daybreak depress the spirits of men and the vitafity of men

54 MILITARY SANITATION" AND SANITARY SERVICE.

and animals. Especially is it hard on animals to march before they
have had their food in quiet and at the customary time. In very
hot places, however, marches are best conducted either in the early
morning hours or late afternoon and evening. When a day's march
begun in the early forenoon can not be concluded by 1 p. m. it is
wiser to break its fatigue by a halt and Hght lunch shortly before
noon. Similarly, all-night marches should be broken about mid-
night by a hght meal. Customarily men march 50 minutes and
rest 10 in the hour, thus covering about 2h miles each hour. A
faster rate is more than proportionally wearisome. It is wise to
march methodically by the watch. The leading troops march more
easily than the tail of the column. Therefore, in long marches each
unit should have its turn as the leading element. At the first halt
on the day's march a period of 20 minutes is usually given men to
relieve themselves, readjust packs, or otherwise get in marching trim.

Marching troops can eat and digest most anything, so that no
special sanitary rules apply to troops in this status. A moderate
morning meal eaten leisurely at least one half an hour before taking
the road is the best provision for the coming journey. The discipline
of a command is well gauged by its conduct respecting water drinking
on the march. It is an excellent rule for a company conoLmander to
require his men to start the day's march with a canteen filled with
water, and with a clear understanding that none shall have further
supply until at least one-half hour after concluding the day's march.
The only exception is the march in excassively hot weather, when a
greater water supply must be provided. This should either be trans-
ported with the command or taken from sources examined or ap-
proved by the commanding ofiicer. Men should never be allowed to
break ranks and forage for water except in circumstances of extraor-
dinary necessity. This rule should be enforced for disciphne and
training as well as health. The cardinal rules for a snapshot judg-
ment of water supphes have been already recited. If you have a
medical officer along, put him on the trail of the water supply as soon
as you near the place of noon or evening halt. If not, exercise yoiu-
owTi judgment, remembering the instructions in Field Service Regu-
lations concerning the boihng of suspicious waters, and the protection
of your water supply by guards.

The care of the feet of your men is extremely important. It
should have begun long prior to a march by personal supervision of
the shoeing of your men ; by personal bimonthly inspection of yoiu*
men's feet; by inspection of the shoes and socks of your men before
the march; and by the hardening and seasoning of yom* men by prac-
tice hikes. These are all prescribed by War Department orders, and
if their provisions have been inteUigently and faithfully executed
you will have little or no trouble on the march. But if you have
neglected them, your men will suffer, and you may have the mortifi-

MILITARY HYGIENE.

cation of seeing your company crippled })y the disability of footsore
men. Higher commanders now place the blame for tliis condition on
the unit commander. In order to lessen the woes of the footsore,
require your men to start with good shoes and socks, and if allowable
with a pair of gym shoes or shppers for resting the feet after the day's
march. At the termination of a day's march, men should bathe their
feet when practicable in cool water, dry them, and apply clean dry
socks, immediately washing out the pair worn. Blisters are best
treated by zinc oxide plaster or dusting with the regulation foot pow-
der. Prevention is much simpler and more satisfactory than cure of
bruised and blistered feet.

Wlien troops are marching in an inhabited country or when travel-
inof along routes which will be traced or retraced by themselves or
their comrades, it is imperative that the road shaU not be left in a
polluted state. Therefore, when a command reaches the place for the
day's halt, the commander selects sites for latrines, and causes these
trenches to be dug at once. In a fly country a guard is placed over
each straddle trench to compel men to cover their deposit with earth.
Before resuming the march, the site of the bivouac is properly policed.
This constitutes the ''good manners" of an Army.

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LECTURE IV.

THE SANITARY SERVICE OF THE MARCH IN CAMPAIGN.

It may be said that the sanitary service of the march should begin
with the physical examination of the recruit. Napoleon, the most
illustrious of all eugenists, is alleged to have begun before this, when
he sent recruiting sergeants, selected for their mental and physical
qualities, to the villages of France, almost depopulated of fit adult
males by the ravages of war. Certainly the selection, training, cloth-
ing, and equipment of the soldier must be controlled carefuUy, in
order to permit efficiency on the march and in combat, and this can
not be too painstaking and thorough. Given the recruit of proper
conformation, as shown by physical examination, he should be
trained physically and mentally for the duties which will be required
of him. His clothing, shoes, and equipment must be furnished and
adjusted in such a manner as to permit freedom of movement, ^^'ith-
out constriction or interference with organic functions; and he
must be instructed and physically trained by carefully graduated
exercises in use and manner of can-iage of equipment, marching, and
personal and general hygiene. This training must not be excessive
as to duration in time of effort at first, because the average Amerioan
recruit has had httle training in walking and weight carrying, and
his physical development is not completed. Excessive drill will not
only retard his set up and development, but may possibly give a
temporary breakdown in some part of the organs of locomotion
(most frequently in the feet) and by reason of exhaustion and dis-
comfort affect his morale as a marcher.

The sanitary service on the march in campaign concerns itself
with the institution of proper sanitary measiu-es for the prevention
of disease, the care and evacuation of the sick, and the conduct and
administration of the personnel and material for these pm-poses on
the march, in camp, and combat.

The attached sanitary troops, before beginning the march, super-
vise the final sanitation of the abandoned camp, bivouac, or field,
and arrange for tho care and transportation of the sick and disabled ;
usually each battalion surgeon with his imit personnel covering tho
command to which he is attached, under the supervision of the
Burgeon, who makes a final survey of the situation. The battaUon

SANITARY SERVICE OF THE MARCH IN CAMPAIGN. 57

sanitary personnel, consistin*^ of a medical ofFicer, a noncommissioned
oflicer, and an orderly mounted, and one or more litter squads of
two men each, march at the rear of the battalion to which attached.
This position places the sanitaiy personnel at a point whore on the
ordinary march it will be able to obsei-ve the general condition of
the personnel of the command and come up in the course of the
march to any fall outs, without the necessity of special exertion on
their part, or upon the part of anyone in going foi-ward to secure
their services; and permits obsei-vation of signals from the front,
should service be required in this direction. This position at the
rear of the battalion leaves the personnel in position to cover, with-
out unnecessary movement, the battalion or any part of it should
it deploy.

The medical officer with the battalion wdll not at all times confine
himself to a position at the rear of the battahon, but will, from time
to time, go forward to inform himself as to changes in march condi-
tions; the condition of various members of the command he has
imder observation; in response to calls for services; and to observe
conditions of water or other supply on the route of march; and at
halts will supervise disposal of excrement, wastes, etc. Before the
noon halt, if there be such a halt intended, and before approach to
camp, he should ride forward in order to inform himself as to water,
drainage, terrain, etc., in order to give such assistance, from a stand-
point of sanitation, as may be necessary.

Cases, sick or disabled, requiring care or treatment, are sent with
a pass, showmg the name, company, and regiment or corps, of the
sick person, to the medical officer in the rear. The medical officer
returns the pass showing the disposition of the case. The medical
officer should dispose of tliis case according to the conditions; he may
reheve him of his pack, if he be an mfantryman, and require him to
march, or he may put him in an ambulance or any other transpor-
tation, if there be no ambulance attached to the organization ; or he
may require him to march fuU pack, at the rear of the organization,
under observation. Wherever a fall-out is separated from the or-
ganization, he is given a diagnosis tag, showing the orders given him.
The arms and personal equipment of a foot soldier accompany him,
the moimt, saddle equipment, and saber of a mounted soldier are
returned to the troop, usually by the noncommissioned officer, who
accompanies him. (F. S. K., 343.)

Rapidly moving mounted commands will usually have no trans-
portation other than mounts or gmi carriages for the disabled, in
which case, the squadron surgeon, must act m accordance with the
patient's condition, and the circumstances of the march. The pa-
tient may be required to foUow the command at a walk, he may be

58 MILITARY SANITATIOISr AND SANITARY SERVICE.

sent back, escorted or unescorted by a sanitary soldier, with or with-
out wheeled transportation, toward the main body, or the lines of
communication; or he may be left, with or without an attendant, under
shelter, to be cared for by friendly mhabitants or to be picked up
by sanitary troops, furnished with proper transportation.

Whatever action is taken with regard to the disposition of the dis-
abled and their equipment, careful note and report must be made
of it, m order that aU may be cared and accounted for, and at the end
of the march, collected, examined, treated, and, if necessary, evacu-
ated to the rear.

Those sanitary troops attached to separate or independent bat-
talions will have, in addition to their personal equipment, one pack
mule with aid station equipment, which wiU accompany the bat-
tahon combat train, of which it is a part. The sanitary troops
attached to a regiment are usually divided for march, camp, and
combat duties into the battalion or squadron, and headquarters
sections, giving to the regiment of infantry three battahon and one
headquarters section.

The headquarters section usually consists of the senior medical
officer, the senior noncommissioned officer, one orderly, all mounted,
and from two to four privates in numbers, and mounted or dis-
mounted, in accordance with the allowance of men and animals for
sanitary troops of the arm with which they are servmg. The senior
medical officer— the surgeon — ^with his mounted orderly marches
with the staff of the regimental commander, unless there be no other
medical officer with the regiment, then he marches in the rear. He
is required to be with the regimental commander, in order that he
may be available for consultation with regard to sanitary matters,
and that he may be informed as to general and special situations, as
they may arise, relating to various conditions that might affect sani-
tation and care of the troops, and the handling of the sanitary troops;
the selection of camp sites, examination of water and food supplies,
disposal of wastes, and dispositions of the sanitary troops.

The senior noncommissioned officer of the sanitary troops (head-
quarters section) with the privates of the Medical Department
attached to his section, marches at the rear of the last battalion,
with the sanitary troops of that battalion, and has in his charge the
pack mule, carrying the regimental aid station equipment, and the
ambulance, if the regiment is part of a reinforced brigade or division
of which ambulance companies are a component. If the regiment is
actuig independently, he will be in charge of the three or foiu' ambu-
lances and, on an-ival at camps, the wheeled transportation, which
carries the regimental infii-mary or hospital. The position of the
headquarters section of the regimental sanitary personnel at this
point on the ordinary march permits conti'ol of equipment and

SANITARY SERVICE OF THE MARCH IN CAMPAIGN. 59

transportation on tlio march, and in case of deployment leaves this
equipment in proper position, in readiness to advance and establish
where directed. Under this condition the vs^agons of the regimental
infii'mary or hospital would be back in the regimental field train.

On a march in retreat, in a brigade or division, if the regiment is
not acting as advance or rear guard, the distribution of sanitary
troops is the same as given for the ordinary march.

If the regiment is marching alone with an advance guard of one
battalion, the disti'ibution is that of an ordinary march and the
battalion sanitary troops will march with the reserves of the battalion,
with possibly one man with support, if such there is. The formation
will practically be the same for a regiment acting as advance guard
with a battalion as the support — each battalion will carry its person-
nel as usual, the surgeon will be with the commanding officer, and
the battalion forming the support will have one or two men of the
sanitary personnel with the advance party.

In a retreat of a regiment, or a regiment acting as a rear guard,
the reserve will be reinforced by the sanitary personnel from the
main body of the battalion or regiment, in order that the womided
of the retreating rear guard may be rapidly evacuated ahead of the
ti'oops. If ambulances are available, as in a regiment acting inde-
pendently, it may be weU to attach one to the tail of the main body,
between it and the reserve of the rear guard, leaving the pack mule
and remaining ambulances to march with the leading battalion.

Ambulance companies are divisional sanitary organizations, but
for purposes of care and transportation of the sick and wounded,
may be attached to separate brigades, which are operating away from
the division. Under the conditions of the ordinary march, when
hostile contact is not expected, ambulance companies march and
camp together, with the exception of one ambulance company, which
imder proper orders may have its ambulances distributed through
the column, one to each regiment, for use in transportation of the
disabilities that occur on the march. (F. S. R. 341.) Under these
conditions of the ordinary march, these ambulance companies, not
concerned in the regimental service for the day, march as do other
organizations ; their positions ordinarily in the rear of the field trains
when marching as a unit, with their field wagons; when marching
with light transportation (pack mules) only the ambulance compan-
ies march in advance of the field trains.

Under conditions of untrained, or fatigued pei"sonnel, bad weather,
or long marches, action may be taken to increase the number of am-
bulances temporarily attached to the regiment, for the pui'poses
of the march, as much as may be necessary. These ambulances so
distributed to the regiments are for use in transportation of the disa-
bled and their equipment, and must not be diverted to any other use.

60 MILITARY SANITATION AND SANITABY SERVICE.'

They are under the orders of the director of ambulance companies
and their movement will be controlled by hun, in carrying out the
orders of the surgeon or the commandmg officer. At the beginning
of an engagement, or at the end of the march the distributed ambu-
lances will be assembled by the orders of the director, usually given
through the company commander. All disabled sick in the ambu-
lances at this time who require more than temporary care or ti*ans-
portation will usually be sent back by the regimental sui'geon with
ambulances. When they move to assemble in preparation for an
engagement, the disabled will be collected at some central point in
the rear for further evacuation, if on arrival at camp, at the probable
site of the camp infirmary, or to the field hospital for fm*ther treat-
ment and evacuation according to the conditions and orders.

This arrangement of the ambulance companies in column for the
ordinary march, is to perlnit such use of organizations as may be
necessary for the transportation of the disabled, and to permit rapid
collection of the disabled on arrival at camp, without unnecessary
movement of disabled or transportation.

The ambulance companies whose ambulances are not distributed
to the organizations on the march, are held in their position behind
the field trains, as they camp at the rear of the center of the division,
and ordinarily not more than one is concerned in regimental duty.
With this position, they do not become involved in the movement of
the field trains to their organizations or on their return; and are in
position to join the column for the next day's march. . The details
for march duty, with the regiments, will be made by the dhector,
ordinarily by roster, and the positions in column will be determined
in a like manner by the director of ambulance companies, acting as a
battalion commander.

Changes from the routine order of march, will usually be made on
recommendation of the surgeon, in the march order, according to the
necessities of the case. This position of the ambulance companies
behind the field trains, places them sufficiently far forward to permit
m case of rencontre, advance of the ambulance companies sufficiently
early to be of use when required, and yet not have them as far for-
ward as to have them unnecessarily involved in conflict.

The ambulance companies with light transportation, march at the
tail of the combatant column; such a position usually is the result
of a desire to have the more mobile part of the organizations ready
for early use, or is the result of difficult roads, or failure of heavy
wheeled transport; either condition, if the ambulance companies
were kept behind the heavy transportation of the field trains, might
possibl}'- put them so far back as to render them useless.

The usual order of march of an ambidance company is that of
ordinary comimands of mixed organizations. The foot troops, the

SANITARY SERVICE OF THE MARCH IN CAMPAIGN. 61

bearer sections with litters, first, followed by the pack mules with the
dressing station detachment, next the ambulance detachment, and
lastly, the tlii'ee wagons: The first wagon carries reserve dressings
and equipment lor the di"essing station, and, where possible, accom-
panies the di'essing statioji party forward as a combat wagon.

The road distance of an ambulance company on the march without
elongation is 280 yards; the road distance for three ambulance com-
panies with 15-yard interspace, 870; the usual distance given for
four companies is 1,160 yards, but rarely will these be found together.
The director of ambulance companies ordinarily accompanies the
ambulance company in advance on the march, such a position places
him so that he will be able to receive messages from the front and
rear easily and yet supervise the work of his organizations as it occurs.
This advanced position also gives him an opportmiity to famiharize
himself with the conditions of roads, terrain, etc. On ordinary
marches, particularly when the roads are dusty, the dismomxted
detachments of the sanitary battahon are frequently marched together
as a matter of comfort, followed by the pack, ambulance, and wagon
detachments, combined in order of the companies; such action, while
removuig the transportation from immediate control of the com-
mandmg officer, does not cause material delay in going into action;
as these detachments have medical officers m command, and objec-
tion on this score does not hold good, the conditions of the march
are certainly improved greatly.

The march ui the presence of the enemy, where hostile contact may
be expected, requires as it does with the line troops a different
arrangement of the ambulance companies m the column. With the
reinforced brigade, the single ambulance company attached is moved
up in advance of the field trains, to the tail of the column of com-
batant troops, so that it will not be forced to participate in the retire-
ment of the field trains, if such retirement is necessary, and that it
may be in readiness for action should the brigade deploy for attack
or defense, and in case of retreat be sufficiently advanced to permit
detachment of a platoon of ambulances and bearers for duty with
the rear guard for the purpose of expediting the evacuation of the
wounded.

The distance from the reserve of the rear guard to the tail of the
main body of the brigade vtill be about 4,000 yards, a distance that
could be traversed by the ambulance company, if necessary, while
the brigade is deploying, if it were desirable to bring it up to this
pouit. Such action, however, would not be contemplated mitil late
in the action, and if the dressing station estabfishes it will bo well
to the rear. The regimental sanitary personnel will be sufficient to
care for the woimded mitil the dressing station can go into action
and the position of the ambulance company at the rear of the column
is correct for a columii of this size.

62 MILITARY SANITATION AND SANITARY SERVICE.

With a brigade in retreat, however, if the ambulance company
were marched with the leading troops (with the same 4,000 yards
from the reserve of the rear guard), in default of wheeled transporta-
tion the wounded resulting from a general rear guard action must
be abandoned or carried by hand.

If, as mentioned above, a platoon of three ambulances be attached
to the reserve of the rear guard, with five or six litter squads from
the bearer detachment, these reinforced by the regimental sanitary
personnel will be able, imder ordinary conditions, to evacuate a con-
siderable portion of the wounded requiring transportation.

With a division marching in the presence of the enemy or when
hostile contact may be expected, ambulances will not be distributed
to the regiments, but will be held with the ambulancte companies.
With the normal advance guard of one brigade, one ambulance com-
pany will be attached to the advance guard and march usually at
the rear of the reserve, as the distance from the tail of the reserve
to the tail of the combatant troops of the main body wiU, without
elongation, be some 7 miles, a distance too great to permit a unit
of the size of a brigade to be without medical assistance other than
the regimental personnel during the time it would take an ambulance
company to come to the front. If a general action is imminent, the
advance guard will be engaged for a considerable time, and the ambu-
lance company, equipment, and personnel will be required early. If
the advance must continue, this equipment will be required to take
over the woimded and release the regimental personnel, so that it
can continue with its command. If a retreat is required, this organ-
ization, well up to the scene of action, offers the only means of evacu-
ation of the wounded.

The positions of the sanitary imits of a aivision m retreat are
identical with those of a march formation with advance guard, ex-
cept that organizations are faced about, and, if necessity arises for
delaying actions of some duration, the ambulance companies with
the brigade rear guard may be reinforced by additional ambulance
and bearer platoons, in order to expedite the evacuation of the
womided of this force, which must retreat soon.

Flank guards of a brigade or more, when detached a sulhciont
distance from the main body to warrant such action, should b(^
furnished a proportional amount of sanitary assistance. As such a
command must keep in movement consonant with the movement of
the main body, it must not be impeded by the disabled, and th(>
allowance of ambulance company personnel and equipment should bo
li})eral. The method of distribution of sanitary personnel of a flank
guard on the march is that of a brigade or division when hostile
contact is expected.

SANITARY SERVICE OF TTTE MARCH IN CAMPAIGN. 63

The distribution of the three ambulance companies on the march
with a Cavah-y division conforms to that of an Infantry division,
except that on account of the superior mobihty of the Cavalry
division on marches where contact may be expected, it may be fre-
quently necessary to carry the packs of the dressing-station equipment
and bearer detachment in ambulances, leading the unloaded puck
mules from the tails of the ambulances in order to keep up with the
command; the wagon transportation being directed to follow at best
speed consistent with constant marching. Such an arrangement per-
mits these organizations to go forward with all the speed that can be
expected from mule-drawn wheel transport. When getting into
ground unsuitable for wheeled transportation, the pack mules can be
reloaded and the bearer detachment move out on foot from the
ambulance head with light transportation.

The position of the field hospitals of an Infantry division on an
ordinary march is at the rear of the ambulance companies, which are
preceded by the field trains — the director of the field hospitals usually
marches with the most advanced organization. The duties of the
field hospitals on the ordinary march are limited to arranging for
estabhshment of sufficient equipment to shelter the daily increment
of disabled, prior to evacuation. As these organizations camp,
usually with the ambulance companies, in a position to cover the
rear of the center of the divisional camp, their place in the columil
coincides with this intent and permits entrance into the column the
following day without confusion.

The necessity of use of field hospitals in action, such as would occur
only under the conditions of a meeting engagement, does not require,
and in fact forbids early establishment; and the position of the field
hospitals in this column, some 8 miles from the head of the main
body, keeps them well out of range of light artillery fire and yet
permits arrival in proper position within two hours if necessary.
Wliile the field service regulations require a field hospital to be
located, so as to permit early care of the sick on arrival at camp, the
camp infirmary, marching at the rear of the brigade, now provides for
and can do this, until the estabhshment of the field hospital. Under
conditions where delays of trains may occur, a field hospital may be
marched at the tail of the main body, in order to place it in position
to estabhsh an hour and a quarter earlier. As the road space of a
field hospital company is only 160 yards, such an arrangement will
have little effect in displacing the field trains to the rear.

Field hospitals with organizations marching when hostile contact
is expected march with the ambulance companies in advance of
the field trams, some 6^ miles from the head of the main body in posi-
tion to halt in readiness to establish or march forward according to
the necessities ; should the division deploy, this position in the column

64 MILITARY SANITATION AND SANITARY SERVICE.

puts them v/ell up to the front and clears them from bemg involved
in the field trains should action occur. This is essential, as the trans-
portation of these organizations, field wagons, is heavily loaded and
can not move with rapidity. Position of these organizations farther
forward with the column would expose them to involvement in the
movements of the combatant troops and possibly to artillery fire with
no advantage, as these organizations will not ordinarily be needed
mi til the action has well developed, and in their present position have
ample time to establish whenever ordered.

Field hospitals attached to brigades acting independently conform
to the same conditions as in the march with larger units. Advance,
rear, and flank guards of less than a division do not ordinarily have
field hospitals attached to them but depend upon the field hospitals
attached to the mam body.

In the retreat the positions of the field hospitals are the same as in
the column on a march to the front, the advance when hostile contact
is expected, except that the organizations are faced about. Owing
to the slow movement of these organizations the transportation and
material could not be used nearer the enemy, but the pei-sonnel will
be available to assist the ambulance companies with litter bearers, in
evacuating from the front, and for care of excess wounded sent back to
the sanitary, field, ammunition, and supply wagons for transportation.
• All movements of the divisional sanitary units other than those
routine to the march are directly controlled by orders from head-
quarters of the command, usually upon the recommendation of the
surgeon of the command. Detachments for ambulance duty with
regiments, advance, rear, and flank guards, are made by roster, where
possible; where organizations are on continued duty as flank guards,
etc., it is advisable not to make frequent change of sanitary imits, on
account of the unnecessary movement involved. The orders with
regard to the sanitary troops may come from the combatant com-
mander, or from the surgeon, when such authority is delegated to him.

Under the changes of the Tables of Organization, 1914, and Field
Service Regulations mentioned, the Reserve Medical Supply Com-
pany will cease to exist, and it will not be considered.

The relations of the lines of communication, sanitary service, to
the march in campaign consists in the renewal of the teclinical sup-
plies of the service, by timely issues, renewal of personnel, and the
evacuation and care of the disabled. With the ordinary march these
duties lie largely under the control of the surgeon, advance group, of
the line of communications, whose duties are practically those of an
advance field and forwarding agent for the surgeon of the base group.
With the line of communications short, and near the base, and efii-
cient transport lines by rail, water, or motor between the base and
the transportation head, there will be little intervening in the way of

SANITARY SERVICE OF THE MARCH IN CAMPAIGN. 65

sanitary establishments or e(iuipment; but as the hne extends, estab-
lishments and units must be brought up and pLaced in accordance
with conditions and requirements. Under the conditions of the long
line of communications, intermediate medical groups maybe required.

The duty of supply for the sanitary units, which start the cam-
paign with sufficient medical supplies for one month, will be handled
by timely issue from the advance medical depot, usually at a rail,
water, or motor head. These supplies for issue must be sent for-
ward to the distributing point by lines of communications trans-
portation (as the abolition of the Medical Reserve Supply Company
l)y recent action furnishes no supply wagons for this purpose)
and will there be taken over by field wagons of the ambulance com-
pany and field hospital companies, which will issue to the organiza-
tions, as required. Requisitions for supplies required will come
from the chief surgeon of the units requiring these supplies, and
probably they will be issued under his direction. This matter of
issue under the new conditions has not been worked out as yet, but
the method given follows the former method. Issues to regimental
.sanitary service can be made by using the regimental pack mule as
transport, or by the camp infirmary wagon attached to each brigade.
The tecluiical supplies required consist of medicines, dressings, and
hospital stores, such as arrowroot, chocolate, extract of beef, spices,
soap, candles, evaporated milk, tinned soups, etc., all packed in
convenient standardized containers; the medicines and foods in tin,
whenever their chemical properties permit. Shipments of supplies
of tliis character, on account of the urgent need for them, usually
will be accompanied to the distributing point by a noncommissioned
officer of the sanitary service of the advance group, in order to insure
rapidity and certainty of delivery.

The service of the evacuation of the disabled sick of the marcli
in the campaign will be organized on the same basis as that for
those resulting from combats. The daily increment of sick for
trained troops in campaign, as given by Straub, will average about
1 per cent, divided into the following classes:

J. Sick in quarters: Percent.

(a) Able to do duty (light) 0.3

(b) Unable to do any duty 3

2. Sick in hospital:

(d) Severe 15

Class.

Duration

treatment

(days).

Average

days of

disability.

Day when
maximum
number is
reached.

3-5
5-14
14-50

d . .

98756°— 17-

66 MILITAEY SANITATION AND SANITARY SERVICE.

But with relatively untrained troops or difficult conditions of
march, weather, improper food, etc., these averages may be much
increased — even from 5 to 15 per cent.

The cases covered by classes (a) and (b) , amounting to 6 per thou-
sand, will under ordinary conditions of march recover within three or
four days; a considerable number of these may be able to march
without equipment or ride on the field wagons and be available as
guards, etc. It would be uneconomical to send these to the rear, and
ordinarily they can be cared for in the regiment or at the camp infir-
mary and sheltered with their own equipment. Classes (c) and (d)
will average from 10 to 30 days lost by sickness, and will require hos-
pital treatment. Such cases can not accompany the command, and
must be evacuated. Sick call will be held by the attached sanitary
personnel, and the light cases separated from those requiring evacua-
tion to the rear. The light cases vnJl be treated by the regimental
sanitary personnel, or if their equipment is sufficient, at the camp
infirmary; a classified sick report will be ma-de to the division sur-
geon and the evacuation cases taken to the camp infirmary in order
that they niay be collected by the ambulance detachments assigned
to this duty. From the brigade collecting point the evacuation cases
are taken to the field hospitals, designated to receive these cases,
pending evacuation, or if the fines of communication, sanitary trans-
port head, such as a transport column, or hospital ship, or train, is
sufficiently near to require no extended movement by the ambulance
company, which in all probabifity has made considerable march, the
disabled may be defivered directly to the fines of communication;
such conditions are unusual, and the chief surgeon \\dLl ordinarily
require defivery to the field hospitals.

The director of field hospitals, fike the director of ambulance com-
panies, will receive information from the division sm-geon as to the
number of evacuation cases, and each of these officers will have desig-
nated the units to take care of the transportation and shelter these
cases, and they vrUl be held at the field hospitals pending arrival of
the lines of communication, transport colunm. These cases for a
division will amount to about 75 men, of which a considerable num-
ber will be recumbent. The total sitting for an ambulance company
of 12 ambulances is at most 108. The total recumbents 48, ordi-
narily, one ambulance company will be sufficient to collect them, and
for pm'poses of economy in travel that company assigned for duty
with regiments on the march will usually be designated as a routine
for this duty by the director of ambulance companies, as it has
marched in ■svith the regiments and is iJi-cad}^ loaded \nth some of
the cases, and Mali collect the remainder while at the regimental camp
or at the infirmary.

SANITARY SERVICE OF THE MARCH IN CAMPAIGN. 67

The capacity of the field hospital is 216 beds; it will sot up such
bedding units as required for the disabled, using available shelter,
when possible, in place of tentage.

The division surgeon will notify the hues of communications of the
number and classification of cases as soon as they are reported, and
give the point at which they are collected. Owing to the fact that
lines of march may be changed and means of transportation fail, the
advance surgeon will have his transport column of mule ambulances
or motors well up to the tail of the column, in the zone of advance at
all times, in order that field hospitals may be evacuated as speedily
as possible. Evacuation of the disabled will be effected as rapidly
as possible to rail or water transportation heads, if practicable, dis-
tance, weather, and road conditions considered. If evacuation can
be made by rail or water, as when the line of march follows or inter-
sects such routes of transportation, hospital trains or boats will be
arranged for to arrive at a place and time agreed upon by the division
surgeon and the advance surgeon. If evacuation must be by road,
such a route should be selected as wiU be different where possible from
that traversed by the ammunition and general supply trains, in order
to prevent interruption and congestion of traffic. Rest stations must
be established, if the number of wounded and distance of march war-
rant them. Evacuation by rail or water will require receiving detach-
ments at the transportation head, with minor fixed hospitals at the
refilling point, or back farther on the line for arrest of the cases of
lesser gravity, with rest and feeding stations for improvised ambulance
trains.

Dm'ing the march in campaign the evacuation hospitals attached
to the line of communications will be kept well up to the head of the
line, so that they may be available for rapid movement to the front.
These units are without specially assigned transportation and must
use water or rail transportation where possible.

Wagon or motor transport from the rail or water head niust come
from the lines of communication for the final movement to the relief
of the field hospitals. Under conditions of necessity these organiza-
tions may be used as receiving hospitals on the lines of commimica-
tions, but their mobility must be impaired as little as possible, and
when filled, substitute organizations must be sent up from the rear.

Convalescent camps and sanitary detachments may be estab-
lislied in the advance medical section of the lines of communications
under special conditions, but ordinarily these will be back in the inter-
mediate or base groups.

The service of supply of sanitary personnel begins within the home
territory. Drafts of sanitary troops are forwarded to the base of
the lines of communications and held in causal camps, under the
control of the surgeon, line of commmiication, and under the authority

68 MILITAKY SANITATION AND SANITARY SEEVICE.

of the commanding officer, line of commmiication, assigned to duty
on the line of communication, for organization of new units, such as
fixed hospitals, rest stations, convalescent camps, etc., or to the
organization in the zone of the advance. The relations between the
sanitary service of the zone of advance with the line of communica-
tion must be carefully accorded, or much difficulty will result.
Constant communication must exist between these sections and
between the sections of the line of communication themselves, and
the various officers of these sections should be given wide latitude
as to arrangement of the duties of their service.

The essential features of the sanitary service in campaign are
prevention of disease and care, and prompt graded evacuation of
tiie disabled, in such a manner as to keep the units organized, supplied,
and unencumbered, so that they will be available for use under stress
of a large increment from epidemic or combat, and yet move no
case farther to the rear than his condition requires.

LECTURE V.

SANITARY SERVICE OF THE CAMP.

The sanitary service of the camp should begin with an examination
of the camp site, as to position, drainage, soil, vegetation, shade,
evidence of recent occupation, medical history of the tract and
vicinity, and presence of objectionable insects; the investigation of
source, purity, and quantity of water supply, and means of distribu-
tion—food supply, as to quantity and quality, purity and method of
handling, and quantity and quality of wood and straw, and location
and availabihty, and the location of buildings, roads, and means of
transportation that might be available in the care or evacuation of
the tUsabled. Such an investigation should be made for every camp
or bivouac by a medical officer, sent ahead with the quartermaster,
who will perform similar duties in conjunction with the medical
officer.

Mihtary necessity under stress of campaign or combat may require
that the various considerations inquired into be ignored in part or
altogether — for very temporary camps or bivouacs, for large or
small commands, but early search for proper sites, fulfilling the con-
ditions to be discussed later, will result in such material advantage
to the command, in the case of supply, early establishment without
confusion, comfort, and preservation of good feeling and health, that
such action should never be omitted either for march bivouacs and
camps or semipermanent camps.

The position or situation of the camp with relation to towns, vil-
lages, rail or water transportation lines, and roads must be consid-
ered from the standpoint of supply, shelter, and means of transporta-
tion for the command and the sanitary service, as well as with regard
to transmission of communicable diseases within the native popula-
tion, or in the command. The situation of the camp site, with re-
gard to protection from prevailing winds or exposure to desirable
breezes, proximity to insect-producing streams, swamps, or collec-
tion of decomposing organic matter; possibility of flooding in wet
weather; or dust, or sand storms in the dry season; prevalence of
fogs, and nearness to potable water and other supplies in sufficient
quantity; and accessibility to transportation must be given due
weight. Poor drainage or a high level of ground water will not only

70 MILITARY SANITATION AND SANITARY SERVICE.

affect the comfort of the command by keeping them constantly
damp and possibly cold, but wiU actually conduce to transmission
of infections, by interfering with disposal of waste, and may pro-
duce collections of water sufficient to produce breeding of diseased-
carrying insects — aside from the material damage done to equipment
and dispositions.

Soil conditions such as presence of a high content or organic mat-
ter, or clay, conducing to retention of moisture, fine sand, to the ex-
tent of dustiness, are objectionable and unhealthy and should be
avoided.

Rank vegetation on a camp site furnishes shelter for insects, pre-
vents drying of soil sufficient to permit a dry camp or bivouac, col-
lects dew and rain, and in general indicates a high organic content
and high ground water, and should be avoided, or if time permits,
eliminated. Excessive shade produces the same conditions that does
rank vegetation and should be avoided. Camp sites should in gen-
eral be in the open not only to give the sod the benefit of the drying
effects of the sun but also that most important effect, disinfection.
Shade is as valuable and enjoyable for the soldier as for any one else,
and shade trees in the vicinity of a camp in the summer season are
highly desirable, but given the choice of canvas under the sun or
shade, choose the' sun.

Careful examination of the history of cholera and typhoid in the
mihtary service has forced the conclusion that commands, camping
on sites formerly occupied by infected contmgents, have frequently
derived their infection by occupation of old sites, and has led to the
avoidance of these wherever possible. Experience with typhoid in
our own service during the Spanish War, that of the Enghsh in the
Boer War, and that of the Germans in the Franco-Prussian War has
led to this conclusion, which was confirmed by bacteriological inves-
tigation of the soil and water supply. The presence of disease-carry-
ing insects must be considered with the medical history of the vicinit y
of the camp; such history can usually be ehcited by questioning thv
people hving in the neighborhood, or consulting towni registers, or
health officers, with regard to the prevalence of tyj^hoid fever,
cholera, dysentery, malaria, yellow fever, dengue, typhus, and
cerebrospmal menmgitis.

Typhus is a disease which wo need not consider ordmarily in the
United States but, smce the constant prevalence of an attenuated
form in New York has been proved by Brill and confirmed by the
discovery of the causative microorganism and method of transmis-
sion by the body louse, this disease, always present in Mexico, must
be of mihtary in,terest. This particularly in view of its appearance
in some European armies, under good sanitary control, in the present
war. Presence of insects, such as fleas, mosqmtoes, ticlis, and bugs,

SANITARY SERVICE OF THE CAMP. 71

and lico, must not only be considered from the standpoint of disease
carriors, but also from consideration of personal comfort; for wliile
the buffalo gnat, the black flies, the Canadian flies, and the various
midges, and deer flies may not be as yet implicated in the carriage
of diseases, their presence in considerable number not only will worry
a command to the point of complete loss of rest, but they may mate-
rially affect the animal transportation. Investigation of the water
supply vnll be made by gross examination, as to color, odor, taste,
with a survey of the som"ce, watershed, with an inquiry as to the
history and use of the water and natives using it; and, if time and
apparatus be at hand, a chemical and bacteriological examination.
The quantity must be measured, and estimation of the amount re-
quired by the command must be made on the basis of the need, for
the type, and duration of the camp, and the character of methods of
distribution and sanitary installations. The food supply will also
be investigated on the same basis as is that of the water, particular
attention being given to milk and beverages, and method of han-
dling. The quantity of the local food supply will be investigated
with view to procurement of special diet articles for use of the sani-
tary establishments, as will also the quahty, quantity, and location
of wood, straw, and forage items essential to the comfort of the sick
at all times and to the whole command in inclement weather, when
a timely certificate, given by the medical officer to the quartermaster,
may result in the avoidance of a materially increased sick report.

The investigation of means of shelter and transportation and con-
dition and direction of roads may later have an important value in
the location of sanitary miits and the evacuation of the wounded;
and should not be neglected by the medical officer, sent in advance,
as he will usually have time and opportunities to survey the country
before it is occupied by troops, and can acquire a much better idea
of the general conditions than officers arriving later.

Having reported the results of liis sanitary survey of the camp
sites, the sanitary inspector wiU consult with the advance quarter-
master as to distribution of water guards and water supply or dis-
tribution points, and location of unit camps, in order to prevent con-
tamination. In large units, ordinarily a special quartermaster and
sanitary officer mU be detailed for selection of the site, the march
camp, or permanent camp, and they should coordinate their duties
as much as possible on the basis of practical efficiency.

SANITARY ROUTINE.

Given the camp site selected and the various investigations com-
pleted, the sanitary inspector reports the results to the commanding
officer, or the chief surgeon if there be one. If the camp is to be a

72 MILITARY SANITATION AND SANITARY SERVICE.

permanent one the sanitary service concerns itseK with the supervi-
sion of the various sanitary establishments, the details of the hand-
ling and periodical examination of the water supply, the chsposal of
waste water, and wastes, such as human and animal discharges,
kitchen wastes, the examination of the food supply and its prepara-
tion, the investigation of the health and habits of the command, the
prevention of disease and the care and evacuation of the sick, and the
organization and training of the sanitary personnel.

Orders concerning the special detail of the sanitation of the par-
ticular camp are recommended, and periodical inspection is made,
both by the general sanitary inspector of the camp and also by the
senior medical officer. Special sites for the camps of cU visional san-
itary units are arranged for and camp hospitals are established. Camp
hospitals are a revived feature of our service, the particular function
of which is to care for the temporarily or semipermanently ill, pend-
ing evacuation, in order to prevent the field hospitals from becoming
immobihzed with disabled and thus lose the freedom of action neces-
sary for training or movement with the combatant organization to
which attached. The camp infirmary will be situated, where a camp
conforms to the scheme laid do^\Ti in the diagram in field service regu-
lations, in such a position as to permit ready access from all of the
regiments of the brigade to which attached, and with personnel
assigned by the senior medical officer of the biigade from the regi-
ments which the infirmary serves; and vnR be available as a collect-
ing point for temporary treatment and evacuation of the sick. Dur-
ing occupation of the camp the ambulance companies wiU be available
f(^r the transportation of the sick from the camp infirmaries to the
camp hospital, and from there to the evacuation transport head, if
the command is not under campaign concUtions or the distance too
far. In such case the fine of communications, if they exist, wiU be
called upon to perform evacuation from the camp hospital. The
regimental sanitary personnel will, in the permanent camp, busy
themselves with the physical examination of the command with
respect to their general physical condition and freedom from disease,
and fitness for the field, with the examinations of recruits, the admin-
istration of propliylactics for prevention of infectious diseases, and
the examination and the care of the sick and the sanitary inspection
of the camp site, and environs of the command to wliich attached,
and the instruction of the sanitary personnel in tlieir duties, and the
ofiicers of the combatant units in the first aid and personal hj^giene.

For purposes of instruction and duty the regimental sanitary per-
sonnel may bo divided into squadron or battahon sections as outfined
in previous lectures. With this system in use, sick call will be held ui
each battahon by the medical officer on duty with the battahon
assisted by the noncommissioned officer on duty with the battahon

SANITARY SERVICE OF THE CAMP. 73

Boction aiid a. momoraudiiui sickroport sent to Uic n^gimental surgeon,
too-ethor witli sucji sick as require treatment not afforded by the
personal equipment. The battalion sick reports will b(^ consolidatcul
and the sick requiring special treatment or evacuation will be sent to
tlie cam]) infirmaries.

As a routine, ambulance detachments will visit the (;amp infii-m-
aries twice daily, and specially in emergency, and clear them to the
camp or field hospitals. For emergency duty in treatment of tlie
sick, etc., one battalion sanitary personnel miit mil be detailed for
(l^ity — the medical ofiicer being required to act as regimental sanitary
inspector for the day; to attend to emergency calls and examinations,
such as the examination of recruits, etc., the enlisted personnel assist-
ing in this work, night nursing, etc., in addition to their routine.

Tlie duty tour for the emergency scpiad is usually 24 hours, during
which time they will remain in the vicinity of the regimental sanitary
equipment and camp. The emergency officer will mark his tent by a
red cross guidon by day, and a green lantern at night, so that his
whereabouts may be known, and will notify the emergency sergeant
of his whereabouts, if it is necessary that ho leave the vicinity of his
duty and assignment.

Each medical ofiicer will form a sanitary squad of his battalion imit
and will be held responsible by the surgeon for the sanitary inspection
and condition of the area assigned to the battaUon. The sanitary
squads will be responsible for the sterifization or treatment of the
water for their battaUon and the supervision of the details of disposal
of wastes, sanitary police of the area, including drainage and oiling of
pools, policing of latrines, and abolition of sanitary nuisances.

The battafion surgeon will observe the condition of the battaUon
personnel as to health, habits, clothing, and food supply, making
frequent inspections of meals; will be charged with the physical
examination of the personnel under his charge and will be authorized
to make direct recommendations to the battaUon or company com-
manders concerned for the betterment of sanitary conditions in
accordance with the poUcy laid down by the regimental surgeon.

The division of duty in this manner does not reUeve the regimental
surgeon from responsibility or duty in this connection, as he should
make daily sanitary inspections of the camp and command, but
permits more rapid amelioration of sanitary conditions and gives each
medical officer a definite personnel and miit to which he is attached.
Such continuity of duty gives the medical officer a closer knowledge
of the individuals mider his care and supervision, and produces the
best results in medical and general service .

The enlisted sanitary personnel become acquainted with the
individuals of the battaUon, with which they are on duty and are able
to fiuTiish valuable information, both to the combatant personnel

74 MILITARY SANITATION AND SANITARY SERVICE.

as to sanitary proceedings, and to the medical officer as to the habits
of the men as affecting their general status. Sick call held in the
battalion area instead of at the regimental aid station, will be finished
without loss of time, and will generally carry less malingering to
escape fatigue duties; the service is brought to the men, by an officer
who knows them, mider conditions which will exist more or less in
campaign for which all are being trained.

The sanitary inspections of the camp, kitchens, latrines, incin-
erators, dumps, etc., will be made at such an hour that will permit
completion of the routine poHce of these installations in order to give
an idea as to the character of this work; and, in order that this may
be properly accomplished, the general sanitary order must fix a time
for the completion of this police. Inspections will also be made at
odd times in order to gain information as to whether the maintenance
of this police through the entire day is satisfactory. Ordinarily the
battahon surgeons will accompany the regimental surgeon on his tour
through their areas, and the regimental surgeon will accompany the
camp sanitary inspector through the regiment. At these inspections
sanitary defects will be noted and memoranda made by the inter-
ested medical officers. The medical officers responsible for the areas
found defective will report them to the combatant officer responsible,
with suggestions as to correction, and, if thought necessary, to the
commanding officer of the unit, either verbally or in writing. Fre-
quently camp or regimental orders require corrections of defects
reported by a sanitary inspector without requiring reference to the
camp or regimental commander, and it is customary to invite atten-
tion of regimental, battahon, or company commander to sanitary
defects that require only local action, without making special report
to higher authority, making written note of such action. Such direct
methods, if carried out in proper manner, prevent delays and ordi-
narily accompHsh the results most satisfactorily.

The first sanitary inspection occurs in the fixed camp in the morn-
ing, usually about 9 o'clock, an hour at which routine police of
kitchens, streets, latrines, picket lines, and areas is usually com-
pleted, leaving the remainder of the morning for administration
duties and instruction. At this time will occur the biweekly physical
examination of the command, usually in the company streets, by the
medical officers combined, moving from one battalion to another, in
order to perform this duty as rapidly as possible with lack of exposure.
In camps where it is difficult to secure security from observation it is
well to fix a time of assembly immediately after reveille for this pur-
pose, at which time there is sufficient light and freedom from visitors;
but in bad weather, incfined to be chilly, an hour nearer noon is
advisable.

SANITARY SERVICE OF THE CAMP. 75

Tlio administration of prophylactics by hypodcu-inic injection will
usually bo done in mobilization camps, at cantonment, or field hos-
pitals, in preparation for field service; but exposure to special dis-
eases may require administration in the field. This will usually be
done by combining all available equipment and marching sections of
the command to the camp infirmaries, or if the command be small, to
the aid point; propliylactics for prevention of venereal diseases will
be available at the organization sanitary aid point.

In camps of instruction and mobilization, drill, and instruction
should be carried out thoroughly, and the regimental surgeon will not
only instruct the sanitary troops proper in their duties in camp,
march, and combat, but will, if authorized, have the band participate
with the sanitary troops in this instruction. The band is an essential
aid to the sanitary service in combat and must not only receive drill
and instruction for this service, but with the sanitary service receive
special physical training to prepare them for the severe effort which
will be required of them. Neither the duties of the personnel of the
band or of the Hospital Corps in time of peace give them the physical
fitness that litter carriage requires and the requirements of combat
will find them inefficient unless this is done.

The entire command must be instructed in the hygiene of the in-
dividual, and of the camp, march, and battle, and, while the regula-
tions require instruction by the company officers, it is thought best
that in preparation for campaign this instruction be given the regi-
mental medical officers, who are especially quaHfied in this work.
The command should be instructed in the construction, use, and
police of the various devices required in the sanitation of the perma-
nent or the march camp, and one definte system should be constructed
and demonstrated for each condition. At present so many types of
camp sanitary installations are used that much confusion results.
Most of these devices are good, but many of the best require so much
labor, material, and time in their preparation that their construction
and use as a means of camp sanitation is inadvisable. In order to
attain some idea of standard measures or devices for camp sanitation
these }vill be discussed as briefly as possible.

WATER SUPPLY.

Amount required depends upon type of camp, method of distri-
bution or supply, sanitary installations, and weather. Camps with
piped supply to company kitchens, shower baths, and water carriage
sewer systems in hot weather will require 25 gallons per diem for
each man and 10 gallons for each animal. Bivouacs and march
camps will require a minimum, 1 gallon for each man for drinking
and food, and from 5 to 7 gallons to each animal. This where water
must be carried by hand for personal and kitchen use and the ani-
mals taken to it. For purposes of ablution and kitchen service, this

76 MILITARY SANITATION AND SANITABY SERVICE.

must be increased by at least 3 gallons per man. Requirements of
procurement from natural containers as streams, ponds, springs, and
wells wdll require designation of special points for procurement for
water for drinking, cooldng, and for use of animals, and washing
and bathing, in order to prevent pollution and soiling; and guards
to enforce the regulations. These arrangements will be made in ad-
vance as mentioned above and required by Field Service Regulations
240, and consideration given as to the most available means of sort-
age and disinfection if such be found necessary.

Means for storage must be taken in case of insufficient supply
early before time of expected use, ordinarily improvised from ma-
terials at hand. In the choice of these materials care must betaken
that these are sufhciently clean for the purpose, and if there is any
doubt of the purity of the water or storage containers measures of
disinfection must be arranged for. At the present date there are
three methods by wliich this may be accomplished with equipment
at hand or improvised in march camps or bivouacs. Boiling in in-
dividual or organization containers, precipitation with chemicals and
filtration with the various types of filters, or sterilization by chemi-
cals in special containers. Of these the tin cup and canteen, or the
company kettles serve for boihng; for precipitation and filtration
the Darnall filter as issued is satisfactory; and for chemical sterihza-
tion the Lyster water bag serves most satisfactorily, on account of
ease of transport and rehabihty. The Lyster bag is now a part of
the company equipment. The last two methods however require
special equipment and are not always at hand. Where possible the
matter of water steriUzation should be turned over to the sanitary
service, in order to give it responsible supervision, and can ordi-
narily be handled by the battahon sanitary detachment, if it is af-
forded transportation or aid for procurement and dehvery. It can
be considered as constantly ti-ue that water from the average stream
or pond in any moderately populated area is infected and will require
sterihzation. K this is so, some special sterilization apparatus will
be necessary. Of these the most efficient, bulk, weight, and de-
livery considered, is the bag with the chemical agents.

For permanent camps the water should be delivered in such a
manner that it will not require treatment by the troops and, if such
action is necessary, treatment must be done at a central plant,
under proper direction and control, with the usual bacteriological
checks by a laboratory designated for this purpose.

Care must be taken in camps supplied by pipe to prevent waste
and give sufficient drainage about points of delivery. It can not be
too much impressed upon organization commanders that wells, as
sources of water supply, can not but be regarded with suspicion with
regard to capacity.

SANITARY SERVICE OF THE CAMP. 77

Ordinarily there is at hand no method of judging capacity except
by the testimony of inhabitants. Tlic demands of a single family
or group of families upon a given well is usually so small that the
ordinary well gets a reputation for inexhaustibility. The first 15
mijmtes or half hour after the arrival of a regiment fmds the water
taken from the two or tlu-ee wells available, roily, and another
quarter of an hour frequently finds them exhausted. If they are
not exhausted the constant demand has brought in surface water,
l(M) rapidly filtered through the earth to insure precipitation or
nitrification, and as a result we find the neighborhood privy vault,
cesspool, or barnyard puddle contributing its moiety to the liquid.

The average reginaent can wreck a pump, curb, and casing in half
an hour, and, if method of removal is not regulated and controlled,
pollute the well contents by drippage from dkty boots within that
time. The essentials for preservation of a well and its equipment is a
guard who will require that no vessel smaller than a bucket is filled
at the well and that the method of removal proceed carefully under
his control without wastage, and that no refilling be done within 40
feet of the well, and that removed from trails which would lead to
muddying and soilhig of the curb.

An almost indispensable equipment for the procurement of water
for a battalion or regiment in campaign is a horizontal marine pump,
with 50 feet of 3-inch suction and 25 feet of delivery hose. Such an
apparatus is relatively indestructible and will give sufficient delivery
for the command without soiling of the source of supply. It can
be controlled by one sentry, and worked by the company water
detail. After a command is trained to its use, no sentry is required
other than for general patrol of the general water supply line.

FOOD SUPPLY.

The sanitary service wiU examine the food supply from aU sources
with regard to its quantity, quality, source, methods of handling
and preparation, this by inspection of the quartermaster issues,
method of transport to the organizations, and care and storage
therein. Company kitchens and messes will be inspected with regard
to their cleanliness, the method of storage and haTidhng food, and the
personnel of the kitchen will be scrutinized, with regard to possibility
of their being carriers of infectious diseases.

Under the stress of march conditions and the necessity of local
purchases the especial care in examining food supplies, that is used
in time of peace may not be used, and supply from the quartermaster
must be as carefully inspected, as that offered for sale from civil
sources. Inspection of abattoirs, storage plants, butcher shops,
groceries, and dairies furnishing supplies must be made and action
be taken to prevent entrance into camp of supplies from noninspected

78 MILITARY SANITATION AND SANITARY SERVICE.

and insanitary sources. The general provision that articles shall
not be offered for sale within the camp Hmits except at authorized
estabhshments, under military control, will materially limit con-
sumption of insanitary foods, and, imder proper conditions the
visiting of insanitary establishments may be forbidden. With large
forces the use of a mobile laboratory will materially aid the work
of examination of food and water supply. Such organizations are a
feature of the sanitary service of all European armies and are author-
ized and have been used in our own.

DISPOSAL OF WASTES.

Like the water supply the methods of disposal of wastes of camps
are dependent upon permanency, purpose, and supply of the camp,
the environs, character of the soil, the drainage, and the appropria-
tion available; and the individual who adapts his methods to these
conflicting conditions will accomplish the best results.

Permanent camps and cantonments will undoubtedly save in the
long run by installing a proper water carriage system for disposal of
body discharges and Hquid wastes, but ordinarily the initial expense
is too great m consideration of the allotments for this purpose.
The danger of production of epidemic diseases by insect carriage
from human discharges, as proven within the last 20 years, has
caused the adoption of many expedients for the proper disposal of
feces, urine, and garbage; aimed at prevention of contact with or
breeding of fhes in wastes. These vary from, destruction of wastes
by fire to storage and disinfection.

Destruction of human wastes by fire is imdoubtedly an ideal method,
but it has been found expensive, and the various incinerators used
have been so bulky and heavy that it is only adapted to fixed or
permanent camps and cantonments ; and there are other less expen-
sive means that have been found effective. The average initial cost
per seat of the latrine incinerator has been some $40, and while they
have materially safeguarded health these devices have not been an
unalloyed comfort, as anyone can testify who has had his appetite
materially affected by fumes from the stewing contents of the pans
carried by on an unpropitious breeze. Another objection to these
latrine incinerators is that in ordinary camps conditions will require
use of some extemporized latrine, usually some type of trench, and
troops should be trained m their use and construction under favorable
conditions.

The large camps are ordmarily estabhshed for purposes of in-
struction, mobilization, or concentration, usually with personnel
that requires instruction in general, and they should here be shown the
latrine that will be used by them in campaign. For camps of more

SANITARY SERVICE OF THE CAMP. 79

than one day, a trench of sufficient width (2 feet), and depth accord-
ing^ to probable duration of the camp, and len<^th proportioned to
the command it is to serve, is required. Seats should be in the pro-
portion of 1 to each 10 men and length on the basis of 2^ feet to
each seat. Field Service Regulations, 246, provides for 6 feet as the
depth for permanent camps; such depths should depend upon the
character of the soil formations.

Access by flies must be prevented by police with earth or other
suitable material, if fly-light covers can not be made, and some means
of support such as the pole in ordinary use should be provided. It is
needless to say that where possible arrangements should be made for
seat covers. In arrangmg the seat hole, it will be found an excellent
plan to make it sufficiently long from front to rear, and this can be
done by cutting out a notch in the front and rear for the purpose of
preventmg contact with the seat, at these points, and soiling by
urme and feces. A special urine trough protected from flies by use
of crude oil should be provided where possible. A very necessary
precaution to prevent flooding is the construction of a ditch or dike
well away from the trench to prevent access by storm water. The
burning of oil and straw or similar material does not accompUsh
disinfection to any extent, but does destroy fly eggs laid on the surface
and furnishes a layer of oily ashes and soot, which covers the surface
and walls of the pit and renders it repugnant to flies. A growing
practice in burning out of latrines is to do this without removing the
box. This method prevents the constant removal of the box, with
necessity for closing up crevices, and fills the interior and all cracks
with a smoky soot, that serves to keep fhes away. If properly
handled the boxes and shelter will not be burned. The only objection
to this method is that the seats become smoked and blackened and
are unsightly.

Straddle trenches of the width of a spade, the length of a spade
and handle, and the depth of half of the length of a spade and handle
are provided for one-night march camps. These are provided in the
proportion of 1 to 10 men, and should be placed parallel to each
other, with long axis parallel to the company street, at a considerable
distance away, so as to permit construction of new trenches of neces-
sity, nearer the company, in order that filled trenches must not be
traversed in going to new ones. The earth removed should be
thrown to the end nearest the company instead of on the long sides
and used for poUcing. The psychology of the use of the straddle
trench is interesting. All latrines should be located and drained
in such a manner as to prevent pollution of the water supply.

In permanent camps urine cans should be used in the company
streets, between darkness and reveille, to prevent pollution of the

80 MILITARY SANITATION AND SANITAEY SERVICE.

camp ground. The garbage cans used for this purpose should be re-
moved and emptied immediately after reveille in the latrine for this
purpose and burned out and suimed. Lights should be kept burn-
ing in the latrmes and at the uruie cans during darkness.

In addition to the means for disposal of human discharges given,
the Reed trough, with the so-called odorless excavator, has been
used at times. These have been found dirty and objectionalde,
besides liable to disarrangement. In permanent camps with high
ground water, as found on the coast or in river villages, difliculty
wiU be foimd with trench latrines here; a dry earth system will be
found the least expensive in actual cost, but here, as weU as with the
Reed trough, objection on account of liability of scattering removed
material can be raised.

Kitchen waste of permanent camps or semipermanent camps is
best disposed of by incinerators, preferably in the camp kitchen
incinerator, which if properly constructed and administered wiU dis-
pose of all dry and liquid garbage of the company, including waste
proper and sweepings. The essentials of this sanitary installation
are simplicity of construction and management, with efficiency and
economy of fuel. Various devices, such as the beehive, the Alamo,
and many others have been used and all have merit; but most of
them require considerable time, labor, and special material, and
have not the almost universal apphcabdity of the simpler fonns.
Of these, probably the simplest is a trench 4 feet long, 2 feet wide,
and 1 foot deep, filled with stones throwm in loosely to the ground
level. On the long side of the trench, stone walls 1 foot high and 18
inches wide are placed and backed by earth. Such a trench wiU
accommodate two or three sticks of cordwood, and if kitchen liquids
are poured over the stones on the sides and ends in small amomits
from time to time, will consume these and aU of the relatively dry
garbage of the company. The ends are left open for the removal of
debris, draft, and the placing of wood. Experiments have shown
that sufficient heat for evaporation from an ordinary fire penetrates
the stone bed only to the distance of 1 foot, and additional depth is
not only a waste of labor but objectionable in that it creates a layer
of undestroyed putrescent material at the bottom of the trench.
The stones selected for use m these incuierators should be about s
or 10 inches m diameter and as fire resistant as possible. These
incinerators, owing to destruction of the stone by heat and water,
require reconstruction from time to time. For a company of ordi-
nary size, larger pit incinerators are unnecessary and wasteful of
fuel. The incinerator trench should be diked or ditched to present
floodmg.

In addition to the ordinary garbage, tm cans should be weU burnetl
out to destroy organic matter. Incinerator debris should be re-

SANITARY SERVICE OF THE CAMP. 81

moved twice daily and stacked for removal. As it is iiuiocuous, it
need not be covered.

Experience has shown that many difficulties of administration and
control cause the larger improvised mcineratoi's, made for use of
battahons, to be inefficient and uneconomical. The company in-
cmerator has proven its worth, is subject to direct control, and
should be used as a matter of training.

Kitchen wastes are usually disposed of in march camps and
bivouacs by use of kitchen sink pits, with diameter and depth varied
to suit the size of the command and the length of use. They should
be poUced with earth and ditched in a manner similar to trench
latrines. All trenches must be filled and banked on breaking camp.

The disposal of manure and care of the picket lines is important,
in view of the fact that the most common source of flies m camps are
collections of manure. While flies will breed under favorable circum-
stances in almost any decomposing organic matter, which is not
repulsive or poisonous to them on account of the contained chem-
icals, their chief breeding ground is excrement of animals and man.

Ordinary police of the camp is usually sufficient to prevent, de-
stroy,- or remove ordinary collections of organic matter, but the
ubiquity of horse droppings and the urine-soaked ground of the
picket hne afford excellent breeding places which are promptly used
by ffies. Under ordinary weather conditions of summer the fly
matures in from 10 to 14 days, and destruction of organic material
must occur within this lesser hmit. In order to prevent increase of
ffies, action must be taken to hmit movements of horses and mules
in the vicinity of the camps to the limits of the corral and designated
roads, which wOl be regularly pohced and require special attention
to the removal of all droppings in and near the camp area. Action
must be taken to designate hitching points for animals and forbid
general entrance to camp streets. Tlie manure should be gathered
from the roads, picket hues, and camps, and removed to a distance
from the camp and burned. If arrangement is made with civilians
to dispose of this for fertilizer, care must be taken to see that it is
removed at least a fly ffight from camp, and preferably spread out on
the ground it is to cover.

Thin layers of manure will dry out sufficiently to furnish no avail-
able pabulum for larvae, and are not objectionable. Horse manure,
unbroken, is covered by a fine pelhcle of mucus, which favors reten-
tion of moisture and development of larvae. When this is broken it
dries quickly and is unfavorable soil for growth of maggots.

The soil of stalls and of the picket fines is a fruitful source of ffies,
however well they are swept, as the maggots find a hospitable environ-
ment and rich food supply in m-ine-soaked earth, and penetrate it
frequently to the depth of 6 inches and undergo transformation into

98756°— 17 6

82 MILITARY SANITATION AND SANITARY SERVICE.

the perfect fly and emerge from the burrows ready to play their
distinct game of pussy wants a comer between the camp latrine and
the soup tureen.

Careful scraping of the picket line to the depth of an inch or so,
and thoroughly burning over with straw and petroleum three times
a, week will destroy eggs and immature larvae which will not have
penetrated far beneath the surface in the short interval of time be-
tween burnings. It would seem that consideration of the life history
of the fhes and the probability of the short duration of march camps
would not require enforcement of the sanitary measures outhned for
disposal of wastes of camps of an impermanent nature. It must be
remembered, however, that the single organization represented in this
camp may be followed by others, and the same considerations that
caused the selection of this site may cause selection by another in this
vicinity, and that the command must not only take the sanitary pre-
cautions outhned to protect themselves now, but the other organiza-
tions of the zone of the advance, those of the lines of communica-
tions, and the civil inhabitants of the territory occupied are entitled
to consideration. These sanitary measures are not only directed to
prevention of production of insects, but also to the prevention of
carriage of disease by them.

Many insects are merely mechanical carriers of disease, and a fly,
in being, may dabble in the seductive dehghts of typhoid, cholera, or
dysentery stool and furnish a company with all of the invalidism it
wants; or transfer glanders, tetanus, or what not in the way of dis-
ease, from soil or sore, to the heaUng abrasion on the back of 3^our
hand; or the flooded latrine trenches may spill their uncovered con-
tents into the first available stream and give not only typhoid to the
unvaccinated, but its first cousin, paratyphoid, to the first unin-
oculated individual who drinlis from the brook.

DIVISIONAL SANITARY UNITS.

The service of ambulance companies has been outhned in general
for the camp and march in previous lectures. The organizations camp
together in the permanent, semipermanent, and march camps where
possible, unless they are separated for some special duty, when thosi
organizations so separate, as with an advance flank or rear guard
camp, in advance of the trains of the organization to which attached.
This on account of the fact that the nature of tliis detacliment ordi-
narily imphes likelihood of hostile contact. Whatever the natm*e of
the duty, they are camped in a position to give them ready access to
the front and rear, in order to facilitate movement on the execution
of their duties, usually on a crossroads giving roads that lead to the
various sectors of the front. These organizations camp in column of
companies, as does i\j-tillery, with a depth of 350 yards and a brcadtli

SANITARY SERVICE OF THE CAMP. 83

of 100 yards, allowing 25 yards to a company, including intervals.
Accessibility to water is essential to these organizations, owing to
their considerable number of animals, 78 to each company. Where
field hospitals ai'e camped with ambulance companies, as in a division,
the total of animals is 484. Under march or war conditions the camp
of these organizations should be such as to permit their retaining
their place in the column without countermarching.

Aside from the duties of evacuation and transportation of the sick
and issue of medical supplies to organizations attached to the com-
batant troops, these units are in part charged with the procurement
of additional supplies from the line of communications and perform-
ance of guard duty for field hospitals, besides performing their own
camp and stable guard.

Field hospitals in semipermanent camps have little to do with the
care of the sick where camp infirmaries and camp hospitals are pres-
ent. Their duties as outhned in the Manual for the Medical Depart-
ment are the temporary care of the disabled pending evacuation,
and they are the nightly collecting points on the march or in tempo-
rary camps for the individual sick who are unable to continue the
march.

Filling them up with disabled would immobilize them and prevent
mobihty. In any camp no more field hospital equipment is estab-
lished than is necessary for the care of the sick, and usually one field
hospital or part of a field hospital is detailed for this duty by roster.

In march camps in campaign field hospitals ordered to estabhsh
usually do so, taking advantage of such buildings as are available to
save time and labor of unpacking tentage, and accumulate, as early
as. possible, straw bedding and special diet supplies, over the emer-
gency supplies caiTied in preparation for the daily increment of sick.
The field hospital designated for this duty can be marched at the tail
of the column in order to permit early establishment, and will ordi-
narily be ready for action by the time the disabled are brought to
them; the remaining organizations camp with the sanitary train,
guarded by personnel from the ambulance companies. The field
hospitals, as well as the ambulance companies, carry reserve medical
stores and wiU from time to time issue and refill from those sent up
from the advance depot of the fine of communications.

LECTURE VI.

SANITARY SERVICE IN COMBAT.

ATTACHED SANITARY TROOPS— INFANTRY, CAVALRY, ARTILLERY, EN-
GINEERS, SIGNAL CORPS.

The duties of sanitary troops in combat are:

1 . Care of the wounded by application of appropriate measures for
their temporary treatment.

2. The collection and evacuation of the wounded, with care and
distribution to the various estabUshments according to the gravity
of their wounds and probable duration of disability.

3. The separation of the disabled from the nondisabled and action
to return the nondisabled to duty.

4. The preparation of records of dead and wounded.

5. The management of the sanitary service and the renewal of sani-
tary material and personnel expended.

6. The examination and supervision of the interment of the dead
and the sanitary pohcing of the battle field.

The necessity for such a service is essential to preserve morale
among the combatant troops and to prevent depletion of the firing
line by detachment for care of the wounded. Field Service Regula-
tions 344 forbids combatants, unless duly authorized, to take or ac-
company sick or wounded to the rear, and, in the light of the experi-
ences of the Russians in Manchuria, where the firing Hues were de-
pleted by such action, a provision of this kind is necessary. Fischer
quotes Von Tetlau as saying: "Of the Russians, seriously wounded
were carried by four unwounded soldiers and followed by two meni
as companions ; each one who was wounded in the leg supported by I
two well comrades, while a third carried the arms. The companions;
never were in a hurry to return to their organizations." " Help should j
seek the wounded, not the wounded help, else we open the door wide]
for the (un)woundcd to loaf around."

Our tables of organization provide 4 medical officers, 4 noncom-
missioned officers, and 20 privates of the sanitary troops for a regiment
of Infantry. Three officers, 3 noncommissioned officers, and 12 pri-
vates and privates, first class, with a regiment of Cavalry; and 3 offi-
cers, noncommissioned officers, and 16 privates with a regiment of
Artillery.
84

SANITARY SERVICE IN COMBAT. 85

The combat eqiii])ment of these organizations when serving with a
brigade or division having mobile sanitary units, consists of 1 field
desk, 1 box reserve dressings, 1 medical and surgical chest, 1 bucket
(galvanized iron), 1 ax, 1 tent fly, 2 lanterns, and the personal equip-
ment of the men and officers, besides litters, and boxes of surgical
dressing carried in the combat wagons.

The contents of the field desk consist of stationery, blank forms,
and books. As it is doubtful that all of the space will be used for
these articles, the canny medical officer may store dry medicines or
dressings in reserve. Tliis field desk is can-ied on the regimental
headquartei*s wagon. The remaining articles except those of the
personal equipment are carried on the pack mule for use with the
regimental aid station.

The medical and surgical supplies are as shown in tables attached.

This gives with each regiment, in addition to one first aid packet on
the person of each individual, an amount sufficient for first aid of a
regiment acting in conjunction with mobile sanitary units, and suffi-
cient for 20 per cent loss.

Should the regiment be acting independently, it will have available
the contents of the regimental hospital equipment, which will be
pushed forward as a combined dressing station, field hospital. The
medical, surgical, and sterilizer chests and food boxes and cases will
give much additional dressings, supplies, and restoratives, together
with necessary medicines, instruments, appliances, towels, and bedding
for 12 patients.

Independent battalions such as Signal Corps carry the aid station
equipment. Cavalry and Artillery, having a smaller sanitary per-
sonnel, do not have so much personal equipment and dressings, but
have a sufficient equipment for their necessities.

Of means for transportation of patients, the regimental sanitary
personnel has available litters, in amount according to the organiza-
tion, carried by the sanitary personnel attached to each battalion
with the headquarters section, and one litter belonging to each com-
pany carried m the combat wagons or all carried in the combat
wagons.

In the Infantry, there will be eventually available, 8 litter squads
of the Medical Department personnel and 14 litter squads of the band,
provided the band is kept to full strength. Usually this is so with an
Infantry regiment. The Cavalry will have at best, only 4 litter
squads from the Medical Department troops, and the Artillery 6,
with only 6 or 7 company litters. If the regiment is acting alone it
wiU have in addition, 4 ambulances and 2 field wagons attached to
the sanitary troops. The ambulances can carry 4 recumbents and 1
sitting or 9 sitting each, and the wagons 4 or 5 moderately w^ounded
in the usual proportions of recumbents to sitting 3 to 5 ; the wheeled

MILITARY SANITATION AND SANITARY SERVICE.

transportation can carry in an infantry regiment on tlie sanitary,
combat, and ration and baggage sections, field and combat trains, 12
recumbents and 72 sitting cases, these latter including the able to
walks, to the field hospitals, some 28, if necessary.

FIELD WAGONS

Combat.

Baggage.

Kation.

Equals.

4
5

8
17

(-)

Carriages.

2 Plenty.

As noted in the sanitary service of the march, the position of the
surgeon, the battalion sanitary personnel, and the headquarters sec-
tion of the sanitary personnel was that which placed them in a satis-
factory situation with respect to the command, either for the service
of the march or combat.

In preparation for combat the surgeon, up with the commanding
officer, has already traversed the ground to the rear of the probable
position and is informed as to the terrain and, with the commanding
ofTicer will examine the terraui to the front with a view of determining
the probable positions of the combatant troops and probable covered
lines of communications to the rear as representing the course of drift
of the wounded. He will be informed of the plans of the regimental
commander and in consideration of these plans will make recom-
mendations as to the probable site or action of the regimental aid
station. Such action must be dependent upon the type of action to
occur. If it be a planned attack, the surgeon will select a tentative
site for an aid station and hold his equipment in readmess, pendmg
the development of the action. This organization will not be needed
for some time and should not be established until there is a definite
use for it. Changes of disposition may requu-e disestablishment and
change of position, a thing not difficult, unobjectionable when neces-
sary, but nevertheless undesii-able when required through the fault
of too early establishment. A planned defense permits early estab-
lishment and notification of the command as to the position of the aid
station in combat orders.

Rencontre requires, for the aid station and the mobile establish-
ments, delay in estabhshment until the positions of the troops and
the conditions of the action arc determined. Usually demands of
wounded for estabhshment will not be immediate.

Delaying actions require the earhest estabhshment and evacuation
possible, in order to clear the wounded before the retreat. Trans-
portation, if available, should be pushed up as close as practicable.
Consider using combat wagons where advance guard actions follow
the lines of a j)lanned attack.

SANITARY SERVICE IBT COMBAT. 87

The three essentials in the treatment of the wounded in modern
warfare are:

1. The prompt application of a sterile antiseptic dressing in such
a manner as to prevent contact of matter to the wound surface others
than the sterilized dressings and to maintain these dressings on the
wound to prevent this.

2. To describe the wound and manner of dressing on the diagnosis
tag, attached to the person of the wounded man in such a way that
redressing or interference with the first dressing wiU not be required
unless the diagnosis tag justifies or requires such action, or special
conditions make this necessary.

3. To evacuate and treat the sick in a manner to conserve their
strength to the greatest possible extent, with the least morement
to the rear possible according to their condition.

The necessity for prompt dressing in a skillful manner lies in the
strong probability that nature may care for a moderate amount of
infective material carried into the wound by the wounding agent,
but that it may succumb to a larger amount. The sterile cotton
dressings act as a filter to exclude infectious agents and yet permit
the wound to drain and dry while the antiseptics with which the
dressings are treated form an unfavorable medium for the growth of
noxious bacteria.

In addition to prevention of infection, proper dressing diminishes
loss of strength through hemorrhage and produces mental rest.

The use of morphine on the field is a great aid in securing freedom
from pain and worry and decreasing hemorrhage and shock particu-
larly when it may be impossible to secure prompt evacuation. The
conditions of action frequently do not permit evacuation from the
field until cessation of firing or intervention of darloiess.

Tagging is necessary : (a) To prevent interference with the wound
when properly dressed on account of the fact that clotting of blood
and serum in contact with the antiseptic in the dressing forms an
antiseptic seal over the wound, and to reopen it breaks this seal
and exposes the injury to additional chance of infection and hemor-
rhage and may interfere with reparative processes abeady started.
Blood soaked dressings in themselves are not cause for change of
dressing; (b) to conserve time and energy and facihtate transporta-
tion and record. The tag bears the name, rank, organization,
diagnosis, class of case, walking, sitting or recumbent, nontransport-
able — treatment, disposition. Date and name of person caring for
him. They will be affixed to sick, wounded, and dead. The dupUcate
retained in the book, serves as a record for casualty lists, etc., and
the original, as a means of identification record, record of treatment,
movement, etc., prior to admission to the field hospital, the first
organization of permanent regulation record, and serves as a pass

88 MILITARY SANITATION AND SANITAEY SERVICE.

to the rear. By this means, control of the shghtly wounded can be
had and kept away from a dressing station and field hospitals, and
loafing of wounded and malingering can be to a certain extent pre-
vented.

During the Russo-Japanese War this loafing and malingering among
the Russian womided was most pronounced. With the diagnosis tag
properly made out, receiving departments of sanitary organizations
may see at a glance the condition of the patient and make proper
disposition of him without delay and danger of reexamination, and
change of dressing. Tags are affixed by the noncommissioned officer
or officer of the sanitary service who comes in contact with the case,
where possible.

In combat of Infantry the battafion sanitary personnel will accom-
pany the battafion, using their personal equipment; where time per-
mits before going into action, they will draw additional dressmgs
and carry them in their haversacks. As the action will require the
medical officers to be dismounted, all orderfies or substitutes v>ill
depart to the aid station with medical officers' mounts and will be
available for dressers or messengers.

The noncommissioned officers wiU serve as assistants to the med-
ical officer and record and dress cases.

The band in campaign will ordinarily carry light instruments and
under authority of the regimental commander may, when marching
in the presence of the enemy habitually march with the sanitary
troops, as fitter bearers, or, at the beginning of an engagement, be
reported to the surgeon. They should have been well trained in fii-st
aid and duties of fitter bearers, and will be supplied with company
fitters from the combat wagons and used by the surgeon, as a bearer
section, to be sent wherever lies the greatest need for their services.

The sanitary troops (in extended order) wiU be disposed of in such
a manner that one private shall cover the rear of each company in
the best manner possible, exposure and first aid considered, with
orders that they will keep good observation and contact with the
organization to which attached (and if possible contact with the aid
station), whatever the movements of the battafion. If a company is
detached, the private covering that company must continue to do so.
While it is frequently impossible to render first aid to all that faU it
is essential that sanitary personnel be in contact with all troops for
the sake of morale, as weU as actual service. It is not intended that
immediate dressing or removal be made in the face of a dangerous
fire, because few wounded need immediate attention so badly that
the few individuals of the sanitary service should bo sacrificed in the
in<lividual case, when many more valuable, the lessor womided, will
need their service. So rare is the case that needs innnediate service
to preserve life that of 1,440 casualties at Santiago, none such ex-

SANTTAKV SERVICE IN COMBAT. 89

istod. Tho only typo of case tluit ro(|iiir('s such att(vntion is pos-
sibly a homorrhago from a large vessel, and ordinarily, first ai<l, such
as can be given on the firing line, is of little avail in these cases.
Remember, a desperately woimded case, wliile he should have all of
the attention that can be given him, requires and should have the
least interference and movement possible, and in view of results is
not as valuable an asset to an army as one of lesser gravity. Under
tho ordhiary conditions of combat the sanitary troops with the firing
line do not and can not keep up with the line, but keep it under ob-
servation, mider cover, and taking advantage of cover, dress all cases
and remove them to depressions or behind obstacles that would give
them protection from fire. Here the wounded of the battalion will
be collected at a point wliich affords communication to the rear, per-
mittmg early evacuation by the litter squads. It will be infrequent
that conditions will permit early collection.

The position of a battaUon surgeon will ordinarily be at the rear of
the center or inner flank of the battahon in order to place him on the
Hne of drift or communication to the rear, and as close up as fire and
terrain permit. He will notify the enlisted sanitary personnel,
covering the companies, of his position and keep in touch with them
and the battalion. Should the battalion be considerably detached
from the site of the aid station, he will choose a collecting point, per-
mitting movement from the front and evacuation to the rear, where
he will collect the transport cases. Shghtly wounded cases will
either be retm-ned to their units or tagged and ordered to proceed
through the regimental aid station to the station for shghtly wounded
if such exists. After engagement, he will complete the evacuation
of the wounded, assist in the sanitary pohce of the field and assist
in clearing the aid station.

The surgeon, as soon as the command is committed to a position
or the number of wounded warrant such action, will, under authority
of the commanding officers, choose a site for the establishment of the
aid station. This is usually established as near to the firing line as
the conditions of cover for movement under fire toward the front and
rear, line of drift of the wounded, shelter and supply of wood and
water permit. Given cover accessibiHty, and proper lines of drift of
wounded, under protection from fu-e, it should be pushed as far
forward as is possible, so long as it will not, probably, be involved in
the movements of the lines. The consideration of shelter, wood,
and water supply near at hand, while desirable, is not absolutely
necessary, as the first requirement, if in buildings or structures of
similar nature, frequently draws hostile fii'e, and wood and water
can be brought up. Given other considerations, the aid station
should cover the center in order to equalize and lessen distances.
The regimental aid station is httle more than a geograpliical rendez-

90 MILITARY SANITATION AND SANITARY SERVICE.

vous for wounded, where they can be collected for record, dressed,
possibly fed, sorted, and sent to the rear or front. The knowledge of
possibility of food and care will bring the wounded here and permit
organization of the return of the fit, and direction of movements of
ambulants, and evacuation of transport cases.

The commanding officer, combatant troops, of the battaHon and
the sanitary troops with them will be notified of the site of the aid
station by the commanding officer. The surgeon also will notify the
battalion surgeon of the site, the battaHon surgeon will notify the
combatants and his personnel. Contact will be gotten with the
divisional sanitary units at as early a time as possible, and the dressing
station detachments and chief surgeon notified of site and conditions.

When necessity occurs, and not before, the equipment will be
brought up, the packs unloaded, and the tent fly erected, if neces-
sary. Marks (peeled twigs, blazes, or bandages on trees or posts)
will be set up, showing direction to aid station; larger marks are
only advisable where they can not be observed by the enemy, as
they have usually drawn fire both in the Russo-Japanese and Euro-
pean war.

The aid station is organized into a receiving, dressing, feeding,
and dispatching section. The bearers of the band are used in evacuat-
ing from the battalions under the band noncommissioned officer's
and noncommissioned officers and privates of the aid station party
are used for technical work. AH wounded passing thi'ough the aid
station are recorded and those needing it are tagged. The ambulants
are directed to the rear in parties, under charge of a wounded officer
or noncommissioned officer, the shghtly wounded to the appropriate
station — and those very lightly wounded, who do not require move-
ment to the rear, utihzed or returned to their organizations, usually
escorted by the band litter bearers (armed) . Here, as on the filing
line, the least amount of surgical work compatible- with saving life
is done. The greatest attention is paid to first aid, collection, sort-
ing, evacuation and organization of the wounded. Advantage wiU
be taken of all adventitious materials or aids in this work. Should
movement of the command require it, the station may be reestab-
lished where necessary, leaving the collected disabled in charge of
sufficient personnel to care for them imtil taken over by the organ-
izations at the rear. The personnel with a battaHon not in action,
in reserve, will be utiHzed to the utmost and aU personnel brought
back as a reinforcement, as they clear their front. The pack mule
may be sent to the rear to renew supplies during an action; and,
after the action, must take on supplies to give full complement,
according to the supply table.

On conclusion of the engagement, or during a luU in firing, or
after nightfaU the bulk of collection and evacuation will take place.

SANITARY SERVICE IN COMBAT. 91

The extondod range and rapid lire aetion of modern arms will ordi-
narily prevent succor of the wounded in the zone of fire, and over-
shots, the use of wheeled transport near the rear of the firing line.
Here all removals must be made by hand or htter. The regimental
sanitary troops, with band auxiliary, will make a search of their
sections, collecting the wounded, and tagging the dead alike. If
this is at the conclusion of the action, the sanitary troops will be
accompanied by combatant details which will take over the dead,
examined and tagged and listed, by the sanitary personnel, for
burial: and in cases where necessary, assist the sanitary personnel
in tlie collection of the wounded.

In case the aid station has cleared in its location at the rear, it will
be moved up and reestabhshed on the field and avoid long hauls.
When the wounded are collected and cleared from the aid stations
by the bearers or transport of the ambulance company, a part of
the regimental personnel may be mthdrawn to assist at the dressing
stations under orders from the division surgeon.

The final pohce of the regimental section of the battlefield, after
removal of wounded, wiU proceed under the advice of the local
medical officer in connection with the supervision of the sanitary
inspector of the division.

In trench warfare modern practice shows the best results where,
like in the planned defense, the attached sanitary troops are in the
trenches with the combatants, with the aid equipment and party in a
special communicating trench, in such a manner as to permit access
to all parts of the hne. Here, under the protection of bombproofs and
trenches, most satisfactory work can be done and the equipment can
be much more elaborate and complete. Evacuation to the rear is
ordinarily made in this case under cover of darkness. The possibihty
of good roads under these conditions makes rapid evacuation com-
paratively easy and swift, and can be direct from the firing line to a
field, or even an evacuation hospital, or train, or boat.

Artillery aid stations and those of Cavalry dismounted conform to
the action of those of Infantry, except that care must be taken in the,
case of the aid station of Artillery, to establish rather on the flank
and away from the reserve, as this will ordinarily be searched for in
Artillery combat, and the wounded will be needlessly exposed. The
sanitary troops with a Cavah-y regiment will ordinarily estabhsh
little, and devote most of their attention to accompanying the com-
mand, leaving their wounded with detached personnel to be taken
over by the divisional organizations. As the many small engage-
ments of Cavalry preceding and during general action will produce
many scattered casualties over a wide area, and the aid party will be
of httle use, it will usually be advisable to keep the squadron units to
full strength. Owing to the number of men tliat must be left for the

92 MILITAEY SANITATION AND SANITARY SERVICE.

temporary care of the wounded it would seem that the enlisted
personnel allowed were insufficient. Owing to the necessity of fre-
quent changes of position and plan of action, the regimental surgeon
serving with the mounted organization as well as those on foot will
do well to have a mounted agent with the regimental headquarters
when he is absent at the aid stations or elsewhere, in order to ketu
informed as to the changes in situation.

THE AMBULANCE COMPANY.

The personnel of the ambulance company consists of 5 medical
officers, 2 sergeants, fu^t class, 7 sergeants, and 70 privates, cooks,
farriers, horseshoers, etc. The transportation consists of 18 mounts,
12 ambulances, and 3 wagons, and 4 pack mules.

The ambulance company for duty assignment is divided into four
detachments: The bearer detachment, consisting of 20 htter squads;
the dressing station party; the ambulance detachment; and the
wagon detachment.

The technical equipment consists of the personal medical equip-
ment, the equipment in the packs, and dressing station wagon, and
the food and dressing boxes of the ambulances.

The total of dressings, etc., for combat care of wounded will give
dressings for approximately 1,800 cases and 4,000 cups or dishes of
restorative stimulating food, such as blancmange, beef tea, soup,
milk punch, tea, malted milk, oatmeal, porridge or gruel, and choco-
late. That is sufficient for 10 per cent of casualties, not considering
the dressings put on by the attached units or the equipment of the
other ambulance companies.

As given in former lectures the ambulance companies are under
the direct control of the director of ambulance companies and on
release of this portion of the sanitary train from the control of the
commander of trains, will be managed by him under orders of the
chief of stafl, or surgeon, during and after combat. The activities
of the director and the ambulance companies cover the entire zone
between the firing line to the field hospital. Under the orders or
authority of the chief surgeon, he will establish dressing stations,
change their sites, and make proper arrangements for the collection
and transportation of the wounded.

The four detachments of the ambulance company have usually
different sections on the field for their work. The bearer detachments
collect the wounded from the regimental aid stations, or under favor-
able conditions from the field, and transport them to the ambulance
head, if conditions of terrain or action permit use of wheeled trans-
portation in advance of the site of the dressing station. The dressing
station party remains with the dressing station at its site and is rein-
forced as may be necessary from the personnel of the bearer section.

SANITARY SETtVlCE IN COMBAT. 93

Tlio ambiiliince dctachnuMit transports tlio woiindod from as far
foiward toward tlic actual field as is possible, terrain and fire con-
sidered, to the dressing station or field hospital. The wagon detach-
ment detaches one wagon with the equipment and supply reserve of
the dressing station and sends it as far forward toward the dressing
station as conditions permit. The other field wagons ordinarily
remain back near the divisional field trains when the other detach-
ments go forward.

The time and place of establishment of the dressing station will
be determined by the conditions of the action and the terrain;
for a planned defense, they may be established early and the sites
stated in the combat order; but for offensive, or rencontre actions,
establishment will not be done until the positions of the troops,
the drift of the wounded, and the type of action determines the
necessity. Too early establishment vfill, in case of an advance,
leave the station without function, and require advance and rees-
tablishment, or involve it in the line of fire or movement of troops,
in case of rectification of lines.

The regimental sanitary personnel will be able to handle the
situation at the front for a considerable time, and the wounded
who come back early will ordinarily be ambulants, who have no
need of the dressing station. The transport cases will hardly be
back to the aid station during the first hour of the engagement.
Should the lines advance materially, it will be well to advance the
station to the wounded and avoid littering the patients any farther
than necessary.

Littering, at best, is slow and exhausting work, and every effort
must be made to abridge distance. In the earlier part of the Russo-
Japanese War much difficulty of transport arose through the tend-
ency to too early establishment. In delaying actions with a planned
defense and subsequent retreats, early establishment and evacuation
is necessary, and reinforcement of the sanitary personnel is desirable
and necessary, particularly with bearer and ambulance detachments.
Ordinarily the time for establishment will come when the advance
has ceased and the regimental aid stations have more wounded than
they can care for.

Tlie division surgeon will determine where and how many stations
^vill be opened and will consider in this decision the field of grc^atcst
casualties and probabihty of further action as to location and number
establishing; he may have them establish individually or combine
and, if not pressed, %vill hold one or more in reserve to reinforce other
stations, or to place in points of future casualty, when the proper
time arrives.

Tlie factors to be considered in the selection of a site for the dressing
station, given necessity and consistency as to battle plan and actions,
are :

94 MILITARY SANITATION AND SANITARY SERVICE.

1. Location near a practicable route of evacuation from the front
to the rear, usually on some well marked line of approach.

2. Possibility of cover at site of station from aimed and overshot
fire.

3. Sufficient proximity to aid stations to decrease transport dis-
tance, and, yet, not to include station in minor changes in lines.

4. Proximity to shelter; wood, water; buildings as shelter have
the disadvantage of attracting Artillery fire and are therefore not an
unmixed blessing, and wood and water may be transported if neces-
sary; but frequently the same inequality of ground which affords
cover and covered communication to the front, will give wood and
water.

The necessity for the establishment, on a practicable route is
obvious and, other things being equal, should contemplate a point
wliich will intersect a line of. probable drift of wounded, who will, if
fire and cover permit, usually, follow the line by which they approach
the field — the only route known to them — and will ordinarily follow
ravines or the lower slopes of hills, in order to get advantage of the
cover afforded. Interception of these ambulants is necessary in
order to give them proper direction and care, at a time when the sta-
tion is relatively idle as they usually precede transport cases, and can
oe pushed back to the station for sHghtly wounded on foot, or to the
field hospital, as their condition requires.

Necessity requires that the dressing station be as close up as
possible; a distance beyond Infantry or Artillery fire wouM render
the establishment useless.

Examination of almost any field will show sufficient cover to
permit movement forward of the personnel and equipment with pack
transportation, which may subsequently be sent back for supphes.

On establishment, the bearer section will be sent forward to estab-
lish contact with the aid stations, ordinarily dividing into two sec-
tions of 10 fitters each, with a definite sector assigned, by subdivision
of the ambulance company sector assigned by the director.

The bearer sections will place Red Cross guidons, bandages, or
peeled twigs, as route markers, indicating the direction of the dressing
station, while moving forward and will notify aU regimental per-
sonnel of its location. The commanding officer wiU report time and
place of establishment to the director.

The dressing station will estabfish the following departments:
Receiving, dispatcliing, slightly and seriously wounded, dressing
and dispensing, feeding, and morgue. AU patients received will be
examined, Usted, tagged, if necessary sorted, distributed or dressed,
fed, and dispatched to the rear or front. The sfightly wounded,
requiring evacuation, will be arranged in squads, in charge of a

SANITARY SERVICE IN COMBAT. 95

•wounded ofRcor or noncommissioned officer, and, after feeding,
marched to the station for shghtly wounded; those requiring move-
DKMit to the front turned over to a provost officer.

The amhulant, seriously wounded, will be sent to the field hospital
on foot, convoyed by ambulances loaded with transport cases; and
the transport cases after being grouped as sitting and recumbents,
loaded as such by the dispatching section.

No oj^erations other than those immediately necessary to save life
will be done, such as tying or clamping an artery, or opening the
trachea; and such operations will be rare. Feeding will be limited
to stimulating and restorative food and drinks, and has been found
advantageous, not only from a standpoint of pure medicine, but also
as a means of securing attendance of the slightl}^ wounded, who
otherwise may straggle without control. Possibility of food and aid
brought many to the dressing stations in the Balkan and Manchurian
wars.

For purpose of bringing up reserve supplies and collecting local
comforts, such as straw, hay, etc., the reserve wagon will be brought
up if possible and the ambulance detachment will establish ahead
at, or to the front of the dressing station, where roads and cover
permits, in order to decrease litter haulage.

Every effort should be made to prevent overcrowding of dressing
stations, and to facilitate evacuation. Additional transportation,
field wagons and local transport, may be used.

Neither the dressing station nor the ambulance detachment must
bo held back on account of casual fire, but must advance from cover
to cover until it reaches a relatively protected zone. Movement in
colmnn will frequently draw fire, as at 600 yards, with present
system of marking, an ambulance can not be differentiated from a
field wagon, so that movements in evacuation can be frequently
best accomplished by single wagons. The capacity of a dressing
station m material has been given, 1,500 to 2,000 cases, the capacity
of the personnel is given as from 15 to 20 dressings per surgeon per
hour m fair weather. Although the Japanese state that at Mukden,
two surgeons and two assistants placed 25 to 30 dressings per hour
and could have done 30 to 40 in the same time, in sununer. Fischer
quotes Schaefer as saying that it was not unusual for a surgeon to
do 24 dressings in an hour.

With two medical officers, this would give from 30 to 40, per hour,
a considerable number of wounded, more than half, will be properly
tagged and dressed, and these will not need dressing, giving a capacity
of 60 to 80 per hour to the dressing station unreinforced. If addi-
tional help is necessary in the early stages of the action, it must come
from the medical officers of the bearer detachment, who can double
the capacity of the dressings; and if more is needed, such can come

96 MILITARY SANITATION AND SANITARY SERVICE.

from the personnel of the field hospitals if they do not go into action,
and after the aid stations are cleared can come from them; an() the
chief surgeon may direct such reinforcement.

After fire has ceased and the stations cleared, the bearer detach-
ment must search for the wounded. With the combatant forces in
position, this can not be done until after nightfall and then under
difficulties. The Manchurian war showed that moonlight permitted
view of the searchers, and in dark night, artificial light drew fire.
While on the western front in the pan European war, the close prox-
imity of the lines renders it almost impossible, so much so that maiiy
wounded have lain for days without succor. Systematic search will
be made where possible, by assignment of sectors, and the wounded
will be evacuated to the ambulances, which can usually be brought
up under the conditions that render this collection possible.

After clearing the wounded to the field hospitals, the director of
ambulance companies will usually receive orders to pack. If help is
needed at the field hospitals, personnel will be assigned from tlie
ambulance companies for this purpose; and the ambulance compani(>s
will bivouac on the field with the command or camp with the field
liospitals, as directed.

The work of these organizations, both for men and animals, is
exceedingly arduous and without regard to hours. Under condi-
tions of combat and after, Httle rest can be given. Great care mu^t
be taken to secure the most economical use of these organizations, in
order to prevent exhaustion.

LECTURE VII.

SANITARY SERVICE IN COMBAT.

STATION FOR SLIGHTLY WOUNDED— FIELD HOSPITAL COMPANIES,
ADVANCE GROUP, LINE OF COMMUNICATIONS.

This is an establishment of our sanitary service created as a result
of experience gained in the Civil War and emphasized by observa-
tions during the Russo-Japanese War. It has been adopted by the
Austrians, British, and Germans, following our example.

This station is established for the purpose of diverting the ambu-
lant slightly woimded from the field hospitals, and evacuation hos-
pitals. If they have been given a definite dressing by the regimental
personnel these wounded can be sent directly to the slightly wounded
station, without mterfering with or encumbering the service of the
dressing station and field hospitals.

The cases sent to these stations are the slightly wounded ambulant
cases, who are capable of marching back to the railhead or if neces-
sary to the convalescent camps or establishments for slightly womided
in the advance group of the Ime of communication, on their own feet.
Such cases comprise wounds of the upper extremities, superficial
wounds of the trunk, head, etc., which will prevent full participation
in active service, but will, ordinarily, be able to care for themselves
and result in early return to their organizations. This class of cases
vvould fill the space required for care of the more seriously wounded
and add to the burden of the transportation, if cared for by the other
institutions, and straggle, and be lost from control, and materially
delay their recovery and restitution to their organization, if turned
loose to make their way to the rear uncontrolled. Genuine slightly
wounded requiring control by this station amount to some 12 per
cent of all casualties, and these, together with a considerable num])er
of cases of wounds so slight that they should be returned to their
organizations, and malmgerers formed the contmgent, who dui-ing
our war of the rebellion, and the Russo-Japanese War, particularly
in the Russian service, the bulk of the straggling wounded who were
annoying; as they were not only disorderly, but caused material
depletion of the total of rifles. Such cases were seized upon by
enthusiastic citizens in our Civil War, and in the early days in the
French service of the pan-European War and taken, unrecorded, to
98756°— 17 7 97

98 MILITARY SANITATION AND SANITAKY SERVICE.

the rear in great numbers. They were lost to the services for con-
siderable periods of tune and contributed much to permanent
absenteeism.

The station for slightly wounded assists much in the sorting pro-
cess and may catch a considerable number of more serious cases,
which can be detained and sent with proper transportation to the
field hospitals.

Under proper administration of the sanitary service no wounded
man should be permitted to move farther to the rear than the field
hospitals or aid stations, when not in custody of the sanitary service ;
and no woimded man should be permitted to move in the zone in
front of the field hospitals and aid station untagged or unattended.
Such requirement will ensure control of wounded and give the best
results m economy of service. Malmgerers and trivial case will
not find encouragement or license, and will remain with their
organizations.

The routine in the past for the battle malingerer has been to avoid
contact with the regimental sanitary personnel, by whom he is gener-
ally known, by skulking, and by attaching himself to some nonsanitary
unit by affecting shght wounds, gain the rear. The requirement of
constant sorting out and control will make this relatively impossible.

The personnel of the station for sHghtly wounded will ordinarily
consist of a medical officer, a noncommissioned officer, and six or eight
men of the sanitary contingent and should include a squad of the
mihtary police for the control of the trivially wounded and maling-
erers, and their restitution to their organizations.

The equipment of the station for slightly wounded will ordinarily
consist of dressmgs, medicines, food, and cooking utensils, in addition
to that of the personnel. Shelter will not, usually, be provided, but
advantage will be taken of buildings near the point for estabhshment.
AH that is needed at this point is sufficient personnel to record,
examine, readjust dressings, and provide stimulants and restorative
food, as the cases will have been dressed before arrival. Some shelter
should be provided with straw or improvised bedding, as some cases
will become exhausted through shock and loss of blood or serious cases
may be picked up — which will require subsequent removal.

The personnel and material will come from the ambulance company
or more commonly from the field hospitals as these organizations will
usually be more or less idle at the time of estabhshment and hardly
greatly occupied until the necessity for the unit has ceased— when the
equipment and persomiel withdrawn can most readily join these
organizations, as the distance of these organizations from the front
is somewhat similar. The camp infirmary equipment will be avail-
able.

SANITARY SERVICE IN COMBAT. 99

Tlie sito for the station for slightly wounded should be well to the
rear on the line of drift of wounded, well out of range of direct fire,
preferably at a fork or convergence of roads from the flank and center,
near some easily recognizable object which can be mentioned as a
guide to its location. For purpose of recognition of its position this
object as a church, school, monument, or natural formation should be
selected, where possible, from those passed by the command on
advance to the front. A most satisfactory distance from the firing
line is one of some 2^ or 3 miles, with the understanding that the
slightly wounded station should be in advance and well removed from
the site of the field hospitals in order to divert the shghtly wounded
from them.

Owing to the fact that these stations are to be estabhshed well to
the reur and their ephemeral nature, a site can be chosen early and
their location announced in the combat order. Ordinarhy only one
shghtly wounded station is established for a division and none for
units of lesser size; but where natural or artificial conditions render
it hkely that the entire area can not be drained by one such station
more may be established.

The station consists of a receiving and forwarding section, a dress-
ing and a feeding section. The wounded are examined, listed, sorted
according to their condition, and tagged if necessary, and fed ; some
dressings may need renewal and some exhausted or hemorrhage cases
may require rest or hospital treatment. Of course these will be
detamed.

Those to be sent to the fine of communication will be arranged in
detachments of 30 or 40 and placed under charge of slightly wounded
officers or noncommissioned officers, who will be given orders, where
possible, with a list of men in his charge, giving the route of march.
This route should coincide with a hne of evacuation of wounded so
that these detachments may be convoyed or supported by wheeled
convoys of wounded in order to give care to the exhausted.

The commanding officer of the slightly wounded detachments
should be directed to leave any exhausted cases under shelter on
the route and notify the nearest sanitary echelon of their condition
and position. If the road be long, arrangements \vill have been
made for rest and refreshment stations, which will be necessary for
both the shghtly wounded and the transport cases.

Field hospital companies belong to the divisional sanitary train.

The field hospital companies are controlled by a director of field
hospitals whose duties correspond to those of the director of ambu-
lance companies and the field hospitals, moved, estabhshed, and
closed by orders of the Chief of Staff or chief surgeon usually through
the director, following the methods outUned for ambulance com-
panies.

100 MILITARY SANITATION AND SANITARY SERVICE.

The purpose of the field hospital is to provide temporary shelter
and care for the seriously wounded or sick in camp and, during and
after combat, pending their evacuation to the rear. Their capacity
has been changed from shelter (tent) and bedding for 108 to 216
patients, giving for a division 864 beds and they carry technical
equipment for many more patients provided shelter and bedding
material can be secured from local sources.

The personnel consists of 6 medical ofTicers, 9 noncommissioned
ofhcers, and 58 privates, cooks, etc. Transportation, 15 mounts,
7 field wagons.

The equipment of our field hospital differs from that of the Euro-
pean armies in the fact that it provides more tentage and bedding
equipment, and medical and surgical equipment. The European
armies depending upon adventitious shelter, bedding, and household
equipment as a whole or in part; and in that part of the functions of
the field hospital are covered in the dressing station of the sanitary
company or ''ambulance" and part by the clearing or evacuation
hospital.

A recent reorganization of the French service found necessary
during the present war has recognized the necessity of this organi-
zation, which they only had as did the EngHsh in the shelter section
of the "field ambulance" by introducing a new miit — the sm-gical
operating hospital, a motor transport affair of 100-bed capacit}^, with
a special motor operating room. One of these to an army corps.
The functions of this organization are covered by the equipment of
our field hospitals. Although present practice and opinion in
America and abroad questions the advisability of performing any
but the most immediate necessary operations, at a point in front of
the more or less fixed hospitals; because not only must there be little
or no pressure of wounded when these are done, but also cases of
this character require post operative rest, which can not be secured
in a mobile unit.

The field hospital, packed, is as mobile as its method of transpor-
tation, field wagons, permits. Motor trucks, under favorable con-
ditions, would materially increase this mobility and decrease road
distance, but such transport while found satisfactory abroad in th(>
present war, is of doubtful or impossible utihty in America, with
oiu" poor roads and bridges — such was the opinion formed, as a
result of observation, in the Connecticut maneuvers of 1912.

Not counting the desperately wounded who can not endure extended
transportation, and will consequently, not be taken to the field hos-
pitals, unless they establish on the field, the field hospitals may bo
expected to care for about 60 per cent of the total casualties, a high
percentage of which must be be(hhHl until evacuation. The bedding
capacity of the field hospitals as given above is 864 patients and

SANITAIiV SERVICE IN COMBAT. 101

capable of extension, depending on local improvised shelter and
bedding, straw with persoi\al blankets collected on the field.

For an Infantry division this will givo a capacity to accommodate
a total casualty of roughly 10 per cent. The average daily battle
casualties as shown in the Franco-Prussian War was for the Germans
4.7 per cent and in the Manchurian for the Russians 1.7 per cent and
the Japanese 2 per cent. The high losses shown in some battles in
Manchuria of as high as 68 per cent for some organizations were dis-
tributed over several days, although one division lost 30 per cent in
a. single day. No sanitary service can be equipped to handle such a
higli daily loss and, in view of the average losses given and possi-
bility of reinforcement by organizations from divisions less hardly
pressed, this capacity of 10 per cent carries a fairly high factor of
safety.

In combat, field hospitals will establish at positions and times
selected by the division commander, or surgeon, in the absence of
instructions. In an attack they will not be established until the
advance has ceased or the numbers of wounded at the dressmg sta^
tions justify such action. In a planned defense they may be estab-
lished or at least in position of readmess early, to establish when
required. In a meeting engagement, the field hospitals will be halted
off the road until the course of action is determined.

In preparation for combat the field hospitals will be assembled and,
when establishment is justified, one or more will be sent forward to
cover the lines of evacuation from the various sectors; those remaiu-
iQg unestablished to be held in reserve and fed in either position, as
a reuiforcement of other hospitals or mdependently.

The field hospital can be established in about one hour, and if
clear, packed m one and one-half hours; and, filled with wounded,
vvill require three ambulance companies for its evacuation and a
much longer time to dispose of the wounded and pack. Particular
caro must be taken to avoid establishment too early or in an unsuit-
able position, because for use for the day after establishment, it is
practically immobile.

The site of establishment should be some three or five miles to the
rear; protected as much as possible from dhected artillery fhe; on
good roads, to the front and rear; and near the probable route of
sanitary evacuation, which will place it away from the route to the
front carrying ammunition and reinforcements. An ample supply of
good water is necessary, and it should be located, where possible, near
suitable buildmgs; these can be utilized as shelter in place of or in
addition to the tentage carried; in addition to shelter, the vicinity
should also afford household conveniences, straw and wood. In
selecting a location for a field hospital, while due regard should be
given to the proximity of permam^nt objects, as a means of locating

102 MILITARY SANITATION AND SANITARY SERVICE.

it; nevertheless the buildings, or site occupied by it, should not be
capable of being seen from the front, owing to the tendency of hostile
Artillery to fire on aggregations of buildings, men, or troops. Expe-
rience in the pan-European War would lead to the assumption that
the Red Cross flag is not easily recognized, as such, at distances given,
or that its protection has been disregarded. When establishmg with
adventitious shelter much of the heavy equipment of the field hos-
pitals will not be unpacked, and the personnel will be employed in
collecting and improvising local equipment and materials for hospital
uso.

The various routes to the field hospitals will be marked by day
and night, by guidons, signs, or lanterns. The same care here is
not necessary, as in the dressing stations to avoid attracting hostile
attention, by guide flags, as the distance is too great to permit
recognition of ordmary sized flags.

Given other conditions as satisfactory, the field hospitals will be
located so as to cover the field of greatest casualty, and, should the
enemy retire, they will be located near the dressing stations or on
the field itself. Where field hospitals are ordered up to replace a
dressing station, they will transfer the equipment, by exchange, and
take over the wounded, releasing this part of the ambulance com-
pany for further duty elsewhere.

The positions of the field hospitals on the march with a division,
when hostile contact is expected, lend ease to their establishment, or
position in readiness, following deployment of the division. Their
position at the rear of the main body places them some five miles to
the rear of the head of the main body, and should this deploy on a
position taken up by the advance guard movement forward at ordi-
nary gaits, could put the field hospitals near their probable position
within an hour and a half after the order for deployment is given,
rather too early for a position in readiness.

In order to clear the road, however, and put them near where will
be their probable location, plans of the division commander, roads
and terrain, and probable field of casualties and fire considered, the
field hospitals will be moved foi-ward, or assembled at a convenient
point on a probable route of evacuation.

The director will inform himself of conditions of shelter, suppl}'^,
and communication in the rear of the sector covered by the division,
and, as soon as he receives information as to the sites of the field
hospitals, will designate the organizations and arrange for use of
shelter and supplies at hand. He will get in touch with the director
of ambulance companies and arrange for coordmating his service with
that of the trajisport. The <livision surgeon will be notified of the
time of establishment as it occurs.

SANITARY SERVICE IN COMBAT. 103

The field hospital will establish : A receiving and forwarding, slightly
wounded (sitting), a seriously wounded (bed), an operating, dispen-
sary, kitchen, morgue, and transportation department.

The receiving and forwarding section will record, sort, and assign
patients on receipt and dispatch through the transport section, mov-
mg the received patients to the wards and operating section, accord-
ing to their classification, or turn them over to the transport column
for evacuation. The operating section will, as stated before, avoid
operations, which can be delayed until more suitable environments
are available, and confine itself to those immediately necessary to
save life, or to prepare patient for evacuation. Patients will be
cleared from the field hospitals established, ordinarily, by transfer to
line of commimications columns, transporting them to evacuation
hospitals on trains or water transportation or, in default of these lines
of communications, to other field hospitals at the rear, in order to
permit release of mobile units to join their command. Transfer of the
disabled is most easily and satisfactorily made by bringing up evacua-
tion hospital personnel and equipment on wagons or motors and
exchanging equipment.

Under conditions where it will be impossible to evacuate all of
the wounded in a field hospital (as where one is detailed to care for
desperately wounded, in an advance or immobdized with wounded in
a retreat), these wounded may be left with suitable personnel and
equipment and the remainder move out with the train.

The personnel of the field hospital company will ordinarily furnish
the personnel for the station for shghtly wounded, and this will usu-
ally be designated by the director from that of a field hospital which
will be placed nearest this organization, in order to avoid unnec-
sary movement of transportation and personnel in estabhshing and
closing. Prior to the time when field hospitals estabhsh or in delay-
ing engagements, when estabhshment would be inadvisable, the per-
sonnel of the field hospital companies may be used to advantage as
bearer detachments and reinforcements to the dressing station per-
sonnel.

The entire sanitary service of the division must be under the ob-
servation and control of the division surgeon, either through the
chief of staff, or direct. The service of the regimental sanitary troops
will be largely independent, under the control of the regimental
commander and sm'geon, as to estabhshment, disestabhshment, and
interior administration, but, under the regulations a surgeon may
be detached for duty at a dressing station and field hospitals, and
this will be done by the chief sm^geon, when necessary, from those
organizations least engaged with casualties.

The surgeon will require reports of the time and site of estabhsh-
ment and disestabhshment, the number of casualties, etc., in order

104 MILITARY SANITATION AND SANITARY SERVICE,

that he may be able to direct the sanitary service economically and
use the regimental and divisional sanitary personnel in the best
manner, in the service of dressing and evacuation.

While the station of the division siu-geon is with the headquarters
of the division, he must exercise general supervision over the entire
field, either by use of his assistant and the sanitary inspector, or by
leaving one of these in charge of his office, by direct examination of
the conditions. The duties of the surgeon lie in administration and
direction, and he can best serve the* sanitary service by exercising
these fiuictions, rather than by personal care of the wounded. He
will coordinate the work of the several fines of sanitary aid, in order
to procure rapidity and continuity of action, in care and evacuation
of the disabled; and, guided by his information of the plan and course
of the combat, direct the movement, establishment, and closure, of
the organizations within his department.

Orders for this purpose will be issued by the chief of staff upon
recommendation of the division surgeon or may be direct by the
surgeon, when so authorized l^y the division commander. It would
seem that in stress of a general action it would be necessary for
orders to be issued frequently, direct by the surgeon to the du-ector
of ambulance companies and field hospitals in order to avoid
damaging delays, and it is probable that the division commander
will issue general authority to cover such action. Orders to
directors and unit commanders shoidd be so worded, as to cover
the general requirements, leaving, as in orders for combatant com-
manders, arrangement of details to the officer of whom the action is
expected.

Orders directing estabfishing or requiring movement to a position
in readiness should carry the phrase "in the vicinity of" or "near a
certain point," in order to permit use of natural or artificial features
of terrain, shelter, cover, or supply. Orders to directors should be
sufficiently broad to permit adaptation of the units on hand to the
particular requirements.

Communication and interchange of information will be constantly
kept up between the sanitary service of the zone of advance and the
fine of communication in order that the service of the medical sui)ply
and evacuation may be most efficient. Arrangement will be made
for movement of supplies to the railhead or distributing point and
transportation to organization for reequipment after combat. The
advance surgeon will be notified of the location of field hospitals and
the distribution and classification of wounded or sick therein, together
with conditions of roads, etc., in order that they may be taken over.
On the march and in camps preparatory to evacuation, rendezvous
points for collection of disabled wiU be arranged for between the divi-
sion and advance surgeons, and the sanitary service line of communi-
cations Mill l)e kept informed as to possibility of combat, change of

SAN1TAI;^ SKUVICE IN COMBAT. 105

route, presenco of epidemics, etc., in order that preparation can be
made in advance for unusual conditions.

The police of the battlefiekls, as stated before, will be attended to
by the local commander in liis sector. Usually the sanitary inspector
will be detailed to supervise the sanitation of the field and wiU be
given such saaitary and combatant assistance by local commanders,
under ordei-s from the division commander, as may be necessary.
Sites for interment or cremation of men and animals will be chosen
by the sanitary inspector with due regard to character of soil, drainage,
convenience to field, and unlikeUhood of disturbance by flood or
animals. Action will be taken to procure medical officers and chap-
lains from the troops of each locahty for examination and record of
the dead and for appropriate services; and details of a noncommis-
sioned officer or private from each company to assist in recognition,
in cases where the identification tag is not found ; and burial details
for collection and transporting the dead and preparing and conduct-
ino- the work of interment or cremation. All dead will be recorded
on casualty fists, with organization and cause of death, and separate
trenches prepared for the unknown and the known of our own troops,
and for the enemy's. Those of the same organization wiU, as m^uch
as possible, be buried together, and those of our own troops will have
their tags buried with them, secured to the neck by a copper wire of
generous size. The tags of the enemy or of the cremated dead will be
retained. Careful note of location and contents of burial trenches
will be made to facifitate later removal and recogrution. Trenches
will be made at least 5 feet deep — that is, bodies should be covered
by 4 feet of earth — in order to prevent escape of gases of decomposi-
tion or exhumation by flood or animals.

All spare earth should be used in mounding trenches, in order to
provide for sinking and to give additional covering. As a matter of
sentiment and comfort to relatives, it is well to have chaplains of
several denominations hold services for the dead, so that each may
have the benefit of the particular rites of Ins church.

Given proper space and soU, burial, if properly conducted, is not
objectionable. Ordinarily, in disposition of the dead, the end to be
secured is destruction of the putrescible parts of the body, in the least
time, without real or sentimental offense. To secure the most rapid
decomposition, all clothing, covering, or boxing of bodies should be
interdicted and the mass of dead should be supported upon a course
of open stone or logs in the bottom of the trench, with a drain for
fluids leading to a lower pit. The mass should be topped with a
layer of straw or branches, in order to prevent too close contact of the
earth, which will prevent drainage and rapid disintegration, and
lastly mounding with all earth removed. The use of fime or of other
disinfectants on the bodies, or in the grave, prevents rapid disinte-

106 MILITARY SANITATION AND SANITARY SERVICE.

gration and defeats the purpose of interment, without accomplishing
anything that can not he done by four feet of earth. Properly
located and drained trenches will secure this and be relatively safe.

Cremation is usually impracticable on account of difficulty of pro-
curing fuel in sufficient quantities, as one single body on an open pyre
will require one-third of a cord of wood and at least five hours of at-
tention. While this is an ideal method of disposition of the dead,
pubhc sentiment is as yet hardly sufficiently educated to make it
justifiable, when interment is practicable; but where fuel is at hand
and character of soil or rock formations and lack of space, as within
a beleaguered area, does not permit interment, it is demanded.

The records of the friendly dead will be data for casualty reports.
The tags, records, private papers, and possessions of the hostile dead
will be turned over to the provost marshal, who will send them to
the War Department for ultimate transmittal to relatives, or other
parties in interest, in the home country.

SERVICE OF THE LINES OF COMMUNICATIONS, BEFORE, DURING, AND

AFTER COMBAT.

As stated in former lectures the sanitary service of the lines of
communications is divided according to the general organization,
into advance, intermediate, and base groups ; each with their proper
surgeon and equipment of personnel, units, and supply — with the
advance and intermediate groups subordinate to the commander at
the base.

The functions of the surgeon of the base group are practically those
of a division surgeon, and he is governed by similar regulations. He
will have charge of the direction of the transportation, care, and distri-
bution of patients from the time that they are turned over to the lines
of communications until their final disposition, either by transfer to
the service of the interior or return to their organizations, and for
the purpose of caring for them he will utihze all means of transporta-
tion, hospitals, and convalescent camps within liis control and, imder
authority of the commanding officer, lines of communications, will
create or estabfish such other organizations as may be necessary. He
will arrange for the supply of sanitary personnel for the lines of com-
munications and to the sanitary troops of the zone of advance, and
in order to regulate the flow of these personnel to the front will
estabfish casual camps for these troops; will establish and control
depots for sanitary suppfies, which will be issued to the organizations
on the fines of communications and the zone of the advance; and
will exercise sanitary supervision and control over the area of the
lines of communication and the country contiguous thereto.

Previous to combat the surgeon, base group, will bo informed as to
the probability of action and will direct his subordinates to prepare
all of their organization for additional service. All lu)spitals and

SANITARY SERVICE IN COMBAT. 107

institutions will bo rosiij)pli(Hl aiul cleared of patients, and mobile
and semimobile units collected at convenient points in tlio advance
or intennediate groups for service. Advance depots will be supplied
and additional units organized as required.

. On notification of imminence of action the surgeon advance groups
will bring his evacuation hospitals up to the railheads, and if the
probable seat of action is well removed from water or railheads, wiU
provide motor or wagon transport for them, so that they can be
advanced as necessary. Hospital trains or boats will be brought up
to the transportation head and sections of advance supply depots
equipped with transportation for movement to the distributing point.
The evacuation ambulance company will be reinforced by additional
wagon or motor transport and advance well toward the tail of the
column in the zone of the advance. Sites and shelter for hospitals
and convalescent camps will be selected and plans and equipment
for improvisation of trains and boats for patients prepared, in accord-
ance with local conditions. Details for embarkation stations will be
brought up and rest stations, personnel, and equipment reinforced;
and all measures possible taken to secure rapid and efficient evacua-
tion, care, and distribution of the disabled.

The evacuation ambulance companies of the lines of communica-
tions are allowed normally on the basis of one to each division, and
carry the same personnel and equipment and transportation as do the
ambulance companies, less the four pack mules. They will be used
for road evacuation of the disabled from the field hospitals to the
evacuation hospitals or rail or water head. Under normal con-
ditions of daily flow of disabled and .usual road distance, their capacity
is ample, but in preparation for combat they must be largely increased
as to transportation and personnel by attachment of enlisted men and
wheeled vehicles with enhsted or civihan drivers.

These organizations under usual conditions of weather, work, on
more or less satisfactory roads, can employ motor transportation with
excellent results. On the continent, where the roads are admittedly
better than in America, transport colmnns are composed entirely of
motor ambulances, organized in groups of 50, divided into three
sections. The use of such means of transport has made possible the
rapid evacuation of the enormous number of wounded, which would
otherwise have encumbered the mobile organizations for days. To
man this additional transportation, the bearer detachment is available
either as attendants or chivers. Automobile transportation in tliis
organization is more economical in persomiel, as the chauffeurs them-
selves can be used as a loading detail and attendants, as they have no
teams that require watchmg when halted. The transport column,
when route conditions require extensive marches, will establish rest
stations en route for the care, feeding, and treatment of the wounded

108 MILITARY SANlTAnON AND SANITARY SERVICE.

en route, detaching a medical officer or a detail of enlisted men and
equipment for this purpose.

The rest stations of a line of evacuation is on a byroad, and will be
established at points at march intervals or less and will be an-anged
by use of buildings or other shelter for feeding and dressing ordinary
cases in transport and bed equipment for those cases that become
imtransportable. Arrangement must be made for. rapid feeding at
these points, and measures will ordinarily be taken to apprise the
stations of the time of arrival of convoys of womided. Should the
route of evacuation be relatively extended and permanent, special
parties will be sent up from the sanitary reserve of the line of commu-
nications to relieve the evacuation ambulance company persoimel
and equipment.

Transport colimins and rest station parties of volunteer aid societies
are extensively used abroad for this duty, and can be weU used in
oiu" service particidarly as a second echelon on long routes of evacua-
tion . Where convenient, those colimms and rest stations in the ad-
vance section should consist of the military sanitary service.

Embarkation stations are formed at the transport head, particu-
larly^ at rail and water heads, for the reception, care, and loading of
the disabled; delivered by transport units, pending arrival of other
means of transportation : these correspond in organization and equip-
ment to rest stations, but must have greater bed, feeding, and shelter
facilities. They may be formed of line of connnimications reserves
or from aid societies personnel, with a military control. As ihcj are
relatively stationary and wiU have advantage of good shelter and
accommodations near a fixed line of transportation, they can be
manned by voluntary aid personnel to advantage. Their fimctions
and duties are obvious.

Rest stations on railway and water transport lines wiU ordinarily
not be required by hospital trains, as they will be equipped with
ordmary necessities for feeding and caring lor the sick. Trains and
boats for patients, however, wiU not be provided with facilities for
feeding the disabled; rest stations must be equipped with material
and personnel for this purpose. They will be located on a siding or
dock, where boats or trains can be stopped conveniently, and will
have meals prepared in advance, through proper notification. In
order to expedite movement, action can be taken, as in the Gorman
service, to load prepared meals and serving equipment on trains at
the rest stations. The serving equipment to be brought back on the
next trip.

More elaborate dressing and ward equipment will be provided at
these points than is had at the road stations. The pei*sonncl should
consist of 2 medical officers, and some 15 or 20 cooks or attendants,
arranged in day and night shifts.

SANITARY SERVICE IN COMBAT. 109

The evacuation hospitals are allowed 2 to a division; pcrsoini el,
14 medical officers and 129 enlisted men; equipment of 2 field
hospitals and divisible into sections. Evacuation hospitals have
no transportation fixed, but will requrre some 16 wagons. Held
well up on the lines of conimimications, they will be available for use
at the front as soon as the conditions of the combat are detenniiied.
Their f miction is to provide more elaborate care for the woimded
than can be given in the field hospitals, and they will be used primarily
to clear the field hospitals, so that they can move forward with the
command. As they have no transportation, they will, ordinarily,
be kept on a water or rail transport line, packed for rapid movement.

In or after combat, these organizations may be established in
whole or part, or by section at the lines of comnumication transport
head, or near the field, or moved to the field and take over the
womided and field hospitals, by exchange of equipment. In the
movement to the field, if no other transportation is available, the
evacuation ambulance company may be used as transportation.

The equipment of the evacuation hospitals permits use of tentage
for shelter, but wherever possible, buildings of the locality wiU be
taken. Here, more elaborate surgery can be done, as these hospitals
may be fixed, if necessary, and reserve organizations sent up from
the base of the general line of commmiications. Here, the definite
sorting of patients will be made, and distribution according to
probable length of disability be accomplished. The lightly womided,
sent to the convalescent camps, advance groups; those of moderate
severity to the hospitals of the intermediate and base groups, in-
fectious cases diverted to special hospitals, and the relatively per-
manently disabled sent to the base, en route to the service of the
Ulterior.

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