UC-NRLF B M blT 3fiD LECTURES ON Military Sanitation and Manage* ment of the Sanitary Service — ^ ARMY SERVICE SCHOOLS SPECIAL REPRINT FOR OFFICERS' TRAINING CAMPS GOVERNMENT PRINTING OFHCE WASHINGTON 1917 LECTURES ON 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 3 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. 5 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 — 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 22 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 23 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 I 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. (c) The interior should be perfectly smooth, the heel broad and low, the sole but moderately thick. (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 37 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 I 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.) (c) Locally grown green vegetables, uncooked. (Dysenteries and diarrhea.) 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. 55 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. S MO 'Z AmbJjfK^ " \A. \ QMedrcol 5o.. J^,^.^,^ Suppli^ Depot I I ZMQISCM I — j 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: (c) Slight 15 (d) Severe 15 I Class. Duration of treatment (days). Average days of disability. Day when maximum number is reached. a 3 3-5 5-14 14-50 3 4 10 32 4 6 15 51 b 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 C9 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. I 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 I 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 86 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. 10 4 1% 4 5 6 8 17 28 22 26 (-) 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 ins 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 I 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