LlBRApy A COMPL,ETE HANDBOOK FOR THE SANITARY TROOPS OF THE U. S. ARMY AND NAVY AND NATIONAL Guard and Naval Militia BY CHARLES FIELD MASON Colonel Medical Corps, U. S. Army FOURTH EDITION, REVISED Approved by the Surgeon-Generals of the Army and Navy PROFUSELY ILLUSTRATED NEW YORK WILLIAM WOOD AND COMPANY MDCCCCXVII 4 , / BIOLOGY LIBRARY Copyright, 1917, BY WILLIAM WOOD AND COMPANY PREFACE TO THE SECOND EDITION In presenting the second edition of this handbook the author desires to say that every page has been carefully examined, corrected, and brought up to date. Many of the parts have been entirely rewritten and numerous new and improved illustrations inserted. The general size, plan, and scope of the work remain, however, unchanged. Charles Field Mason. Washington, January 31, 1909. PREFACE TO THE FOURTH EDITION In this edition it has been deemed advisable to omit the part on drill regulations for sanitary troops, and to considerably expand those on nursing, and those on pharmacy. The appearance of a revision of Army Regulations and of the Manual Medical Department since the last edition of this book was brought out, has required a complete rewriting of those parts, while all the chapters have been carefully revised, corrected and brought up to date. Charles Field Mason. Washington, December i, 1916. '^ ^ O 7 r% "^ TABLE OF CONTENTS PART I SANITARY TROOPS IN POST AND FIELD CHAPTER I PAGE The Sanitary Troops in Post 3 Organization of the sanitary troops; instruction; promotion; duties; uniform; rules for hospital administration. CHAPTER n The Sanitary Soldier in War 12 Administration zones. Objects of Medical Department Administra- tion. Duties of the Medical Department. Personnel. Titles of Med- ical officers. Insignia. Status of personnel. Organization in war. The service of the interior. Mobilization camps. Concentration camps. Camp hospitals. Hospital trains. Rest stations. Hospital ships. The theater of operations. The zone of the advance. Camp infirmaries. The ambulance company. The field hospital. The sta- tion for slightly wounded. The line of communications. Base hos- pital. Convalescent camp. Contagious disease hospital. Trains, boats and ships. Sanitary squads. Rest stations. Base supply depot. Advance supply depot. Evacuation hospital. Evacuation ambulance company. Administration. Resume. PART II ANATOMY AND PHYSIOLOGY CHAPTER I The Skeleton and Joints 37 Bone. Cartilage. Classification of bones. The vertebral column. The pelvis. Joints. Lower extremity. Thorax. Upper extremity. Skull. Teeth. CHAPTER H The Muscles, Cellular Tissue, and the Skin 48 Muscles, voluntary and involuntar>^ Action of muscles ; the sterno- mastoid, biceps, diaphragm. The connective or cellular tissue; fat. The skin and its appendages. Functions of the skin. (V) vi CONTENTS CHAPTER III PAGE The Nervous Svstem and Special Senses 53 The cerebro-spinal system ; brain, spinal cord, and nerves. The sym- pathetic system ; ganglia and nerves. The special senses ; touch, taste, smell, hearing, and sight. CHAPTER IV The Digestive Apparatus 61 The alimentary principles and their uses ; albuminates, fats, starches and sugars, minerals. The alimentary canal and digestion. CHAPTER V The Blood and the Circulatory System 69 The lymphatic system and its functions. The blood ; its composition and uses. The heart, arteries, capillaries, and veins. The circulation of the blood. The special arteries and their compression points. Spe- cial veins. CHAPTER VI The Respiratory Apparatus 8l The larynx and vocal cords. The trachea, bronchi, and air cells. The lungs and pleura. Respiration. Air. Ventilation. Heat regu- lation. CHAPTER VII The Excretory Apparatus 85 The skin, lungs, and bowels. The urinary organs ; the kidneys, ureters, bladder, urethra. The urine. The suprarenal glands. PART III FIRST AID CHAPTER I Emergencies, Contusions and Wounds Bp How to act in emerpencics; removal of clothing. Contusions; shock and its treatment; treatment of contusions. Wounds, incised, lacerated, contused, punctured, poisoned, gunshot. Wound infec- tion: septicemia and pyemia. Treatment of wounds; first-aid packets. Wounds of the skull, of the chest, of the abdomen, of the bladder. Bites of insects, of tarantulas, scorpions, and centipedes; bites of snakes, of rabid animals. Tetanus; anthrax. Poisoned arrows, etc. CONTENTS vii CHAPTER II PAGE Hemorrhages 96 Capillary bleeding ; nose-bleeding, bleeding from a tooth socket. Venous bleeding. Arterial bleeding, primary, intermediate, and sec- ondary. Treatment of arterial bleeding; compression with the fing- ers; with the tourniquet; the Spanish windlass. Bleeding from special arteries ; in the upper extremity, the lower extremity, the neck, the tongue, the lips, the face, the scalp. Bleeding from the lungs, the stomach, the bowels. CHAPTER ni Dislocations and Sprains 103 Dislocations, definition of; symptoms, diagnosis from fracture and sprain; treatment. Special dislocations; shoulder, lower jaw, fingers, knee-cap. Sprains; definition; symptoms, treatment. Sprained ankle. CHAPTER IV Fractures 108 Fractures, definition of ; compound, simple, comminuted, compli- cated, impacted, green-stick ; causes of ; symptoms. Treatment ; of simple fractures; setting, splinting; of compound fractures. Healing of fractures. Splints. Special fractures ; of the skull, spinal column, ribs, pelvis, nasal bones, lower jaw, clavicle, arm, forearm, meta- carpals, fingers, thigh, knee-cap, leg, foot. CHAPTER V Foreign Bodies 119 In the eye. In the ear. In the nose; maggots in the nose. In the throat. In the air passages. In the stomach and intestines. In the skin. CHAPTER VI The Effects of Heat and the Effects of Cold 12a Heat-stroke. Heat exhaustion. Burns and scalds: burns from cor- rosive acids and caustic alkalies. General freezing. Frost-bite. Chilblain, CHAPTER VII Insensibility and Fits 126 Fainting. Concussion and compression of the brain ; apoplexy. Lightning stroke. Electric shock. Acute alcoholism. Epilepsy. Bright's disease of the kidneys. Opium poisoning. viii CONTENTS CHAPTER VIII PAGE Asphyxia 130 Forms of asphyxia : causes, treatment. Artificial respiration ; Schaefer's method, Marshall Hall's method. Drowning. CHAPTER IX Poisoning 136 Caustic acids. Caustic alkalies. General management of cases of poisoning. Emetics, antidotes, combating the tendency to death. Special poisons; phenol (carbolic acid), wood-alcohol, food-pois- oning, ptomaine poisoning, "knock-out drops" (chloral), arsenic, corrosive sublimate, nitrate of silver, phosphorus, strychnine. Skin poisons; poison-ivy, poison oak, poison sumach. PART IV NURSING CHAPTER I The Ward 141 Wards in post hospitals ; arrangements, heating, and ventilation. Field hospital wards. The wardmaster. Night nurse. Ward clean- ing. CHAPTER II Ward Management 147 The new patient. Serving diets. Administering medicines. The use of the hypodermic. Dying patients. Care of the dead. Autop- sies. CHAPTER III Beds and Bed-making 152 The hospital bed ; its preparation ; changing bed linen. Changing the bed. Changing the mattress. Beds for operative cases. Fracture beds. The bed-rest. Air and water mattresses. Bed sores. CHAPTER IV Baths and Bathing ■ iS7 Purposes for which baths are given. Classification of baths. Sponge baths. Sedative bath. Hot-water baths. Hot-air and steam baths. Cold baths. The Brandt System. The cold sponge. Bed tub-bath. Alcohol bath. Bakes. Electric light bath. The foot bath. Sitz bath. CONTEXTS ix CHAPTER V PACE Enemata, Irrigations, Douches, Catheterization, etc 163 Encmata, classification of. Laxative enema ; nutrient enema ; medicinal enema. Irrigation. Urethral injections. Douches; spinal; nasal, eye, ear. Catheteriza- tion. Irrigation oT the bladder. Catheterization of the ureter. CHAPTER VI External Applications 169 Hot-water bags, bottles, etc. Poultices. Stupes. Cold compresses. The ice bag. Ice-water coil. Mustard plaster. Liniments. Dry cups. Biers' cups. Blisters. The Paquelin cautery. Lunar caustic. Blue stone. Nitric acid. CHAPTER VII Temperature, Pulse, and Respiration 175 Normal and subnormal temperature. Fever; classifications of fevers. The clinical thermometer. Charting temperature. The pulse; varieties of. Respiration; varieties of. Pulse, respiration, and temperature ratio. CHAPTER VIII Symptoms and Clinical Record 179 Symptoms; subjective, objective, feigned; the attitude and ex- pression ; mental conditions ; the eyes ; the hearing ; the skin ; the tongue, mouth, and teeth ; cough ; the appetite ; vomiting ; the stools ; suppression, retention, and incontinence of urine ; cough ; hiccough ; pain ; hallucinations and delirium ; sleep. Clinical records ; history, treatment, charts. CHAPTER IX Bandaging 185 The triangular bandage and its application to various parts of the bod}-; the slings. The roller bandage; sizes; method of rolling; rules for applying ; the figure of eight ; the spica ; the knotted turn ; recurrent of the head ; recurrent of a stump ; application to various parts of the body. Flannel and rubber bandages. Fixed bandages; plaster-of-Paris bandages. CHAPTER X Infection and Disinfection eoo Definition. Disinfectants ; dry heat, flowing steam ; boilmg water, corrosive sublimate, phenol, cresol, quick-lime, chlorinated lime, formalin, sulphur. Prevention of spread of infectious diseases. Dis- infection of sputum, feces, urine, vessels, infected clothing, bedding, beds, rooms, tentage. X CONTENTS CHAPTER XI PAGE Instruments and Appliances 208 Description of the ordinary instruments and appliances. Special appliances and apparatus of the medical department of the army; compressed air apparatus; electric batteries; restraint apparatus; steam sterilizing apparatus ; aspirating case, emergency case. Diag- nosis tags. Field equipment; desk; food box; commode chest; acetylene chest; regimental combat equipment; mess chest. CHAPTER XH The Operating-room and Surgical Nursing 242 The bacteria of surgical infection. Toxemia, septicemia, and pyemia. Preparation of the patient for operation; after-care; dressing. Preparation in the operating-room. The sterilizer. Sterilization of instruments, trays, dressings, sutures, and ligatures ; metal and glass syringes ; rubber goods, web catheters ; water. Normal saline solution. Drains. Disinfection of the hands and field of operation. Care of instruments, etc., after the operation. Operations in the field. CHAPTER Xni Nursing in the Infectious Diseases. How Infections Spread. Vac- cines AND Antitoxins. Typhoid Vaccinations 252 Typhoid fever. Dysentery. Cholera. Malaria. Yellow fever. Cerebro-spinal meningitis. Gonorrhea. Chancroid. Syphilis. Pul- monary tuberculosis. Pneumonia. Influenza. Follicular tonsillitis. Diphtheria. The eruptive fevers. Mumps. Erysipelas. Wound infections. Plague. Typhus. PART V MESS MANAGEMENT AND COOKING CHAPTER I Mess Management 259 The mess ; sources of supply in post and field. The rations. The diet. CHAPTER II Cooking 266 The kitchen. Effect of cooking on foods. Boiling, stewing, soup- making, roasting, baking, broiling, frying. Bread-making. CONTENTS xi CHAPTER III PAGE Recipes 270 Liquid diets. Semisolid or light diets. The hospital stores. The rations. Approximate measures. PART VI MATERIA MEDICA AND THERAPEUTICS AND PHARMACY CHAPTER I Materi.\ Medica and Therapeutics 287 Drugs ; active principles ; classification. Administration of medi- cines; dosage. Army and Navy supply tables. CHAPTER H Pharmacy 311 Definitions. Pharmaceutical operations. Official and non-official preparations. Directions for making emulsions, pills, ointments, powders, and suppositories. Weights and measures. Filling prescrip- tions. Incompatibility. PART VII HYGIENE. POST AND CAMP SANITATION CHAPTER I Water , 32? Daily allowance. Surface and ground waters. Purification of. water; the Lyster sterilizing bag; the Darnall siphon-filter; other processes. Water-borne diseases. Collection of samples. CHAPTER II Air and Ventilation 343 Composition of air; impurities. Floor space and cubic air space. Ventilation ; natural and mechanical. Heating by stoves, furnace, Hot water, steam. CHAPTER III The Disposal of Wastes 349 Disposal in posts ; by pits, pans, water carriage. House drainage. Bacterial methods for purification of sewage. Disposal in the field; with moving commands; construction of sinks; in fixed camps; gar- bage; crematories. Sanitation of camps. xii CONTENTS CHAPTER IV PAGE Disease Prevention 355 T3'phoid, malarial, and yellow fevers, and their transmission by insects. Diarrhea. Dysenteries. Eruptive fevers ; vaccination and vaccinia. Cholera. CHAPTER V Sanitation in the Field 364 Camp sites. Tents. Water supply. Care of the feet. Chafing. Lice. CHAPER VI Personal Hygiene 367 Cleanliness. Dhobie itch. Teeth ; hair. Clothing. Veneral dis- ease. Alcoholism. Food and drink. Exposure to the sun. Chilling at night. PART VIII RIDING, PACKING, AND DRIVING CHAPTER I Riding 371 The equipment of the horse. Riding without and with the saddle. Stable duty. CHAPTER n Pack Saddle and Packing 389 The Medical Department pack outfit ; to use. CHAPTER HI Driving 393 The escort wagon. The army wagon. The ambulance. Harness. Care of animals, wagons, and harness in the field. PART IX ARMY REGULATIONS Army Regulations 413 Medical Department. Hospital Corps. Garrison Service. Field Service. General Hospitals. Service of Hospitals. Hospital Build- ings. Sick Call. Medical Supplies. Artificial Limbs. ^Manual for the Medical Department. I'icld Hospitals and Ambulance Compa- nies. Hospital Corps Detachments. Analyses of Water. Reports, Returns, and Records. Hospitals and Medical Attendance. Service of Hospitals, general. General Hospitals. Supplies and Materials. The Sanitary Service in War. CONTEXTS xiii PART X CLERICAL WORK page Clerical Work 459 List of reports rendered daily, trimonthly, monthly bimonthly, quarterly, semiannually, annually, occasionally ; on breaking up of hospital ; on being relieved of medical propert}'. List of Records. PART XI MINOR SURGERY CHAPTER I Anesthesia, General and Local 467 General anesthesia; preparation for; ether; chloroform. Anes- thesia in the tropics. Local anesthesia; ethyl chloride; cocaine; eucaine; Schleich's method. Spinal anesthesia. CHAPTER n Assisting at Operations. Minor Operations 472 Preparation for operation. Handling instruments. Sponging. Incised wounds ; suturing. Contused and lacerated wounds. Boils. Carbuncles. Felons. Abscesses. Gum-boils. Ulcers. Piles. CHAPTER III Minor Operations, Continued 476 Subcutaneous saline infusions. Rectal continuous saline infusion. Intra-venous infusions; salvarsan. Antitoxin injections. Acupunc- ture. Aspiration. Lumbar puncture. Mercury injections for syphilis. Taking blood specimens. Use of the stomach tube. Forced feeding. Introduction of metallic catheters and sounds into the bladder. Hernia and trusses. Toothache and tooth extraction. Electric bat- teries. CHAPTER IV. Adhesive Plaster, Straps and Strapping 485 To retain splints. Extension in fracture of the thigh. Strapping for fracture of the ribs. Sayre's strapping for fractured clavicle. Strapping a swollen testicle. To draw wound edges together. Removal of adhesive plaster. A COMPLETE HANDBOOK FOR THE SANITARY TROOPS OF THE U. S. ARMY AND NAVY AND NATIONAL GUARD AND NAVAL MILITIA PART I SANITAEY TROOPS IN POST AND FIELD. CHAPTER I THE SANITARY TROOPS IN POST The Medical Department consists of one Surgeon General, chief of said department, a Medical Corps, a Medical Reserve Corps tem- porarily, a Dental Corps, a Veterinary Corps, an enlisted force (Sanitary Troops), the Nurse Corps and contract surgeons. The enlisted force of the Medical Department consists of the fol- lowing personnel : Master hospital sergeants, hospital sergeants, ser- geants (first-class), sergeants, corporals, cooks, horseshoers, sad- dlers, farriers, mechanics, privates (first-class), and privates. Master hospital sergeants are appointed by the Secretary of War, but no person can be appointed master hospital sergeant until he shall have passed a satisfactory examination under such regulations as the Secretary of War may prescribe before a board of one or more medical officers as to his qualifications for the position, including knowledge of pharmacy, and demonstrated his fitness therefoi' by service of not less than twelve months as hospital sergeant or ser- geant, first class. Medical Department, or as sergeant, first class, in the Hospital Corps ; and no person may be designated for such examination except by written authority of the Surgeon General. Original enlistments for the Medical Department are made in the grade of private, and reenlistments and promotions of enlisted men therein, except as hereinbefore prescribed, and transfers thereto from the enlisted force of the line or other staff departments and corps of the Army are governed by such regulations as the Secretary of War may prescribe. The total number of enlisted men in the Aledical Department should be approximately equal to, but not exceed, except as hereinafter provided, the equivalent of five per centum (3) 4 SANITARY TixOOl^'S IN POST AND FIELD of the total enlisted strength of the Army authorized from time to time b> law but in time of actual or threatened hostilities, the Secre- tary of War is authorized to enlist or cause to be enlisted in the Medical Department such additional number of men as the service may require. The number of enlisted men in each of the several grades designated below may not exceed, except as hereinafter pro- vided, the following percentages of the total authorized enlisted strength of the Medical Department, to wit : Master hospital ser- geants, one-half of one per centum ; hospital sergeants, one-half of one per centum ; sergeants, first class, seven per centum ; sergeants, eleven per centum ; corporals five per centum ; cooks, six per centum ; privates, first class, forty-five per centum, and privates nine per centum. The number of horseshoers, saddlers, farriers, and me- chanics may not exceed one to each authorized ambulance company or like organization. Enlisted men may be transferred from the line to the medical department as privates Married men are not accepted as recruits, not transferred from the line for service in the department Can- didates for enlistment should apply to a post medical officer or to a recruiting- officer. Applicants who have graduated in pharmacy, or who have had training as nurses in civil hospitals, should present certificates of their special qualifications. Slight physical defects which, under existing orders, would disqualify for the line, do not disqualify for enlistment in the department, provided they are not of such a character as would interfere with the full performance of the duties of a sanitary soldier in garrison or in the field. If a candidate is accepted he is forwarded to a company or detachment for instruction in: i. Discipline and the duties of a soldier; 2. Care of animals and equitation ; 3, Bearer drill and field work ; 4, Anat- omy and physiology; 5. First aid and personal and camp hygiene, including the sterilization of water and disinfection; 6. Nursing, 7. Army Regulations; 8. Cooking; 9. Materia medica and pharmacy; 10. Elementary hygiene; 11. Clerical work. All privates are in- structed in the first six subjects, and those who show special aptitude take the complete course. Instruction in the first three subjects is continuous throughout the year; the other subjects are included in the regular winter course of instruction covering a period of thirty-four weeks. Field hospitals and ambulance companies maintained in time of THE SANITARY TROOPS IN POST 5 peace are also utilized so far as practicable in teaching recruits the work of the sanitary field organizations. The course of study taught recruits while with these organizations is supplemented by practical instruction at posts and in the field after their assignment to other commands. The course for noncommissioned officers comprises the following subjects: Sanitary administration, pharmacy, clerical work, minor surgery, mess management and Army Regulations. Privates first class and privates who are candidates for appointment as noncom- missioned officers are required to take this course; and in addition the regular course prescribed for their grades, or any part of it, if deemed necessary by the officer in charge of instruction. Privates first class or privates w'ho have shown special proficiency may be recommended for promotion by the surgeon. To test their capacity for performing the duties of a noncommissioned officer, they may be first detailed as lance corporals. Before being appointed sergeants they must pass an examination as to (i) Physical con- dition; (2) character and habits, especially as to the use of stimu- lants and narcotics; (3) discipline and control of men; (4) knowl- edge of regulations; (5) nursing; (6) dispensary work ; (7) clerical work; (8) principles of cooking, and mess management; (9) Hos- pital Corps drill; (10) minor surgery and first aid, including extrac- tion of teeth. The board will require the candidate to prepare a full set of papers pertaining to the medical department, and to drill a detachment sufficiently to demonstrate his thorough knowledge of the drill regulations. The written examination will embrace the following subjects: (i) Arithmetic; (2) materia medica; (3) pharmacy; (4) care of sick and ward management; (5) minor surgery and first aid; (6) elementary hygiene. Ten questions will be asked in each subject. Proficiency in penmanship and orthography will be estimated from the papers submitted. Sergeants who have served a year as such, or enlisted men of the hospital corps who served as hospital stewards of volunteers or acted in that capacity for more than six months during and since the Spanish-American war, may be appointed sergeants first class upon the recommendation of the Surgeon General, provided they have successfully passed a more extensive and detailed examination in the above subjects than is required for promotion to the grade of 6 SANITARY TROOPS IN POST AND FIELD sergeant. A reexamination before his first reenlistment may not be required if his commanding officer and the department surgeon con- cur in the statement that the candidate has performed his duties efficiently ; but a reexamination is called for before a second re- cnUstment, after which no furthei ^examination is ordinarily required. Army Regulations provide for at least one noncommissioned officer and four privates at each permanent military post, with an additional noncommissioned officer for every additional four privates ; six privates when the garrison is two hundred, and two privates additional for every additional one hundred of strength. The uniform for ordinary wear is the same as that of the line except that the facings are of maroon-colored cloth and that the caduceus is the emblem of the corps. Privates first class are dis- tinguished from privates by wearing a caduceus upon the sleeves of the blouse above the elbow. For duty in the wards, kitchen, dis- pensary, and operating-room a. uniform of white cotton duck is worn. The duties of the sanitary troops in time of peace are chiefly con- cerned with the care of the sick; sanitation and preparation for war ; that they are many, varied, and important may oe gathered from the scope of the scheme of instruction detailed in the following pages. The peace hospitals of the army are of three classes, post Jiospitals. department hospitals, and general hospitals ; post and general hos- pitals are distinguished from each other by the fact that the former usually receive only the sick of the post to which they belong, while the generaf hospitals receive the sick from widely separated com- mands. Some of the general hospitals are of a special nature, su-'h as that of Fort Bayard for the treatment of tuberculosis, and the general hospital at Hot Springs, Arkansas, for the treatment of cases requiring a course of bathing Department hospitals correspond in all respects to general hos- pitals except that they are under the control of the Department Com- mander. The duties ol noncommissioned ofificera of sanitary troops are to maintain discipline in hospitals and watch over their general police ; to supervise the duties and assist in the instruction of the subordinate personnel in hospital and in the field ; to look after and distribute hospital stores and supplies; to care for hospital prop- THE SAXITARV TROOPS IX POST 7 erty; to compound medicines; to prepare reports and returns; and to perform such other duties as may, by proper authority, be required of them. The senior noncommissioned ofificer must be an efficient discipH- narian, expert clerk, accurate arithmetician, and a trustworthy phar- macist, with as much knowledge of materia medica, therapeutics, and minor surgery as will enable him to give sound advice and suit- able treatment in the minor ailments and accidents which in civil life are dependent on the resources of domestic medicme or the knowledge of the nearest pharmacist ; in addition, he must have that higher knowledge, for use in the wards, which enables the ex- perienced nurse to appreciate the condition of those who are seriously ill. that their improvement may be fostered and all harmful influences excluded. At small posts, during the temporary absence of the medical officer, the unforeseen casualties and even many of the exigencies of military life impose duties upon him the satisfac- tory performance of which may be of the first importance to the individuals concerned. The following are official rules for the interior administration of hospitals : (a) GENERAL RULES (i) In the smalkr hospitals the senior noncommissioned officer, under the direction of the surgeon, is in immediate charge of the hospital and the Hospital Corps detachment. He will see that all men of the detachment and all patients in the hospital are always present or accounted for. He will require all members of the detachment to perio ta their duties quietly and treat the sick with gentleness and consideration ^ (2) The noncommissioned officer in charge of public property wdl keep an accurate account of the same aud its place of distribution. (3) Each man in charge oi \ department of the hospital, as wardmaster, noncommissioned officer in charge of mess, etc., is responsible tor the prop- erty used in his department. He w:ll ketp a list of the sam* and will by frequent inventories assure himself of its presence. (4) All public property in the possession of the men must be kept in good order and all missing or damaged articles accounted for. (5") A noncommissioned officer or other man, upon his assignment to a department of the hospital, will make himself familiar with the special orders governing it, and all must familiarize themselves with the standing orders of the hospital. ' Til the larger hospitals it may he necessary to distribute these duties among several noncommissioned officers as determined by the commanding officer ot the hospital. 8 SANITARY TROOPS IN POST AND FIKIJ) (6) All noncommissioned otticers and privates of the detachment will be present at all formations unless specially excused. (7) All men on duty in the kitchen and mess room will arise at least one hour before reveille ; all other members of the detachment, unless specifically excused, will arise at or before first call for reveille. (8) Immediately after reveille each man will arrange his bed and personal belongings in a neat and orderly manner. All clean underclothing will be neatly folded and placed in the lockers, which will be uniformly packed; other clothing will be brushed and hung in the lockers or in a specially designated place. Soiled clothing will be kept in the barrack bags. Shoes will be polished and neatly arranged in the lockers or under the sides of the beds. (9) All beds will be overhauled and cleaned each week and, w-eather per- mitting, the bedding and mattresses, together with the other clothing, will be well shaken and hung out to air for at least two hours. Mattress covers will be changed immediately before each monthly inspection or oftener if neces- sary. Sheets and pillowcases will be changed at least once each week. (10) A card bearing the name of the soldier will be attached to the foot of his bed, and his accouterments will be hung, neatly and uniformly arranged, on the foot end iron of his bunk. (11) The squad room will always be kept clean, neat; and orderly. (12) The men will pay the utmost attention to personal cleanliness; each will bathe at least once weekly, his hair must be kept short, and his face shaved, or beard neatly trimmed, and his underclothing frequently changed. (See Army Regulations.) (13) Members of the detachment will wear the prescribed uniform at all times when present at the post. While on fatigue they may wear the fatigue dress. While on duty in wards, dispensary, operating room, mess room, or kitchen, they will wear the white uniform. (14) No member of the detachment will leave the hospital bounds except by permission of proper authority or, !ri case of emergency; in the execution of duty. (15) Immediately after "breakfast ^he hospital will be thoroughly policed in every department. It must be ready for inspection ':. the hour designated by the surgeon and always be kept absolutely clean. (16) No member of the hospital personnel will borrow from or have financial dealings with any patient. (17) When necessary a noncommissioned officer in charge of quarters w'ill be detailed daily by roster from noncommissioned officers on duty with the detachment, and an emergency squad will always be designated. (18) The noncommissioned officer in charge of quarters will make an inspection of all wards and quarters at such times as the surgeon may direct, will report all unauthorized absentees to the noncommissioned officer in charge of the detachment, and will see that no unauthorized lights are burning. In case of fire he will give the alarm and proceed as ordered in fire regulations. He will be responsible for the efficient performance of the watchman's duties. (ig) TTie night watchman, when one is necessan.% will be under the im- mediate orders of the noncommissioned officer in charge of quarters. He THE SANITARY TROOPS IN POST 9 will patrol the hospital grounds at least once every three hours and will be constantly on the alert for fires, lights, and unauthorized persons in or about the hospital. He will at once report to the noncommissioned officer indicated all unusual occurrences and violations of existing orders which come under his observation. (b) WARD RULES (i) The wardmaster oi each, ward is directly responsible to the ward surgeon. He is in charge of his ward and the enlisted assistants and patients in it, and will be obeyed and respected accordingly. (2) The wardmas^ter is responsible for the cleanliness and order of his ward, for the public property therein, and for the effects of his patients until they have been turned over to the proper custodian. He is responsible for the prompt delivery of prescriptions to the dispensary, of medicines to his ward, and of the diet orders to the hospital office. (3) In wards to which members of the Nurse Corps are not assigned the wardmaster is responsible for the administration of medicines and other treatment prescribed, the keeping of records, and all other duties that may be assigned to him by the ward ofiicer. (4) Phenol, bichloride of mercury, other active poisons, alcohol, and alcoholic liquors, when necessarily on hand in the ward, will be kept under lock and key and every precaution taken to prevent their improper use. (5) On the death of a patient the wardmaster will notify the ward sur- geon, or in his absence the medical officer of the day. He will not remove the body from the ward until after it has been examined by a medical officer. (6) The wardmaster will see that patients are acquainted with the ward rules. (7) Before leaving the ward at the end of his daily tour of duty, the wardmaster will turn over to his relief all orders of the ward surgeon, accompanied by such explanation and instruction as may be necessary. (8) Upon reaching the ward, patients will be promptly bathed, clothed in clean hospital clothing, and put to bed, unless their condition indicates other- wise or a specific order forbids. (9) Money and valuables found on patients will be disposed of as pre- scribed in Manual Medical Department. The commanding officer will not be responsible for money or valuables of patients not turned over for deposit in the hospital safe. (10) A clinical record will be carefully kept for each patient. Upon final disposition of the case this record will be completed and signed by the ward surgeon and turned in to the record office. (11) No information regarding the diseases or condition of patients under treatment will be given to anyone except those authorized under the regula- tions to receive it, (12) Visitors will be allowed to see friends in the ward at a specified time, when their presence will in no way disturb other patients; but female visitors will not be permitted in the wards except when cases are serious, and then only by special permission of the ward surgeon. 10 SAXITARV TROOPS IN POST AND FIELD (13) Bed linen will be changed on occupied beds at least twice weekly, and oftencr if necessary to insure cleanliness. Whenever a bed is to be occupied by a new patient clean linen will be furnished. All beddinj; and clothing used by infectious cases will be promptly disinfected when removed from the beds. Patients will not occupy their beds when dressed in other than hospital clothing. (14) Loud noises, boisterous actions, the use of profane language, and gambling are forbidden in the w'ards, and no food, intoxicants, or other articles of food or drink, except as prescribed or authorized, will be brought into the wards. (15) Patients are forbidden to use towels, basins, toilet articles, eating utensils, or articles of clothing pertaining to another patient. ADMISSION AND DISTRIBUTION OF IWTIENTS Upon his admission to hospital a patient will first be taken to the receiving ward, if there is one, or to the office, where his register card will be filled in so far as the data are available at the time, the treatment ward to which he is assigned being noted on the back thereof. There will also be entered on a clinical record brief ( Form 55a) the patient's name, rank, organization, etc., the diagnosis on the transfer card, if one has been received, and the designation of the ward to which he is assigned. This form will accompany the patient to the ward and will be the wardmaster's authority for his admission thereto. Upon reaching the treatment ward the patient will be promptly stripped, bathed, clothed in clean hospital clothing and put to bed, unless his condition indicates otherwise or a specific order forbids. The treatment sheet and the other clinical record sheets if required will be begun immediately upon the patient's admission. The daily routine of the service of a post hospital begins at reveille, when, after roll call, the wards are tidied up and breakfast is served and cleared away before sick-call is sounded. Promptly on this call a noncommissioned officer from each company brings his sick to the place designated for their inspecaion ; usually the hospital or a dispensary. A medical officer examines each man. indicating in the company sick report book those who are to be treated in hospital and those who are to be excused from duty or portions thereof as sick in quarters, etc. Morning reports are then sent to the ad- jutant's office for the information of the commanding officer. Pre- scriptions for those in quarters are now filled, and the register of sick and wounded is brought up to date by the careful entry of the morning's changes. After breakfast the wards are visited and the THE SANITARY TROOPS IX POST 11 ])re5criptioii and diet orders recorded. After this tlie ktichen, dining-room, and other parts of the hospital are inspected, and the regulation visit is at an end. Emergency calls bring the medical officer to the hospital at any hour and generally, when serious cases are on hand, he may be expected before retreat or tattoo. After the morning visit he attends to his patients in the families of officers, married soldiers, laundresses, and other attaches of the garrison, and his prescriptions reach the dispensary from time to time during the forenoon. By the time these are tilled the senior noncommissioned officer has posted the records, supplied the wards with needful articles of bedding, etc., given directions for the diet of the day, and provided the required supplies from his subsistence stores and special diet fund and hospital fund purchases. The afternoon may be de- voted to instruction, exercises, or amusements, in the absence of special call for its occupation otherwise, and the evening to study, or, at certain periods, to the preparation of official reports and papers. The studies of the sanitary soldiers are naturally such as will fit them to act intelligently in all matters relating to the manage- ment of the hospital and the sick and wounded. Every m^edical officer supervises the instruction of his men and the higher education of his noncommissioned officers; the latter guide and perform similar offices to those who serve under them. The medical officer is required by regulations to devote at least five hours each week to instructing the men of the corps in their various duties. These duties wall eventually lead every capable member of the corps to the position of a noncommissioned officer ; but besides this personal influence they serve a higher end by preparing the corps for sudden expansion in time of war. When every sergeant is qualified to undertake the duties of the next higher grade, and every private qualified for the position of sergeant, the expansion of the command can be effected by merely recruiting for the lowest grade. The senior medical officer is responsible for the timely and accu- rate rendition of the reports and papers required in the service of post hospital ; but the work, except in the case of special and profes- sional reports, is usually performed by enlisted men, to whom the clerical work has been assigned. For all routine reports blank forms are provided by the War Department, and full instructions are printed on each of these to insure accuracy, the said instructions having the force of Army Regulations. CHAPTER TI THE SANITARY SOLDIER IN WAR The duties of the sanitary soldier in war are even more varied and important than in time of peace and are apt to be more clearly defined. Thus some men will be assigned as litter-bearers, others as nurses, orderlies, cooks, operating-room assistants, etc. It is neces- sary that even privates should understand something of the field organization of the medical department. ADMINISTRATIVE ZONES In time of war the activities of the military establishment embrace : (i) The service of the interior. (2) The service of the theater of operations. The service of the interior is carried on by : (i) Department commanders. (2) Bureau chiefs, having for this purpose general depots of supply, general hospitals, arsenals, etc. (a) The service of the theater of operations is carried on by the commander of the field forces. The theater of operations is divided into two zones : (i) The zone of the line of communications. (2) The zone of the advance. (b) The senace of the interior functions both in peace and in war ; that of the theater of operations in war only OBJECTS OF MEDICAL DEPARTMENT ADMINISTRATION The objects of Medical Department administration in war are: (0) The preservation of the strength of the Army in the field by (i) the necessary sanitary measures; (2) the retention of effectives at the front, and the movement of noneffectives to the rear without obstructing military operations; and (3) the prompt succor of wounded on the battlefield and their removal to the rear, thus pre- (12) THE SAXITARV SOLDIER IX WAR 13 venting the unnecessary withdrawal of combatants from the firing line to accompany the wounded, and promoting the general morale of the trcops. (b ) The care and treatment of the sick and injured in the zone of the advance, on the line of communications, and in home territory. . DUTIES OF THE MEDICAL DEPARTMENT The Medical Department is charged with the administration of the sanitary service. Specifically, its duties are : (a) The initiation of sanitary measures to insure the health of the troops. (b) The direction and execution of all measures of public health among the inhabitants of occupied territory. (c) The care of the sick and wounded on the march, in camp, on the battlefield, and after remo\al therefrom. (d) The methodical disposition of the sick and wounded. (e) The transportation of the sick and wounded. (/) The establishment of hospitals and other formations necessary for the care of the sick and wounded. (g) The supply of sanitary material necessary for the health of troops and for the care of the sick and wounded. (h) The preparation and preservation of individual records of sickness and injury, in order that claims may be adjudicated with justice to the Government and to the individual. PERSONNEL OF THE SANITARY SERVICE General Enumeration In time of .war the sanitary service includes: ( 1 ) All persons serving in or employed by the Medical Depart- ment, including officers and men temporarily or permanently detailed therein. (2) Members of the American National Red Cross assigned to duty with the Medical Department by competent authority. (3) Individuals whose voluntary service with the Medical Depart- ment is duly authorized. (a) The personnel of the Medical Department and all other per- sons assigned to duty with that department are collectively called sanitary troops. 14 SANITARY TROOPS IN POST AND FIELD The following persons serve in or are employed by the Medical Department : (1) Medical officers of the Regular Army (including officers of the Medical Reserve Corps), of the Organized Militia called into the service of the United States, and of the Volunteer Army. (2) Physicians under contract. (3) Members of the Dental Corps. (4) Members of the Hospital Corps. (5) Members of the Nurse Corps. (6) Officers and soldiers of the line or staff detailed for duty with the Medical Department. (7) Civilians employed by the Medical Department. TITLES OF MEDICAL OFFICERS The title of the senior medical officer on the staff of the com- mander of a field army is " chief surgeon " ; of a line of communica- tions, " surgeon, base group " ; of a division, " division surgeon " ; of a brigade operating independently, "brigade surgeon"; of a detachment, regiment, or smaller command, " the surgeon " ; of a field hospital or other sanitary formation, and of an ambulance com- pany or detachment thereof, " commanding officer. INSIGNIA OF SANITARY PERSONNEL. FORMATIONS, AND MATERIAL (See Rules of Land Warfare.) In campaign, all persons belonging to the sanitary service and chaplains attached to the Army wear on the left arm a brassard bearing a red cross on a white ground, the emblem of the sanitary service of armies. This brassard is issued and stamped with a num- ber by competent authority, and in case of persons who do not have military uniforms it is accompanied by a certificate of identity. Brassards will be issued to the uniformed personnel of the sani- tary service and to chaplains by the senior medical officer of the organization with which they are on duty. To other individuals entitled thereto under the provisions of the Geneva convention brassards and certificates of identity (Form 61) will be issued by the division surgeon, surgeon, base group, the department surgeon, or the Surgeon General, as the case may require. The certificate of identity will bear the same number as the brassard. THE SANITARY SOLDIER IX WAR 15 The person to whom a certificate of identity is issued will retain it in his personal possession and exhibit it when called upon by com- petent authority to do so. Care will be exercised to prevent the cer-tificate of identity or its container from coming into the hands of another person. The loss of a brassard or of a certificate will be investigated and reported by the immediate commander to the office which issued the lost article. All sanitary formations display during daylight (reveille to re- treat) the Red Cross flag accompanied by the National flag. If a sanitary formation falls into the hands of the enemy it displays while in such situation the Red Cross flag only. At night the positions of sanitary formations are marked by green lanterns — a camp infirm- ary by one green lantern ; a field hospital by two green lanterns, one above the other ; and an ambulance company or its dressing station by one green lantern above one white lantern. All materiel pertaining to the sanitary service is also marked with the Red Cross emblem, a red cross on a white ground. STATUS OF SANITARY PERSONNEL AND MATERIAL All the personnel of the sanitary troops and armed detachments or sentinels ordered by competent authority to guard sanitary for- mations are respected and protected under all circumstances. If they fall into the hands of the enemy, they do not become prisoners of war but are disposed of as provided in Article 12 of the Geneva convention, 1906. In order to obtain this protection, the command- ing officer of every sanitary formation should require of his subordi- nates a strict observance of the terms of the Geneva convention. ORGANIZATION OF THE MEDICAL DEPARTMENT IN WAR The following table gives an outline of the organization of the Medical Department in war: 16 SANITARY TROOPS IX POST AND FIELD T3 3 en — 5. .»' 5 t o o ~- i; 3 «^ o &> > "S oSc ^ « g*— -^— ' S-"-;"-^ -'Tie-- •^if- « ^ g. n c^ ^:-i 5 2 5 ■" ? c--=-= c ? i- '-^ gig e->^-i|i ^-' Is .1 ^sig5 2li:iE'iPlEp ""■>"> 5'Et: o = ■- ^■- "■' o-S" ^ — — °— S"^ c-S — rs'S-r; >^ ^^ -' r- r- r- X . X vJ X (, ■^, — t) V 4^***.- "5 ^ OJ •S"c« :5oE = o„ . eof van visic geon one of Ii n e c a t i o (surge b a s group) n — ~ i: N «^ "^ N o c t; — o ? «J ^ CL u <1^ U THE SANITARY SOLDIER IX WAR 17 THE SERVICE OF THE INTERIOR MOniLIZATIOX CAMPS (See Artny Regulations: Organized Militia.) The places of assembly for Volunteers and for the Organized Militia of a State, Territory, or the District of Columbia when called into the service of the United States are known as mobilization camps. CONCENTRATION' CAMPS (See F. S. R. : Service of the Interior.) The places which are selected by the War Department, when war is imminent or has been declared, for the assembly of troops for joint operations or for embarkation, are known as concentration camps. CAMP HOSPITALS A camp hospital is an immobile unit organized and equippe_ for use in camps where the care of the sick would otherwise result in the immobilization of field hospitals or other sanitary formations pertaining to organizations. HOSPITAL TRAINS AND TRAINS FOR PATIENTS Hospital trains are Medical Department organizations and will be provided by the War Department when required for the trans- portation of the sick and wounded. In cases of emergency when hospital trains are not available ordinary trains for patients will be provided for the temporay use of the Medical Department. A hospital train made up of lo cars, of which 8 are for patients (capacity 200), is allowed, in accordance with Tables of Organiza- tion, a personnel of 3 medical officers (captains or lieutenants) ; 3 noncommissioned officers (i sergeant first class, 2 sergeants) ; 2 act- ing cooks; 22 privates first class and privates (20 nurses, 2 orderlies). REST STATIONS Rest stations -will be organized at points on the railway lines where attention can best be given to sick and wounded en route. So far 18 SANITARY TROOPS IX TOST AND J- J IT J) as possible the personnel of such stations will be obtained from the American National Red Cross. HOSPITAL SHIPS AND SHIPS FOR PATllIXTS On over-sea ex])editions hospital ships and ships for patients may both be required. 'J"he}- will l)e pro\ided by the War Department. Hospital ships are Medical Department organizations and will be used solely Ijy that department. Ships for patients are ordinary transports or vessels turned over to the Medical Department for temporary use in emergencies when hospital ships are not availaljle. The personnel of a hospital ship (capacity 200 beds) consists of 5 medical officers (i lieutenant colonel or major, 4 captains and lieutenants); 5 noncommissioned officers (i sergeant first class. 4 sergeants) ; 5 acting cooks; 30 privates first class and privates (29 nurses, i orderly). ;HE THEATER OF OPERATIONS THE ZONE OF THE AD\'ANCE The sanitary personnel of the zone of the advance may be divided into two general groups, as follows : First, that attached to line organizations smaller than a brigade, which functions under the immediate orders of the organization commanders; second, that comprising the sanitary trains, which functions under the orders of division surgeons in accordance with such general or specific instruc- tions as they may receive from their division commanders. (i^ee also Field Service Regulations.) Sanitary troops with line organizations, including detachments with regiments, battalions, trains, etc., vary in personnel with the strength of the organization served and the nature of the duties they are required to perform. (See Tables of Organization : Jl'ar — Regimental Organization.) When a regiment is operating independently the Medical Depart- ment equipment available for its use consists of the first-aid packet carried by each officer and enlisted man of the Army as a part of his individual equipment ; the articles carried as individual equip- ment by each medical officer and by each enlisted man of the medical department ; the combat equipment ; the camp infirmary equipment ; THE SANITARY SOLDIER IN WAR 19 and the additional articles necessary for the establishment of a regimental hospital. (a) The additional articles for the regimental hospital will be taken to the field only under circumstances requiring the organiza- tion to provide hospital care for its own sick and wounded. When a regiment or other line organization is operating as a part of a division the Medical Department equipment provided for its exclusive use consists of the first-aid packets and individual equip- ments mentioned in the preceding paragraph, and the combat equip- ment. A small box of surgical dressings and one or more litters are carried on each ammunition wagon. The requisite articles for the establishment of the aid station are carried on the pack mule allotted the sanitary service, which marches with the combat train of the organization. The medical officer responsible for this equip- ment will see that it is complete and that it is maintained intact for service in combat. (a) On the march and in camp, with the exceptions noted in para- graph 6oi, M. M. D., the medical supplies and dispensary service recjuired by regimental organizations are provided through the medium of the camp infirmary. (b) In combat it is contemplated that the expenditures of dress- ings, etc., from the equipment of regimental organizations will be replenished from the reserve supplies of the nearest ambulance com- pany or camp infirmary. On the march the duties of the sanitary personnel are to render first aid where required, to transport the sick and wounded, and to make suitable disposition of them on arrival in camp Ordinarily the surgeon marches with the regimental commander, and one medical officer marches in the rear of each battalion. Each officer is mounted and accompanied by a mounted orderly. The remaining regimental sanitary personnel usually march with the battalion units. When out of the presence of the enemy, ambulances are ordinarily ordered distributed by the division commander throughout the column, in the rear of regiments, battalions, etc. Unless otherwise ordered these ambulances join their companies at the end of the day's march or at the beginning of an engagement. When a regiment operates independently it may be assigned its full quota of four ambulances. 20 SANITARY TROOrS IN POST AND FJELD A soldier falling out of the marching column from sickness or injury is sent to a medical officer in the rear, with a pass from his company commander, showing the soldier's name and organization. The medical ofhcer returns the pass, showing the disposition made of the soldier. The man may be given authority to ride in the ambu- lance at the rear of the regiment, or his arms and personal equipment may be carried in the ambulance, and he may march at the rear of the regiment with the sanitary detachment. When an ambulance at the rear of a regiment is filled it may fall out and join its company at the rear of the column, and the director of ambulance companies or the ambulance company commander may send forward another ambulance to take its place ; or the ambulance may remain with the regiment, and men requiring trans- portation may be given diagnosis tags authorizing their transporta- tion by the ambulance company in the rear. In the latter case the men fall out and report to the commander of the ambulance company for transportation. The arms, personal equipment, and clothing of a soldier who falls out are taken with him in the ambulance. The horse, saber, and horse equipment of a soldier admitted to the ambulance or otherwise separated from his organization because of sickness or injury are taken back to the troops by the noncommissioned officer who accom- panied him. Upon halting for the night all but the trivial cases are taken in charge by a field hospital designated by the division surgeon, or they are sent to the rear, as the conditions may warrant. It may be necessary to leave them under shelter — in houses, if practical:)le — with the necessary food and attendants until taken in charge by sanitary troops from the line of communications. In combat the duties devolving on the sanitary personnel are to render first aid to the wounded; to establish and operate an aid station, ar. J to collect the wounded thereat ; to direct those with trivial wounds to return to the line, and to direct others with slight wounds to the station for slightly wounded ; and in exceptional cases to transport the severely wounded to the dressing station. The detachment invariably accompanies its line unit in combat, rendering first aid to as many as possible of those who fall out, without losing touch with the command. It is assisted by the band if the latter is assigned to duty with the sanitary troops. THE SANITARY SOLDIER IX WAR 21 Unless medical assistance is available, the wounded apply their first-aid packets, if practicable. With this exception the care of the wounded devolves upon the sanitary troops, and no combatant, unless duly authorized is permitted to take or accompany the sick or wounded to the rear. With dismounted troops the aid station, not more than one for each regfment or smaller independent unit, will be established as the engagement develops and the number of wounded warrant it, pro- viding it is probable that the command will remain, for a short period at least, near the. proposed location of the station. With a mounted command the sanitary detachment accompanies the troops during the whole course of the engagement, pausing only so long as is necessary to render first aid and to collect the wounded at some place where they can be turned over to an inhabitant of the country to be cared for. The commander of the advancing foot troops or of the advance section should be promptly notified of the location of the wounded thus collected. In locating the aid station it is of the highest importance that advantage be taken of any shelter from fire which the terrain affords. To a large extent the distance of the station from the firing line must depend upon this consideration. It will be berne in mind that any building which offers a good target for artillery fire is worse- than no shelter at- all, and that the nearer the station is to the front the saferit will be from dropping projectiles. The surgeon remains, as a rule, at the aid station, with a non- commissioned oflficer and the necessary number of privates, for to this station the commanding officer will send information or orders which he may have to communicate to the surgeon, and through this station the surgeon gains contact with the units of the sanitary train in the rear. The other medical officers and the remainder of the detachment keep in touch with the firing line, tendings the wounded as far as possible and conveying the helpless to the station, if prac- ticable. If the enemy's fire is such that the wounded can not reach the station advantage is taken of trenches, ravines, and other inequal- ities of the ground affording temporary shelter, and the wounded are brought in during intervals in the firing or after nightfall. No one belonging to the sanitary personnel of an organization will go farther to the rear than the aid station, except by authority of the surgeon. 9? SANITARY TROOPS IX POST AXU FIELD The aid station, which will often be but little more than a place for assembling the wounded, should not undertake elaborate or fixed arrangements for their care and treatment, as rts personnel must keep in touch with the regiment and be prepared to close or move the station without delay when the regiment moves. The treatment given will usually be limited to first aid and to the readjustment of dressings. Occasionally it may becinie necessary to ligate an artery or to perform an emergency operation. Fractures, if not previously immobilized, should be put in splints. Diagnosis tags w'ill be attached to all wounded and the duplicates disposed of as directed in paragraph 571 M. }il. D. The arms and equipment of wounded separated from their companies and taken in charge by Sanitary Service - Division l" Br "'■■"-' --Vi, + ''•'■■':tkL.----'^ \^'''' CB Field Hospital Set l/p W-F.eld HospiUI onWa^ons ^Medical Reserve ^ Station fjr Slightly Wounded O Evatu.lmJ foV ^Ambulance Cos Sanitary Column S Exicuatlon Hospital Set Up ^Evaouation HoipiUi on Wa$ons 7^ DA A A (Si ; *»?• iLcf C.Troopi j CajualCa".p ' """ \\ Fig. I. — Sanitary Service. Zones of Administration. the Medical Department should, so far as practicable, accompany them until they reach the line of communications. In the course of battle the advance of troops may result in the aid station being separated so far f re m the line that it can no longer fulfill its pur])ose. In this case it must he advanced to a more favorable location. Ordinarily the wounded left behind will be looked after by the advancing ambulance company. ]:)Ut if it is appar- ent that this will be long delayed a small portion of the regimental personnel may be detailed to remain with them. Similar action will be taken in case of retreat. The closing or moving of the station rests on the decision of the regimental surgeon. In reaching his THE SANITARY SOLDIER IX WAR 23 decision he should be governed by the primary necessity of always keeping in touch with the regiment. The sanitary train is composed of camp infirmaries, ambulance companies, and field hospitals. It is commanded by the division surgeon. CAMP INFIRMARIES Each regiment of a division has assigned to it in time of peace one camp infirmary equipment, including one wagon belonging to the divisional sanitary train. (See Tables of Organization: Peace — Regimental Organizations:) When the division is assembled the camp infirmary equipments authorized for the service of the mobilized division (usually on the basis of one for each brigade) are retained for duty as camp infirm- aries. The remaining camp infirmary equipments, except trans- portation, are turned in to the officer in charge of medical supplies and the wagons thus released are assigned to those units of the sanitary train for which no transportation is provided in time of peace. THE AMBULANCE COMPANY The personnel of an ambulance company at war strength, as given in Tables of Organization, are ordinarily distributed as follows : (a) With the dressing station, including the litter bearers: 4 offi- cers, I sergeant first class, 6 sergeants, i acting cook, 40 privates first class and privates, all of the Medical Department. {h) ^^'ith the wheeled transportation: i officer, i sergeant first class, I sergeant, i acting cook, 28 privates first class and privates (i as farrier, i as saddler, 2 as musicians, 12 as ambulance drivers, and 12 as ambulance orderlies), all of the Medical Department; also I sergeant (blacksmith) and 3 privates (drivers) of the Quarter- master Corps. The function of the ambulance company is to collect the sick and wounded, to afl:"ord them temporary care and treatment and to trans- port them to the next sanitary unit in the rear. In camp the ambulance company operates an ambulance service between the camp infirmaries and the field or other hospitals. On the march ambulances are distributed among the marching troops, usually one to each regiment, for the purpose of supplying transportation to those who become unable to march. 24 SANITARY TROOPS IN POST AND FIFXD In combat the company operates in two parts. 'J"he first estab- lishes and operates a dressing station and collects the wounded thereat, the second operates the wheeled transportation in evacuating the w'ounded. Ambulances must reach the dressing station as early as possible even at the risk of losses. Ordinarily ambulances will carry wounded only from the dressing station to the nearest field hospital, immediately returning to the former; any other destination for wounded must be prescribed by the division surgeon. THE FIELD IIO.SPIT.\L (Capacity 216.) The field hospitals will be numbered from i upward in a single consecutive series for the entire military establishment. The wagons of the field hospital will be marked as prescribed in Tal)les of Organization. The commanding officer of the field hospital is under the imme- diate orders of the director of field hospitals, when there is one; otherwise he is under the immediate orders of the division surgeon. The personnel of a field hospital at war strength, as given in Tables of Organization, are ordinarily assigned as follows: i major (commanding) ; 5 captains and lieutenants (i adjutant and quarter- master, 4 ward surgeons) ; 3 sergeants first class (i acting first ser- geant in general supervision of the hospital and in charge of medical property and records, i in charge of transportation and quarter- master property and records, i in charge of mess supplies and cook- ^"&) J 6 sergeants (i in charge of the dispensary, i in charge of operating equipment, i in charge of patients' clothing and efifects, 3 in charge of wards); 3 acting cooks; 55 privates first class and privates (46 attendants, i dispensary assistant, i artificer, 4 orderlies, 3 supernumeraries) ; and of the Quartermaster Corps, I sergeant (wagon master) and 7 privates (drivers). The function of the field hospitals is to keep in touch w'ith the combatant organizations and to provide shelter and such care and treatment as are practicable for the sick and wounded of the division who are brought in by the ambulance companies until the sanitary service of the line of communications takes ciiarge of them. A field hospital can meet these requirements only when it is relieved so promptly by the sanitary units in the rear tiiat its mobility is not THE SANITARY SOLDIER IN WAR 25 interfered with. Prompt evacuation of the sick and wounded is necessary also to secure for them the faciHties for treatment and the comforts which are available on the line of communications. On the march and in temporary camps, however, the field hospitals are the nightly collecting points for the divisional sick and injured who are unable to continue the march, and must provide for the care of such patients until they can be turned over to the medical service of the line of communications or to a local hospital or hos- pitals. The use of the field hospitals for this purpose should be carefully regulated by the division surgeon. (a) So far as practicable in each division only one field hospital at a time will be used in this service, leaving the others entirely free of patients. Furthermore, only so much of the equipment of the field hospital assigned to this work should be unpacked as is required to care properly for the patients actually in the hospital and their necessary attendants who are to remain behind when the division moves on. The number of personnel detailed to remain will be as small as possible. (b) The equipment which has not been unpacked and the per- sonnel who have not been detailed to remain with the patients will move with the division. (c) Every effort will be made by the division surgeon to dispose of the patients left behind. Should unusual delay in turning them over to the medical service of the line of communications supervene, temporary provision for them should be arranged in civil hospitals of the locality or otherwise as may be most practicable until the medical units of the line of communications can take charge of them. (d) As soon as the patients are disposed of, the personnel detailed for the temporary care of such patients will immediately rejoin the hospital. On the receipt of an order to open a field hospital the following departments will be established: Dispensary. Kitchen. Receiving and forwarding. Slightly wounded. Seriously wounded. Operating room. Mortuary. 26 SANITARY TROOPS IN POST AND FIELD All wounded arriving at the field hosjiital will be received at the receiving and forwarding department, which is the administrative office of the hos])ital. (o) The slightly wounded, able to walk, will be immediately directed to the rear or to the station for slightly wounded, as the circumstances may indicate. (/') The seriously wounded, and the slightly wounded unable to walk, will be assigned to the proper department for treatment. . (c) Records of the wounded will be made as prescribed in para- graph 575 et seq M. M. D. THE STATION FOR SLIGHTLY WOUNDED The station for slightly wounded is a transient divisional organiza- tion on the battle field ; it has no permanent personnel or definitely prescribed equipment. (a) The personnel required for the station, usually one medical officer, two noncommissioned officers, and eight privates, will be detached from such unit of the sanitary train as the division surgeon may elect. In some instances it may be practicable to utilize per- sonnel sent forward from the line of communications. (b) For the equipment of the station one of the camp infirmaries of the division may be utilized, or a medical and surgical chest and such other supplies as are necessary may be tempor.arily detached from one of the field hospitals. The functions of the station for slightly wounded are (i) to afford a place where men who are unable to accompany their units into combat may be assembled; (2) to relieve dressing stations and field hospitals of the congestion incident to the presence of the slightly wounded who can walk and who require but little attention. The station, usually one for each division, is established when combat is imminent. It should be about the same distance from the firing line as the field hospitals. A building should be selected for its use when practicable. It should preferably be located on the route over which the troops have advanced, as this route is the one which the disabled are most likely to follow in working their way to the rear. In any case it should be so conspicuously marked that it can be found readily. Extensive preparations at this station are unnecessary. A tent THE SANITARY SOLDIER IN WAR 27 should be erected, if no building is available, where dressings may be applied or readjusted and arrangements made for the preparation of simple nourishment. Diagnosis tags should be attached to all wounded not already tagged. The duplicates of the tags will be disposed of as directed in paragraph 571 AI. M D. A list of sick and wounded will be prepared as prescribed m paragraph 580 M. M. D. Fig. 2. — Line of Communications. THE LIXE OF COM MUNIC.ATIOXS The line of communications is the connecting link between the service of the interior and the zone of the advance. It is estab- 28 SANITARY TROOPS IN POST AND FIELD lished when an important force is about to engage in field operations involving a movement from a base unless the territory througli which the supply services extend can be safely occupied without military operations of an extensive character. In the latter case administra- tion and supply are accomplished as in the service of the interior. The line of communications is ordinarily divided into a base sec- tion and an advance section. In certain cases, due to prolongation of the line of communications, an intermediate section may be required. An advance section is required at the head of each impor- tant route of supply diverging from the base. The mission of the sanitary service of the line of communications is (i) to provide such adequate facilities for the treatment of the sick and wounded that those not permanently disabled may be returned to the front with the least practicable delay; (2) to furnish such an efificient evacuation service as will promptly relieve the fighting forces of the encumbrance of their sick and wounded and allow the sanitary units in the zone of the advance to maintain con- tact with their combatant organizations; (3) to organize and mam- tain a system of supply that will enable the sanitary troops in the theatre of operations to replenish their equipment and supplies by direct methods and without delay; (4) to maintain satisfactory sanitary conditions among the troops on the line of communications and, if necessary, to take entire charge of sanitation among the inhabitants of the occupied territory. The Medical Department units pertaining to the line of com- munications are the following : Base group. — A medical supply depot, one or more base hospitals, and, when required, convalescent camps, contagious disease hospi- tals, hospital trains and trains for patients, hospital ships and ?hips for patients, casual camps, sanitary squads, field laboratories, and organizations of the American National Red Cross. Intermediate groiif^. — Rest stations, organizations of the Ameri- can National Red Cross, and such other sanitary formations as may be necessary. Advance group. — Two evacuation hospitals and one evacuation ambulance company for each division at the front supplied from the advance section, and an advance medical supply depot. The evacu- ation hospitals and evacuation ambulance companies of the advance section are collectively known as the sanitary column. THE SAxMTARY SOLDIER IN WAR 29 THE BASE HOSPITAL (Capacity 500.) Base hospitals are Medical Department units of the line of com- munications under the supervision of the surgeon, base group. They will occupy buildings, if suitable ones are available. THE CONVALESCENT CAMP In appropriate cases convalescent camps may be established in the vicinity of base hospitals. Such camps will be branches of the base hospital near which they are situated. THE CONTAGIOUS DISEASE HOSPITAL Ordinarily cases of infectious disease occurring among troops in the theatre of operations will be cared for in the isolation wards of base or other hospitals and so far as practicable at or near the place of origin of the disease. In the presence of a serious epidemic, however, special facilities for the isolation of cases may be required. In this event the surgeon, base group, with the authority of the commander of the line of communications, will organize such con- tagious disease hospitals as may be necessary to meet the emergency. TRAINS, BO.ATS, AND SHIPS The general regulations governing the organization, personnel, materiel and operation of hospital trains, trains for patients, hos- pital ships, and ships for patients in the service of the interior will apply also to the similar medical department units on the line of communications, except that the duties performed by the Surgeon General with respect to the former will devolve in the latter case upon the surgeon, base group. SANITARY SQUADS For the purpose of giving attention to sanitary matters not within the control of regimental or other military organizations, sanitary squads will be organized on the line of communications at such places as may be necessary. The personnel of such squads will consist of enlisted men of the Hospital Corps augmented by such number of other enlisted men 30 SANITARY TROOPS IN POST AND FIELD and civilian laljorcrs as the amount and character of the work may justify. Each squad will be in immediate charge of a medical officer. The function of sanitary squads is to supervise or execute, as the case may be : ( i ) The necessary measures for the sanitation of camp sites, towns or villages not occupied or garrisoned, or of such parts of the same as may be otherwise unprovided for; (2) sanitary work that may be necessary for the general welfare but that can not be performed conveniently or profitably by individual organizations ; (3) the operation of sanitary apparatus used by troops in common and not under control of any one organization. Sanitary squads will not be employed to relieve regimental and other similar organizations of the duty of providing for the sanita- tion of their own camps, REST STATIONS Rest stations are organized for the purpose of giving temporary care and treatment to sick and wounded en route. When on railway lines those established on the line of communications are similar in every way to those pertaining to the service of the interior and their personnel should, if practicable be obtained in like manner. THE BASE MEDICAL SUPPLY DEPOT A medical supply depot will be established at the base. The officer in charge of this depot will prepare in quadruplicate a list of all supplies required, showing the maximum and minimum quanti- ties of each article which should be kept on hand in the depot, having due regard in formulating this estimate to the number of troops to be supplied, the time required by the depot to replenish supplies, the character of the military operations in prospect, etc. In stating the minimum quantity of supplies the supply officer should include at least one medical reserve unit for each division at the front, in addition to the supplies likely to be required by the sanitary formations on the line of communications. Three copies of the above-mentioned list will be forwarded through military channels to the commander of the military forces. \\'hcn approved, one copy will be retained at the headquarters of the commander of the field forces, one copv will be sent to the Surgeon General, and one copy will be returned to the officer in charge of the depot. THE SANITARY SOLDIER IX WAR 31 TIIK ADVANCE MEDICAL SUPPLY DEPOT The Stock on hand at this depot will be considered a part of the available supply of the base depot, as far as the table fixing the maximum and minimum stock limits is concerned. THE EVACUATION HOSPITAL (Capacity 43^.) The evacuation hospitals are Medical Department units belonging to the line of communications. Ordinarily two evacuation hospitals will be assigned to a line of communications for each division which it serves in the zone of the advance. They will be numbered and designated like the base hospitals. The primary function of the evacuation hospital is to replace field hospitals so that the latter may move with their divisions, or to take over their patients with the same object in view. So far as it THE EVACUATION AMBULANCE COMPANY Evacuation ambulance companies are organized only in time of war or when war is imminent. They are allowed in the proportion of one for each division at the front. They will be numbered con- secutively from I upward for each field army to which they belong, as " Evacuation Ambulance Company No. i, 3rd Field Army." The primary function of the evacuation ambulance company is the evacuation of field hospitals and the transportation and care of patients en route therefrom to evacuation, base, or other hospitals on the line of communications or to points with train or boat connec- tions for rail or water transport to such hospitals. ADMINISTRATION For administration and control the line of communications is organized as follows : (i) A service of defense. (2) A supply, sanitary, and telegraph service. (3) A service of military railways. All personnel pertaining to the sanitary service of the line of communications report at the base for assignment to duty. Here advance and intermediate sections are organized and sent forward as required. Z2 SAxNITARY TROOPS IN TOST AND FIELD RfiSUAl£ OF THE OPERATIONS OF THE SANITARY SERVICE IN WAR When war is imminent, the Regular Army is moblized at its permanent posts or stations and the Organized Mihtia at mobhza- tion camps. Little is required of the Medical Department at the time of moblization in connection with the preparation of organiza- tions of the Regular Army for active service. Field equipment is maintained at designated stations or depots in readiness for service at all times ; the men of the Hospital Corps available for service with line organizations and with the sanitary train are designated in time of peace and are in readiness to join their respective units. The men composing the line organizations have been given thorough physical examinations which have been made of record, and they have been vaccinated against smallpox and typhoid fever. Each man is equipped with a first-aid packet and has been instructed in its use. So far as the Medical Department is concerned, therefore, these troops should be in readiness to proceed from their points of mobilization to the camps of concentration on short notice. Mobilization camps for the Organized Alilitia are provided in each State. An officer of the Regular Army commands each camp and has on his staff a camp surgeon, usually a medical officer of the Regular Army. Mobilization camps are operated under the control of department commanders, who are responsible for the complete preparation and equipment of the troops which assemble there. The work of the Medical Department at these camps is supervised by the department surgeon and the sanitary inspector of the depart- ment. The camp surgeon is provided with an adequate corps of assistants. Physical examinations of troops mobilized are made and recorded in accordance with specific instructions from the War Department. Vaccinations against smallpox and typhoid fever are administered and records made thereof. Individuals and organiza- tions are furnished such portions of their equipment as pertain to the Medical Department ; and such training in sanitary matters is given both the line troops and the sanitary troops as is possible, and appropriate to each. When for any reason it is impracticable to fully prepare individuals and organizations 'for service at the front, so far as this preparation devolves upon the Medical Department, THE SANITARY SOLDIER IX WAR 33 the camp surgeon will furnish a full report to the department surgeon showing what remains to be done in order that the latter may take the necessary steps to have the preparation of such indi- viduals and organizations completed at the camp of concentration. After mobilization, equipment, and preliminary training, the troops are assembled at concentration camps for immediate use against the enemy or for transport to an over-sea theater of opera- tions. At camps of concentration the general instruction and train- ing of line and sanitary troops in connection with the work of the sanitary service is conducted under the direction of the camp surgeon. On leaving camps of concentration, troops pass from the service of the interior to the theater of operations, where they come under the control of the commander of the field forces. They may pass directly into the zone of the advance or they may traverse the zone of the line of communications before reaching the zone of the advance, or they may be assigned to duty on the line of communica- tions. In the latter case they may be assigned either to the service of defense, to tlie supply, sanitary, and telegraph service, or to the service of military railways. The relations and duties of the sani- tary personnel in this zone are described in paragraphs 751 to 827 U. M. D. The sanitary service of the zone of the advance is treated in detail in paragraphs 630 to 750 M. M. D. The purpose of the service in camp, on the march, and in combat is to render temporary aid to the sick and wounded and to expedite their transi)ortation to the rear, always making such disposition as will secure the retention at the front of all men fit for duty and relieve the fighting force of the impediment incident to the presence of men incapacitated for duty. To that end the service of the advance is assisted by the service of the line of communications, if one has been organized ; otherwise directly by the service of the interior. In either event it cooperates with the advance station of the service in its immediate rear. When battle is imminent, the resources of the sanitary service behind the zone of the advance are placed in readiness to meet the demands for the care and transportation of the wounded which may reasonably be expected, and personnel and supplies are advanced as near the seat of operations as practicable, reaching forward into the zone of the advance if conditions warrant it. 34 SANITARY TROOPS IX POST AND FIELD The troops engaged in combat are accompanied by medical officers and Hospital Corps attendants ; ordinarily a medical officer with a detachment of Hospital Corps men accompanies each Ixittalion into combat, and the surgeon of each regiment with llie equipment carried on a pack mule establishes an aid station. Tlie wounded apply their own first-aid dcssings, if practicable, and the sanitar_\- jiersonnel attached to organizations render first aid as soon as pos- sible. The sanitary personnel with each battalion collect the wounded in groups and transport those who are unable to walk to the regimental aid station. Men with trivial wounds are sent back to their commands when their wounds are dressed, and tho>e slightly wounded but able to walk are directed to the station for slightly wounded several miles in the rear, in order that dressing stations and field hospitals may not be unnecessarily congested by the presence of this class of men. At the aid stations the sanitary service with troops connects with the service of the sanitary train. Each ambulance company establishes a dressing station in a protected location usually some distance in rear of the aid station. The dressing stations send for- ward bearers to remove the wounded \vho have been brought in to the aid stations. At the dressing stations light nourishment is pro- vided, dressings are examined and adjusted or reapi:ilied, as condi- tions may require, and the patients who require transportation are made as comfortable as possible until it is practicable to transport them to the rear, usually to the field hospitals. Whenever possible the dressing stations are so located that they can be reached by wheel transportation, and the wounded are sent to the field hospitals in ambulances. The field hospitals do not perform the functions of civil hospitals or of base or general hospitals, in that their equipment is limited to those things necessary to provide shelter, nourishment, and emergency treatment for patients until they can be transferred to the immobile units at the rear. At the field hospitals no beds or cots are provided. The patients are placed on straw over which ])lankets are spread. The service of the zone of the advance con- trolled by the division surgeon terminates with the field hospitals. The units of the line of communications pushed forward into the zone of the advance relieve the field hospitals of their sick and wounded as rapidly as possible. THE SANITARY SOLDIER IX WAR 35 One of the evacuation hospitals held in readiness at the head of the line of communications will ordinarily receive the patients from the field hospitals. In some cases an evacuation hospital is pushed forward and takes charge of the patients at the location of the field hospital ; in other cases transportation from the advance section of the line of communications is sent forward to the field hospital to receive the patients, and in many cases the wagons going to the rear for supplies will tran>port the patients back to the refilling point where they will be turned over to the wagons sent forward from the advance section. The evacuation hospital is the first sanitary unit in which provision is made to retain patients for any length of time. It is equipped with cots, blankets, and a liberal supply of comforts for the sick, but ordinarily the evacuation hospitals will be cleared of patients as early as practicable in order that they may be ready to receive others from the front. The patients are usually sent back by trains or boats to the base hospitals where all possible comforts and facilities for their care are provided. All sick and wounded who will be abla to return to duty within a reasonable time will be retained in their hospitals rather than turned over to the service of the inte- rior. Patients who no longer need medical attention are placed in convenient camps operated in connection with the base hospitals imtil they regain sufificient strength to return to their commands. The base is the great center of medical activity of an army. Personnel and supplies intended for the .\rmy are accumulated here and sent forward as required. The sick and wounded are sent back to the base and cared for. Records of both supplies and personnel are kept at the base, and such abstracts and tabulations as the chief surgeon of the field army may require from time to time are made here and supplied to him. The losses at the front are being constantly replaced by men sent forward through the channels above described. New recruits are sent to the mobilization camps where they are equipped and drilled and pushed forward to meet the demands in the zone of the advance. Supplies furnished by the Medical Department for troops at the front are ordinarily obtained through the supply depot at the head of the line of communications on requisitions approved by the divi- sion surgeon. Each sanitary formation may make its own requisi- tion, and its supplies may be sent forward from the advance section 36 SANITARY TROOPS IN POST AND FIELD to the refilling points where the transportation furnished by the Ime of communications turns over the supplies to the transportation sent back from the divisional organizations. The stream of supplies coming forward, consisting of rations, clothing, and ammunition, is constant, and ample opportunity is afforded to bring up the articles required by the sanitary service with the other supplies. When found to be more convenient the regimental sanitary supplies may be replenished from camp infirmaries or from the supplies carried by ambulance companies, these latter making requisitions for the supplies which they require. The supply depot at the advance sec- tion draws its supplies from the depot at the base, the stock of which is automatically maintained by the service of the interior. PART II ANATOMY AND PHYSIOLOGY In order that the hospital corps man may intelligently perform his numerous duties in connection with the sick and wounded, it is necessary that he should understand something of the structure of the human body and the functions of its various organs. It is not intended to give him that little incomplete knowledge that is a " dan- gerous thing," but rather a knowledge which, while not like that of a physician, is complete as far as it goes. Wi^ — A CHAPTER I THE SKELETON AND TOINTS The skeleton is the bony framework of the body, gives it stability and form, and protects the organs, while the joints permit of motion. Bone is composed of about one-third animal matter, mostly gelatin, and two-thirds mineral matter, chiefly lime salts. The animal matter gives bone its toughness and elasticity ; this may be demonstrated by leaving a bone for some time in dilute acid by which the mineral matter is re- moved and the gelatin alone is left ; the bone may then be tied in a knot. The miiieral matter gives the bone its hardness ; the animal matter is all removed by burning the bone which then be- comes brittle as chalk. Young bones contain more animal matter and are hence tougher and harder to break ; when they do break, the fracture is apt to be incomplete like a broken green stick. Elderly persons' bones break easily because they contain more mineral matter. (37) — B '—A Fig. 3. — .Section of Fe- mur. A, A, Cancellous tissue; B, compact tissues. 38 ANATOMY AX I) IMIVSIOLOGY If you saw a long bone across, the end will Ije found spongy or caiicdlons, while the shaft is compact and dense. The shaft is also hollow and contains marroii' (Fig. 3). Bone is covered hy a vascular membrane, the periosteum, which nourishes the bone ; where the [)eriosteum is stripped olT, the lx)ne is apt to die from insufficient nourishm-ent, the death of the bone being known as caries or necrosis. The bones of the human body number about two hundred, without counting the thirty-two teeth and some accessory small bones ; taken together with the cartilages they compose the skeleton. Cartilage, or gristle, is an elastic sub- stance, like bone without mineral matter; it is seen extending from the lower ribs to the breast bone and covering the ends of the long bones. The bones are classified as Io\ig, sJwrt, flat, and irregular. The long hones, of which the thigh bone is an exam- ple, form a system of levers ^vhich support the weight of the body and provide the means of locomotion. The short hones, such as those of the wrist, are found where strength and limited motifMi are the requisites; the flat hones, of which the Fig. 4.- .Skeleton. boncs of the skull are an THE SKELETOX AXD TOIXTS 39 cxam[)le, serve principally for protection ; the irregular bones are illustrated by those of the pelvis. In considering the skeleton ( Eig. j ) let us start from the vertebral colitiini, also called the spinal coliinni, spine, or baekbone. The name vertebra is gi\en to each separate bone composing the column. The sep- arate bones are not allowed to rub against each other, but are separated by pads or butlers of elastic cartilage, and at the same time tied together with strong fibrc)us ligaments. These buffers of intervertebral sub- stance break up and distribute the shock which would otherwise result from falls or in jumping. On looking at the spine (Fig. 5) it will be observed that it increases in size from above downward, which is but natural when one considers the increase in weight to be borne by the lower part as compared with the upper. The highest vertebrae, those of the neck, seven in number, and called cervical, support the head only. X^ext in order come the twelve dorsal, which in addition support the ribs, chest, and upper extremities. In the next region, the small of the back, are found the live massive lumbar vertebr?e, which have the entire trunk to support. The vertebral column ends in two large masses of bone known as the sacrum and the coccyx or tailpiece. In the growing youth the sacrum is composed of five separate bones and the coccyx of four, but in the adult these separate bones are welded into one mass. I'-acli vertel)ra consist of a solid body in front and an arch en- closing a central cavity behind. \\'hen the vertebrse are in their natural position one resting upon another, the arches together form a canal, the spinal canal, which in the living body contains and pro- tects the spinal cord. Fig. 5. — 'Spinal ('oluii;;i. .'. Cervical; B, dorsal; C, lumbar; D, sacrum; E, coccyx. 40 ANATOAIY AND PHYSIOLOGY This spinal cord is everywhere in contact with the hony canal in which it lies, so that when a fracture or dislocation of the s])inal column occurs a laceration of the cord is almost certain to occur, and it is this coincident injury to the cord which gives to these injuries their special importance. If the fingers are drawn along the center of one's back they come in contact v/ith a number of projecting bony points; these are the spinous processes of each vertebra and are situated on the back of the arch. Ijoth the sacrum and coccyx take part in the formation of the large girdle of bone met with at the lower part of the trunk under the name of the pelvis, or basin (Fig. 6(, and which receives the weight of the body and hands it over to the lower extremities at the hip joints. The sacrum forms the keystone of the arch, the sides of which are composed of the two innominate hones or nameless hones, separated in front by a pad of cartilage, and all locked together by powerful ligaments. \\'ithin the pelvis are situated the urinary bladder in front and the rectum behind, and, in the female, between the two is placed the uterus. Each innominate bone consisted originally of the three bones, the ilium, ischium, and pnhis, but these become fused to- gether so as to form one bone in the adult. On each side of the pelvis is seen a cup-shaped cavity in the innominate bone, known as the acetahuliim, the purpose of which is to receive the spherical head of the femur, so as to make the hip joint. A joint is the place where two bones meet and move upon each other; the ends of the bones are covered with smooth cartilage and to still further prevent friction the cartilages and the whole joint are enclosed in a smooth, glistening membrane, the synovial membrane, which secretes the sxnoz'ia or joint oil. Fig. 6.— Pelvis. A, Innominate bone; B, sacrum; E, coccyx. THE SKELETON AND JOINTS 41 ^'i Outside the synovial memljrane the bones are firmly bound to- gether by fibrous ligaments, while the joint is still further strength- ened by the surrounding muscles. A joint, 'therefore, consists of bones, cartilages, synovial membrane, and ligaments. Joints differ very much in their character and the kind of motion they permit. Thus we have the almost perfect freedom of motion permitted by the ball-and-socket joints, like the shoulder and hip, the more limited motion of hinged joints, like the knee, and the almost motionless, imperfect joints, such as the sutures of the skull. A dislocation is a slipping away of the joint surfaces from each other to such an extent that they remain " out of place " and the joint is locked; in such a deep, strong joint as the hip, violence is more apt to give rise to fracture than to dislocation. Entering into the formation of the hip joint is the thigh hone or femur (Fig. 7), the largest and longest bone in the body. Like other long bones it has a shaft and tivo extremities. The upper ex- tremity consists of a head, neck and two trochanters. The head is globular and attached to the shaft by a narrow neck set at an angle ; it is in this narrow neck that fracture so frequently occurs. The trochanters are merely bony knobs to which muscles are attached to move the joints ; the great trochanter is the bone which you may feel just under the skin on the outer side of the hip. The lower extremity of the femur is expanded into two broad condyles which with the upper end of the tibia or shin-hone, and the patella or knee-cap (Fig. 8) form the knee-joint. The patella is the small round bone lying just in front of the knee and in the ex- tended position of the leg is freely mov- able with the tendon in which it lies. The knee joint is the largest in the body and from its exposed position one of those most liable to injury; once injured it is apt to be sensitive ever afterward. Beyond the knee we come to the leg composed of the tibia on the inside and the fibula or splint bone on the outside (Fig. 9). The ' % y'f Fig.- Femur. 42 ANATOMY AND PHYSIOLOGY tibia is a strong prism-shaped bone, the inner surface and front edge just beneath the 84/' ankle where it can be felt; such a break is known y|| y as a " Pott's fracture." The ankle joint is made up of the tibia and fibula above and the astragalus below; it is a strong joint, so much so that while it is frequently subjected to violent wrenches and strains, dislocation seldom occurs ; under such conditions the joint surfaces do not slip entirely away from each other, but the liga- ments and synovial membrane are torn and blood is poured out into and about the joint, constituting the condition known as sprain. Beyond the ankle is the foot, composed of the tarsus, metatarsus, and phalanges. The tarsus, be- sides the astragalus, already referred to as helping to form the ankle joint, contains the os calcis or heel bone, and five other small bones, making seven in all. The metatarsus lies in that part of the foot just behind the toes, and is composed of five long bones. The phalanges or toe joints are so called because ^^'^- 'p^J^'''^ ^^^ they are arranged in phalanx or rows ; there are three for each toe except the great toe which has only two. To go back to the vertbral column. Connected with its dorsal portion are twelve ribs on each side, and closing in the space between the ribs in front so as to form the thorax is the breast bone or sternum. It is scarcely necessary to say that the number of ribs is the same in man as in woman, though there is an old tradition that Adam lost one rib in order to gain a wife. The seven upper ribs are connected directly to the sternum in front by their cartilages and are known as true ribs; the five remaining are known as false ribs, and the last two which are not connected with those above are known as floating ribs. The breast bone or sternum is composed of three parts and extends THE SKELETON AND JOINTS 43 from the root of the neck to the pit of the stomach. The thorax or chest so formed is a bony cage which encloses and protects the heart and lungs ; it is separated from the abdomen by a broad, muscular partition, arching upward and known as the diaphragm. Connected with the thorax is the upper extremity composed of the shoulder and shoulder joint, arm, elbow joint, forearm, wrist joint, and hand. The shoulder is composed of the clavicle or collar hone and the scapula or shoulder blade. The clavicle (Fig. lo) is a very strong Fig. 10. — Clavicle. bone with a double curve like the Italic letter «$■. It is connected at one end with the breast bone and at the other with a process of the shoulder blade known as the acromion; it is the acromion process which we feel just under the skin at the point of the shoulder. The clavicle notwithstanding its strength is very frequently broken owing to its fixed position and the fact that it receives the jars transmitted through the upper extremity when one tries to save himself in falling by throwing out the arm. The scapula (Fig. ii) is a freely mov- able flat bone connected at one end with the collar bone to form the arch of the shoulder; its outer angle or head contains a shallow, saucer-shaped depression known as the glenoid cavity for the reception of the head of the humerus to form the shoulder joint. The shoulder, like the hip, is a ball-and-socket joint, but unlike the hip, the socket is very shallow, so that the head of the humerus in the very free motion permitted easily rolls over the edge and becames dis- FiG. ir. — Scapula. 44 ANATOMY AND PHYSIOLOGY located; as a matter of fact dislocation at the shoulder joint is many times more frequent than at all the other joints of the body put together, so that in obscure injuries to the shoulder we always look for dislocation. The arm is that portion of the upper extremity which lies between the shoulder and elbow ; like the thigh it contains but one bone, the humerus (Fig. 12). The upper end of the humerus consists of the head and the tuberosities, the anatomical neck lying between the two, and the surgical neck being the constricted portion of the shaft just below the tuberosities ; the surgical neck is so called because it is the part most frequently broken. The lower end of the humerus is expanded to form the elbow joint and has a projection on each side known as a condyle. The elbow joint is made up of the humerus and the two bones of the forearm, the radius and idna (Fig. 13). The radius lies on the outer side of the arm and is so called because it radiates about its fellow in the mo- tion of pronation, in which the palm of the hand is turned down, and supination, in which the palm is turned up. The radius has a small head which takes but little part in the elbow joint, but a large lower end which with the carpus forms the wrist joint to the entire exclusion of the ulna. It is because of the radius resisting almost alone the force of falls upon the hand that it is broken so much more often than the ulna. Such a break just above the wrist joint is very common and is known as a " CoUes's fracture." The ulna has its upper end most highly developed, forming a projection which extends back behind the elbow joint, protecting it in the same manner as the patella does the knee joint. This protection forms the " point of the elbow " and is called the olecranon. F'^. '3.— Radius and }i Fig. 12. — Hu- merus. THE SKELETON AND JOINTS 45 The zvrist or carpus is composed of eight small bones in two rows of four each, the upper row together with the lower end of the radius forming the wrist joint. The hand is composed of the five metacarpal bones, while the fingers have three rows of phalanges, except the thumb which has two only. Balanced on the top of the spinal column and forming a joint with its uppermost vertebra is the skull (Fig. 14). The skull is usually considered in two parts, the craninui which con- tains the brain, and the face. The cranium is that part which lies above a line drawn from the nape of the neck through the ears to above the eyebrows, and the brain here lies everywhere in contact with the bone so that a fracture of the cranium like one of the spine, derives its spe- cial seriousness from the accompanying injury to the brain. In front, however, just over the eyes, the two plates of which the cranial bones are composed separate to leave a space known as the frontal sinuses; here fractures of the outer plate may occur without injury to the brain. The cranium varies in thickness from about that of paper at the temples to a quarter of an inch or more behind. The visible i)ortion of the cranium is composed of six bones, the frontal in front, the occipital behind, the two parietals on the top. and the two temporals on the sides. In the lower part of the occipital bone is a large round hole known as the foramen magnum through which the spinal cord makes connection with the brain. Tiie face is composed of fourteen bones, arranged mostly in pairs, and forming the two orbits, the nose, and mouth. The only facial bones necessary to remember are the two, tiny, nasal bones which form the arch of the nose, and the two superior maxillary bones and Fig. 14 — Skull, a. Nasal bones; b, superior maxilla; c, inferior maxilla; d, occipital bone; e, temporal bone; /, parietal bone; g, frontal bone. 46 ANATOMY AND PHYSIOLOGY tlie inferior iiiaxillary hone which contain the teeth and enclose the month. Tlie inferior maxillary is the only movable bone of the face; its joints with the upi)er jaw lie jnst in front of the ear where the head of the bone can be felt to move when the mouth is opened. The teetJi appear in two crops; the first, ten in number in each jaw, are known as the milk teeth; at the end of the sixth year they begin to be replaced by the permanent teeth, six- teen in each jaw. The second dentition is not concluded until about the twenty-first year when the wisdom teeth or last molars appear. Every tooth has a erown, the i)art above the gum, a neck, the constricted j)ortion just below the crown, and a root, the part embedded in the jaw. In structure (Fig. 15) they are composed of enamel, the hard surface covering, the dentitic which comprises the mass of the tooth, the cement which covers the root, and the pulp composed of nerves and blood-vessels which nourishes the tooth and lies in its interior. \Mien the teeth are not properly cared for the protective Fig. 15. — Section of Lower Molar, a. Den- tine; b, enamel; c, crusta petrosa; rf, pulp cavity. Canine or Eye Second Bicus- Central Incisor Tooth of Upper pid of Lower of I'pper Jaw. Jaw. Jaw. Fig. 16. Second Molar of Wisdom Tooth L^pper Jaw. of Upper Jaw. enamel cover breaks down, exposing the dentine which rapidly decays, undermining the enamel and finally exposing the sen.-itive pulp; pain then begins, and unless the tooth is filled death of the pulp occurs and the tooth is lost. The four front teeth in each jaw are adapted to cutting and are called incisors: next to these on each side is a tearer or canine tooth, and then two bicuspids: all of these usually have a single root. After the bicuspids come three molars or grinders on each side. The up- THE SKELETON AND JOINTS 47 per molars usually have three roots, two on the outer side and one on the iimer, while the lower molars generally have two roots. A knowledge of the number and arrangement of the roots of the teeth is necessary in order to select the proper pair of forceps to use in tooth extraction (Fig. i6j. CHAPTER II THE MUSCLES. CELLULAR TISSUE. AXn THE SKIN Muscles are simply lecm meat. Each muscle is composed of a number of fibers held together by connective tissue, and collected into bundles which are enclosed in a sheath of fibrous tissue known as fascia. The function of muscles is to contract and thereby move the various parts and tissues of the body; their tendency to contract is constantly present dur- ing life, so that if a muscle is cut the two ends at once pull apart and a gaping wound is left. For the same reason if a bone is broken the contracting muscles on each side of the fracture have a tendency to shorten the limb, making the ends of the bone override each other and produce deformity (Fig. 17). It is this muscular contraction which must be overcome in setting fractures or reducing disloca- tions. As muscles taper toward the ends they become more and more fibrous until white, glistening ten- dons or sinezvs are formed which finally blend with the periosteum at the point of attachment to bone. Most muscles, like those of the limbs, are under the control of the will and are known as voluntary muscles (Fig. 18), while others, like those of the heart and intestinal tract, are entirely involuiitarx. Fig. 17. -Fracture '^^'^ iuvoluutary actiou of the important muscles of Thigh. Deformity which preside ovcr the necessary functions of life from muscular ac- • • • • r ^ ^i • • i . tjjj„ is a wise provision of nature; otherwise one might forget to breathe or make the heart beat, and sleep would be out of the question. The muscles in their action upon the bones produce various special motions; bending a limb is called flc.vion, straightening it is extension; turning the palm down is pronation, turning it up supi- (48) MUSCLES. CELLULAR TISSUE AXD SKIN 49 nation; motion of the limb on its long axis is rotation. Abduction is throwing a limb out from the body, while drawing it toward the body is adduction. Fig. i8. — Superficial Layer of Voluntary Muscles. In a variable time after death rigor mortis sets in. a change in the muscles l)y which they become rigid, and remain so until decomposi- tion begins. When the person has undergone great muscular exer- 4 50 ANATo^r^' \xn pttvstology tion to the ])oinl of exhaustion just l)cforc death this change takes phice almost imnicchalcly, so that the soldier killed in hattle may he found rigidly fixed in the same position in vvhicli he met his death. The only voluntary muscles which it is necessary for you to re- memlier are the sfcnio-mastoid, the biceps, and tre diaphragm. Im- portant involuntary muscles are the heart, stomach, and Madder. The stcnio-mastoid is the prominent muscle seen on each side of the neck when the head is turned in the opposite direction and ex- tending from hehind the ear to the top of the sternum ; its front edge is a guide to the carotid artery. The biceps is the hig muscle on the front of the arm, familiar to all, and the inner border of which is a guide to the brachial artery. The diaphragm is the great muscular partition between the thorax and abdomen. The connective or cellular tissue, so called because of the spaces contained in its spongy structure, connects together all the other special tissues, and serves as a support for the blood-vessels, nerves, and fat. The fat is the padding which fills in empty spaces and gives form and pleasing outlines to the body. Its important functions are to serve as a reserve of nutritive material for emergencies, and to act as a blanket in retaining the bodily heat. The emaciation which follows an exhausting illness is largely due to the using up of the reserve fat, and everyone is familiar with the fact that a fat person stands cold better and heat less well than a thin one. The skin is a tough, elastic membrane which covers the entire body and is continuous at the various orifices Avith the mucous membrane. Anatomically it consists of two layers, the cuticle, and the derma or true skin. The cuticle is that part which is raised when a blister occurs and which peels ofif after scarlet fever. The derma constitutes the greater part of the thickness of the skin, and contains the blood-vessels, nerves, sebaceous and sweat glands. The appendages of the skin are the hair and the nails which are modified cuticle (Fig. 19). The sebaceous glands secrete an oily substance which gives to the skin its softness and plialility; the orifices of the ducts of the se- baceous glands are particularly large about the face and nose, and when plugged with dirt form the familiar black-heads. MUSCLES, CELLULAR TISSUE AND SKIN 51 The sweat glands are in vast numl)ers all over the body and their orifices constitute what are known as the pores. They secrete a variable amount of water, averaging about two pints a day, and the water contains organic matter and salts, and constitutes the perspira- tion or sweat. The functions of the skin are to protect the underlying parts from injury, from the invasion of bacteria, and from undue evaporation; Fig. ig. — Perpendicular Section of the Skin, showing: a. The epidermis, cuticle, or scarf skin; b, a layer of dark-colored cells; c, the papill.t on the surface of d, the corium, derma, cutis vera, or true skin, and c, the fat cells underlying it; /, a perspiratory pore or aper- ture, g, the duct, and h, the coiled substance of a sudoriparous gland; i'. the shaft of a hair, k, its root, and /, sebaceous glands communicating with the interior of the hair follicle. to receive the nerve ends and thereby serve as a special organ of touch ; and through the agency of the sweat glands to act as an im- portant excretory apparatus and a regulator of bodily temperature. The importance of a whole skin as a protection against the bacteria of disease is well known ; subcutaneous wounds, that is contusions, give us little anxiety, but if the skin is broken special dressings must be applied to take its place. Plague frequently invades the body through a break in the protective wall of the skin and syphilis is contracted in the same manner. The excretory function of the skin, by wdiich it throws off poison- ous waste products dissolved in the perspiration, is illustrated by what happens in extensive superficial burns by which this function of the skin is destroyed ; the man becomes poisoned by his own waste products and death is the result. 52 ANATOMY AND PHYSIOLOGY As a temperature regulator its action is shown by the increased perspiration in hot weather, the evaporation of the water serving to cool the body; conversely in winter perspiration is imperceptible. The skin has also absorbing powers; thirst may be allayed by prolonged immersion in a bath; the vapor of mercury and even metallic mercury may be taken up through the unbroken skin. CHAPTER III THE NERVOUS S^■STEM AND STIXIAL SENSES The nervous system consists of the brain, spinal cord, and the nerves constituting the cerebrospinal system, and the ganglia and connecting nerves composing the sympathetic system. The brain situated within the cranium is the seat of the intellect and will, and the great headquarters telegraph office from which all the orders for motion are sent out and to which all the reports called sensations are forwarded. The spinal cord extends downward from the brain through the spinal canal and is largely an aggregation of nerves or wires connecting the brain with all parts of the body. The ganglia (Fig. 2c) are small masses of nervous matter arranged in pairs along the spinal cloumn and in groups about the heart and great viscera ; they are connected with each other and with the cerebro-spinal system, and their distribution is to the heart, lungs, bood-vessels, the gastro-intestinal tract, and the great viscera. The nerves are composed of bundles of minute tubules enclosed in a protective sheath, each of these tubules corresponding to a tele- graph wire and ultimately reaching its destination without branching. The brain (Fig. 21) consists of the cerebrum and cerebellum, and pons and medulla. The cerebrum is the soft, pulpy, oval mass which is seen when the top of the cranium is removed ; it is divided from before backward l)y a deep fissure, almost but not quite complete, so that there is a bridge left connecting the two halves. The surface of the brain presents numerous grooves or sulci, be- tween which are the conrolufioiis. The exterior is composed of gray matter, and the interior of ichite matter, the latter being nothing more than a collecti( n of nerves connecting the various parts of the brain with each other and with the spinal cord. In the interior of the cerebrum are a number of cavities known as ventricles. The gray matter is the seat of the mind. The brain is very delicate and easily injured; injuries or even slight pressure seriously interfere with its fmictions. So when a 54 ANATOMY AND rilVSIOLOGY fracture of the skull occurs with depression of bone, or even a slight bleeding from one of the cerebral vessels, pressure on the brain Fig. ^0. — Sympathetic Systc-in nf 1 Nerves. results and we have unconsciousness or paralysis or both ; this is the condition in apoplexy which is merely a hemorrhage within the cranium ; as the blood cannot escape it must produce pressure. THE NERVOUS SYSTEM AND SPECIAL SENSES 55 Lining the interior of the cranium is a strong fibrous membrane which protects and suspends the brain and is called the dura mater ; this with the pia mater and arachnoid constitute the meninges or membranes, inflammation of which is known as meningitis. If we lift up the back part of the cerebrum we see below it a small mass of nervous tissue known as the ccrebelhim or little brain (l"'ig. 22). It is chiefly concerned with the maintenance of the equilibrium of the body. «'. Fig. 21. — The Hemispheres of the Brain. A, The right; B, the left divided from before backward by o, b, the longitudinal fissure, and connected bj' c, the bridge of transverse fibers called the corpus callosum. On the right side the convolutions and sulci are shown; on the left the upper part of the convexity of the hemisphere has been cut away to show the gray matter d, d, dipping into the sulci and appearing as islands, e, e, in the interior of the white matter; the elongated cavity with curved extremities is the lateral ventricle of that side. The pons is the connecting link between the cerebrum and me- dulla and between the two lobes of the cerebellum. The medulla oblongata is the enlarged upper end of the spinal cord lying just within the cranium, and containing the important nerve centers presiding over the action of the heart and lungs. It is also the part in which the nerves coming from each side of the brain cross over to the opposite side of the spinal cord, so that an injury of the brain above this crossing causes a paralysis on the opposite side of the body. The spinal cord (Fig. 2^,), like the brain, is enclosed in mem- branes and is a tail-like column of nervous tissue composed chiefly of nerves bitt containing in its interior a central colimin of gray 56 ANATOMY AND PHYSlULOGY matter. A pair of nerves leave it opposite each vertebra, those of the cervical region being arranged in two groups. The upper group supplies the face and neck and the interior of the chest ; one of the most important of the branches is the phrenic which controls the movements of the diaphragm. The lower group is known as the brachial plexus and supplies the upper extremity. Fig. 22, — Lower Surface of Brain. C, Cerebellum; M, inedulla; P, pons. The dorsal nerves supply the chest wall, those of the lumbar and sacral regions go to the pelvis and lower extremities; one great cord which emerges from the pelvis on each side and passes down the back oi the thigh is called the sciatic nerve; it is often the seat of the neuralgic pain known as sciatica. As all the nerves of the bod}' except those of the face must pass through the spinal cord on their way to the brain it is evident that if the s])inal cord is cut completely across there must be paralysis of all the parts below ; such a paralysis is called paraplegia. If the injury is high enough up the nerves controlling the action of the heart and THE NERVOUS SYSTEM AND SPECIAL SENSES 57 lungs are involved and death quickly follows. As the motor nerves are cellected in the front part of the spinal cord and the sensory nerves in the back part, a partial injury of the cord may cause paralysis of mo- tion without affecting sen- sation or z'ice z'crsa. There are two kinds of nerve tubules, motor and sensory. The former con- vey from the brain orders directing motion, while the latter carry to the brain in- formation as to sensation. If a motor nerve is cut the muscles supplied by it are paralyzed because orders from the brain can no longer reach them ; if a sensory nerve is cut sensa- tion is lost in the i)art sup- plied by it because infor- mation as to the sensory condition of the part can no longer reach the brain. Usually nerves contain both motor and sensory fibers, but some nerves, like the facial, are jiurely motor. There are certain reports and impressions which are sent by way of tbe nerves from various parts of the body which it is not neces- sary to refer to the brain for its action ; the necessary action is pro- vided automatically by what is called reflex action. ]• IG. -3- —Spinal Cord and >.e:vcs ^8 A^■.\T().\I^• AM) IMIVSIULUGY Fig. 24. Section of Nose, nerves. A, Olfactory The quick withdrawal of the hand when it touche.s something hot and the rhythmical contraction of the heart under the stimulus of its distention with blood arc inslanc > of reflex or automatic action originatiny^ rc.-pectivcly in the gray matter of the spinal cord and ganglia. The special soiscs are toticli. taste, smell, hearing, and sight. The three latter are presided over by special cranial nerves, that is, nerves coming directly from the brain without passing through the spinal cord. The sense of toncli is resident in the skin generally, but is most highly developed in the ends of the fingers. The sense of taste is located in the mouth, more especially in the tongue; for its action it is necessary that the substance should be in solution ; this is in accordance with our knowledge that insoluble medicines are tasteless. The sense of smell resides in the upper na.sal cavi- ties where the fila- ments of the olfac- tory nerve are dis- tributed to the mucous membrane (Fig 24). Hearing or the perception of sound vibrations is provided for by the ear through the auditory nerve. The ear (Fig. 2O , , ,. . ' Fig. Jj. — .^-.-ction of the Ear. B, External ear; .... auilitory canal; consists of the ex- 7, tympanum;/', middle ear;//, ossicles;/-". Eustachian tube. THE NERVOUS SYSTEM AND SPECIAL SENSES 59 tcnial ear, the auditory canal, the tympanum or drum membrane, the middle ear, stretchinj,' across which are the small bones or ossicles, and the internal ear. The tym])anum is stretched like a drum-head across the auditory canal, separating the external and middle ears ; in order that the air pressure on the two sides of the drum may he equalized tiiere is an air tube leading from the middle ear to the throat and known as the Eustachian tube ; stoppage of this tube in chronic inflammation of the throat is one of the causes of deafness. Fig. 26.— Section of the Eye. i, Conjunctiva; 2, cornea ; 3, 3, iris ; 4, pupil; 5. kns; 6, retina ; 7, optic nerve. The sense of sight consists in the perception of light, color, form, size, and distance; it is resident in the eye. The eye (Fig. 26) is situated in the orbit, the projecting upper border of which, together with the quickly moving lids, give it pro- tection. It is covered in front by a thin vascular membrane which also lines- the lids and is known as the conjunctiva. .Light enters through the transparent cornea which is set in front of the eye like a watch-glass ; behind the cornea is hung a curtain of muscular fibers variously colored and called the iris; the black pupil is really a hole in the iris to let in the light which then passes through a crystalline lens just behind the pupil and is brought to a focus on the retina; the 60 ANATOMY AND PHYSIOLOGY retina is merely an expansion of the optic nerve which transmits the himinous impressions to the brain. The dense white outer coat of the eye, lying beneath the conjunctiva, is known as the sclerotic. The eye is a camera, focusing being accomplished by changes in the convexity of the lens effected by the contraction of the ciliary muscle, the muscle of accommodation. Color-blindness is the inability lo distinguish certain colors, par- ticularly reds and greens. CHAPTER IV THE DIGESTRE APPARATUS INASMUCH as the nutritive constitutents of the blood are being constantly used up in the repair of tissue and the production of heat and force, it is necessary that some provision should be made for a constant supply of new material. This is done by the food through the digestive apparatus ; the function of the digestion is to prepare the food for absorption and nutrition. Foods are usually classified according to certain definite com- pounds or alimentary principles which they contain; these are four in number: i. Albuminates, nitrogenous substances or proteids; 2. Fats or hydrocarbons ; 3. Starches and sugars or carbohydrates; 4. Minerals, including water and salts. The especial uses of these alimentary principles in nutrition are as follows: The albuminates are essential for the repair of all the nitrogenous constituents of the body, that is to say, they are muscle and blood l:)uilders ; they regulate the absorption and use of oxygen ; they sometimes form fat, and hence force and heat. The fats produce force and heat, pre\ent the waste of the nitrogenous tissues, and serve as a reserve of heat and force. The starches and sugars also are readily convertible into heat and work, and, though they have little part in the composition of the tissues of the body, they contribute directly or indirectly to the deposit of fat. Water con- stitutes nearly 60 per cent of the human body and is the most im- portant constituent of foods ; without the other foods one may live weeks, but without water it is a question of a very few days. Water is the great solvent without which even the circulation of the blood can not go on. The various salts are also essential ; the alkaline carbonates formed from the salts of the vegetable acids maintain the necessary alka- linity of the blood and body fluids ; without a due proportion of them scurzy occurs. All these alimentary principles are necessary for life; some one or (61) 62 ANATOMY AND IMIYSIOLOGY more of them are contained in all foods; if any one food contained them all in proper proportion that substance would constitute a com- plete diet ; milk contains them all and in a complete form for infants, but for adults a mixed diet is necessary. Beef consists largely of albuminates, pork of fats, bread of starch, candies of sugar. Fig. 27. — ^^iew of Thoracic and Abdominal Organs; anterior walls removed, but the relative position of the ribs, navel, etc., indicated, a. Heart; b. great vessels; c, c, lungs; d, d, diaphragm; e, liver; /, gall bladder; g, stomach; /;, spleen; i, ascending colon; i, transverse colon; /;, coils of small intestine; /, position of ileo-cecal valve at junction of small and large intestines; m, urinary bladder. The proper quantity of the various articles of food necessary per day to maintain a man in good health while performing ordinary labor constitutes a ration. Great exertion calls for an increase of the albuminates and fats, while great cold demands a special increase of the fats. Now these alimentary principles, in the form they exist in in foods, are not ready for absorption ; they must be reduced to soluble forms : the albuminates to peptones, the sugars and starches to glucose, and THE DIGESTIVE APPARATUS 63 the fats to an emulsion; to accomplish this is the purpose of the digestive apparatus. When too much food is taken the excess is not digested but acts as a foreign body, and causes irritation of the stomach and bowels, followed by pain and diarrhea, or the poisonous products of decom- position are absorbed, causing fever — auto-intoxication. A deficiency of food causes the tissues of the body to be drawn upon and emaciation is the result. The apparatus for the digestion of the food consists of the alimentary canal, and the salivary glands, liver, spl«en, and pancreas. The alimentary canal includes the mouth, pharynx, cesophagiis, stomach, small intestine, and large intestine ; it is a muscular tube lined with mucous membrane, about thirty feet long and extending from the lips to the anus (Fig. 27). In the mouth provision is made for the mastication of the food and its admixture with saliva ; beyond this is the apparatus for swallow- ing, the pharynx and (rsophagiis, which convey the food to the stomach, where a partial reduction and solution of it take place ; in the small intestine the digestion and solution are completed, and the nutritive principles, comjiosing the chyle, are separated, by its admix- ture with the liile and pancreatic juice, from that portion which passes into the large intestine, most of which is expelled from the body. In looking into the mouth (Fig. 28), we see the teeth and tongue, already described, and. stretching across the upper and back part, a fleshy curtain known as the palate; hanging down from the center of the palate is the uvula, and on either side behind the palate are the tonsils. In the mouth the food is thoroughly broken up by the teeth and, assisted by the tongue, mixed with the saliva, and formed into a suitable lubricated mass for swallowing. The only digestion which takes place in the mouth is the slight conversion of the starch into sugar; nevertheless thorough mastication is of the greatest impor- tance, as, the more completely the food is broken into small particles, the more easily the digestive fluids of the stomach and intestines get at the particles to dissolve them. If we wish to dissolve out the soluble constituents of a crude drug, we first pulverize it in a mortar, and the same principle obtains here. After the food has been masticated it is pushed into the pharynx 64 ANATOMY AND PHYSIOLOGY by the tongue and there passes beyond the control of the will through the eight or nine inches of the oesophagus or gullet into the stomach. The saliva conies from the salk'ary glands, which are three in number on each side, the parotid, suhmaxillary, and sublingual. The parotid glands are situated just in front of and below the ear, and are Fig. 28. — Section of Head and Xeck. the seat of the inflammation known as mumps. The other salivary glands are placed below the tongue and lower jaw. The stomach (Fig. 29 ) is a muscular bag lined with mucous mem- brane, pear shaped, with the large end to the left and lying on the upper part of the abdomen, largely behind the ribs, and separated from the thoracic cavity by the diaphragm. The heart is just above it, with only the diaphragm between, so that it can easily be seen how distention of the stomach may cause disturbances of the heart and how pains in the stomach are so often referred to the heart. The stomach opens into the oesophagus at one end and into the small intestine at the other by small openings known as the cardiac THE DIGi:STi\ E APPARATUS 65 and pyloric orifices, respectively. The small intestine is about twenty- five feet long-, and lies in the central and lower part of the abdomen, extending from the stomach to the right groin, where it terminates in a valvular opening into the large intestine. The large intestine is about five feet long. It commences at the termination of the small intestine in the right groin, this part of it being known as the cecum and having attached to its lower and Fig. 29.^ Stomach. back part a tail-like a])pendage known as the vermiform appendix; this appendix, about the size of a goose quill and two to five inches long, is the part which is so frequently inflamed, constituting the disease called appendicitis. The cecum as it passes up the right side of the abdomen is known as the ascending colon : under the liver it turns and crosses to the left in front of the stomach, becoming the transverse colon; on the left side of the abdomen it turns downward, the descending colon; in the left groin it makes a curve like the letter S, the sigmoid flexure, and ends in the rectum, which descends to the right and backward to the anus. The intestines are covered with a smooth, shining membrane which lines the abdomen and is known as the peritoneum; inflam- mation of this membrane is called peritonitis. The omentum is a sort of apron made of a fold of the peritoneum, containing much fat, which lies over the intestines and protects them. The mesentery is the name applied to other fold.- of the peritoneum 66 ANATOMY AXD PHYSIOLOGY which bind the intestines loosely to the abdominal walls behind them. In the abdominal walls are certain weak places where blood- vessels pass out of the cavity and the intestines have a tendency to follow the vessels ; these places are the nmhilicus or navel, tlie in- guinal civial, along which the vessels pass to the testicle, and tlie femoral canal, for those to the thigh. When the intestine does so escape we ha\e hernia, nnibilical, itujninal, or femoral, respectively. Fig. 30. — Pancreas in Section to Show Its Duct. In the upper })art of the abdomen, on the right side and extending somewhat to the left, we have the liver (Fig. 27 ) ; it is the largest gland in the body, weighing between four and four and a half pounds, and in its natural state lies almost wholly behind the ribs. The liver has two large lobes, between which and projecting just beyond the ribs is the gall bladder, which empties by a narrow duct into the small intestine just beyond the stomach. To the left of the stomach and al^o behind the ribs is another gland, which has no duct, called the spleen; it is dark colored and about the size and shape of the hand without the fingers. Deeply placed behind the stomach and extending transversely across the abdomen is a slender tongue-shaped gland, the panereas or sTi-'ee thread (Fig. 30 ). It is about six inches long by three-fourths of an inch broad, cream colored, and has a duct which terminates in the small intestine together with the common bile duct. In the stomach the food which has already been masticated and part of the starch converted into glucose by the action of the saliva is brought into contact with the gastric juice; this juice is a sour liquid, containing pepsin and hydrochloric acid, secreted by the countless small glands found in the mucous lining of the stomach. This is the same pejjsin and hydrochloric acid which are used outside the body to digest nu'lk and other albuminates. The contraction of THE DIGESTIXE APPARATUS 67 llie muscular walls of the stomach caused by the presence of food thorouglily mixes it with the gastric juice, and continues this churn- ing motion as long as the food remains. Under this process albuminates are partially converted into pep- tones, a form suitable for absorption, and part of these peptones are immediately absor])ed by the capillaries of the stomach. The solu- tion of the albuminous intercellular materials aids in the liquefaction of other food principles, which pass slowly out of the stomach into the intestine in the form of a whitish fluid known as chyme. The process of stomach digestion rec|uires from one to four hours, de- pending upon the character of the food, the thoroughness of mastica- tion, and other factors. Thus fish and chicken are more cjuickly digested than beef, and beef sooner than veal, baked and stewed meats sooner than the same articles fried. The mucous lining of the small intestine is thrown into numerous folds known as vahulcc coiiniventes, the purpose of which is to in- crease the extent of surface and this is still further accomplished by the innumerable villi or tiny projections which stud the surface of the mucous membrane and give it a velvety appearance. There are also millions of small glands or follicles which secrete the intestinal juice, an important aid to digestion. Beside the intestinal glands we ha\e already seen that the liver and pancrease empty their secre- tion into the small intestine at its upper part. The functions of the liver are many ; the most important are the production and storage of sugar, the production of urea, and the secretion of bile. The bile helps to emulsify fats, stimulates the in- testinal muscle to contraction, acting as a laxative, and is a natural antiseptic preventing putrefaction of the intestinal contents. It is a familiar fact that when bile is absent from the intestine, as in some forms of jaundice, constipation and very offensive stools are apt to result. The pancreatic juice digests all three classes of food, albuminates starches and sugar, and fats. Unlike the gastric juice, it is alkaline and incapable of acting ex- cept in the presence of an alkaline reaction. To digest foods ou/side of the body we now use pancreatin and soda almost to the exclusion of pepsin and acid. Under the combined influence of all these intestinal juices the chyme is soon converted into a milky liquid known as chyle, and this 68 AXATO^rv AXI) ]•[f^'ST( )LOGY is absorbed by both the capiUaries of the intestinal tract, whence it passes to the Hver throui^li the portal z'ciiis, and by the lymphatics or lacteals, another system of vessels which, arising in the inlli, passes through a number of lymphatic glands situated in the mesentery and known as the mesenteric glands, to reach a large duct known as the thoracic duct, which passes up the left side of the spinal column and empties into the left subclavian vein, just before its junction with the left internal jugular. The spleen has no direct part in digestion, but it does serve in- directly by acting as a reservoir for the storage, in the intervals of digestion, of the additional amount of blood needed during digestion. Other important functions of the spleen are the production of leuco- cytes, the destruction of erythrocytes, and the production of uric acid. I'assing on down the small intestine, the intestinal contents become more and more solid by the absorption of the liquid chyle, and this process is continued in the large intestine until finally the indigestible residue is cast out of the body as feces. Some digestion and absorption do take place in the large in- testine, as we know from what occurs when we use nutrient enemata, but the action is not a powerful one. and it is safer to give the enemata predigested. When digestion is incomplete from any cause, putrefactive changes may occur in the undigested portion of food and the poisons result- ing therefrom may be absorbed, giving rise to fever, headache, and other symptoms of auto-intoxication. CHAPTER V THE BLOOD AND THE CIRCULATORY SYSTEM The circulatory systciii includes the lymphatic system and the blood-vessel system. The lymphatic system, or absorbent system (Fig. 51 ), includes the lymphatic and lacteal vessels, and the lymphatic glands. Fig. 31. — Lymphatic System of Trunk, Genitals, and L'pper Ann. (69) 70 ANATOMY AXn T'TTVSIOLOGY The lymphatic vessels are found in all ])art< of tlie body, wherever there are blood-vessels; they contain l\nii)h, a colorless fluid like water, except those of the intestine, which during digestion contain a milky fluid, which gives to these particular lymphatics the name of / /'^^_/ ^ Fig. 3-'. — Thuracic Duct. lacteals. All over the body also are found lymphatic glands, varying in size from a pin head to a small almond ; all the lymph passes through these glands before it reaches the blood by way of the thoracic (Fig. 152) and lymphatic ducts. The lymphatic system has an important function in connection with the elaboration of the blood, THE BLOOD AXl) THE CiJ>LL"L'LAToRV SYSTEM 71 more and more blood cells appearing in the lymph as it passes through successive chains of glands. The glands also serve a very useful purpose in resisting the in- vasion of the body by disease germs. In the case of an infected finger wound, for instance, one some- times sees fine red lines running up the arm and the patient complains of a kernel in the arm-pit ; the red lines are inflamed lymphatics and the kernel is an inflamed gland ; again, in the case of a sore on the penis the glands in the groin swell, constituting a bubo. Certain groui)s of lymphatic glands are impor- tant owing to their connection with special diseases. A characteristic of syphilis is an enlargement of the inguinal, cpitrochlcar, and post-cervical glands, found respectively in the groin, just above and behind the inner elbow, and at the junction of the _ neck with the back of the head, j Red cells,' side'. The inguinal glands also become inflamed in other ^^^^' '" rouleaux, ° _ crenated; ^, /, white venereal diseases. The glands in the front of the ceiu. neck become enlarged, cheesy, and sometimes suppurating in the condition commonly called scrofula, really a tuberculous invasion" through the mouth. The functions of the blood and blood-vascular system are to re- ceive from the lungs and alimentary tract and to carry to all parts of the body the materials necessary for its nutrition and proper temperature and moisture, and to carry away to the excretory organs the waste matters which if retained would prove poisonous. It has also important functions in the protection of the body from the invasion of the bacteria of disease. The total quantity of blood is usually estimated at one-twelfth of the weight of the body, or an average of about a gallon and a half. The blood is red in color, bright red in the arteries, dark red in the veins. It is composed of cells or corpuscles floating in a liquid, the liquor sanguinis. The cells are of two sorts, the red cells or erythrocytes and the li.'hite cells or leucocytes (Fig. 33). The red cells are much the more numerous, there being about five hundred times as many as there are of the white. They are very small, about one-three-thousandth of an inch in diameter, and, though red in mass, the individual cells are 72 AXATuAn AM) I'l l\SlULO(JY ^ct'U under the microscope to be lis^ht yellow in color. They are round, fattened discs, like a cojjpcr cent, except that they are con- cave on each side, and are largely composed of hemoglobin, a sub- stance which has a great oxygen-carrying capacity. The leucocytes are not Hat like a cent, but spherical like a ball, a little larger than the red cells, composed of protoplasm, and capable of changing their own form and of making their way through the unbroken walls of the blood-vessels. The liquor sanguinis consists of scrum and the elements of fibrin; when bleeding occurs the fibrin at once forms and the blood coagu- lates or clots; but for this property of the blood hemorrhages would never stop. Scrum, which is liquor sanguinis less fibrin, contains the principal nourishing ingredients of blood — albumin, fats, sugar, salts, and gases. In a general way the blood current may be likened to a river and the cells to boats floating upon it ; the red cells are the freight boats loaded with oxygen which they receive in the lungs and carry to all parts of the body ; the white cells are the war ships, always on the alert for an attack by disease germs ; when such an attack occurs the leucocytes hurry to the invaded point and a battle ensues in which there are killed and wounded on both sides ; the dead white cells, when in large nmnber, constitute pus or matter. The blood serum itself not only carries nourishment to all parts of the body, but, com- ing back, acts as a sewer, bringing away the waste products, both licjuid and gaseous. In order to maintain a constant circulation of the blood, a com- plete system exists, consisting of a constantly acting pump, the heart, the arteries which carry the pure blood to all parts of the body, the capillaries from which the blood delivers its nutritive materials to the tissues and takes on a load of waste products, and the I'ciiis which return the impure blood to the right side of the heart ; this is the systemic circulation and requires about a half a minute for the en- tire trip; then there is a subsidiary system known as the pulmonary circulation, whose arteries take the impure blood from the right side of the heart to the lungs, in the capillaries of which it is purified, losing carbonic acid and waste matters, taking on a load of oxygen, and then passing through the pulmonary veins to the left side of the heart for another trip through the systemic circulation (Fig. 34). THE BLOOD AXl) THE CIRCULATORY SYSTEM 73 The licart is a conical hollow muscle, situated between the lungs and behind the sternum and enclosed in a tibrous sack, the pericar- dium (Fig. 35). It is about the size of a closed fist, its average weight being three-fourth^ of a pound. The apex is found between the fifth and sixth ribs, ju.-t inside of the nipple line. It is divided Fig. 35. — The Thoracic Organs, a. Right lung divided into three lobes, and b. left lung into two lobes, their anterior margins thrown back to expose the deeper parts; c, trachea, with its cartilaginous rings; d, right bronchial tube; e, right auricle, receiving from above, /, the superior vena cava, which is formed by the junction of g, g, the right and left innominate veins, and each of these by the confluence of h, h, i, i, the jugular and subclavian of its own side; /, the right ventricle, giving issue to k, the pulmonary artery, which divides into two branches,' that for the right lung passing behind the other great vessels; /, /, /, /, pulmonary veins, bringing oxygenated blood to n), the left auricle; •I, the left ventricle, from which the blood is carried to the organs and tissues by o, the aorta; p, p, q, q, carotid and subclavian arteries, given off from the arch of the aorta. by a vertical partition into two lateral halves which have no com- munication with each otlier. Each of these lateral halves is further subdivided by a horizontal constriction into two communicating cavities, an auricle and a ventricle; the whole heart is lined by a smooth membrane, the endocardium, and all its openings are pro- tected by valves (Fig. 36). The right is the venous side of the heart : its auricle receives the venous blood from the entire body through the superior and inferior vena cava; when it is full it contracts and passes the blood into the right ventricle, which, in its turn contracts and sends the blood to the lungs, whence it is returned arterialized to the left auricle, and 74 ANATOMY AND PHYSIOLOGY from there to the left ventricle which forces it through the arteries to all parts of the body. This contraction or beating of the heart takes place about seventy-two times to the minute. The valve between the auricle and ventricle on the left side is known as the )}iitral, that on the right side as the tricuspid, while the valves which prevent regurgitation from the aorta and pulmonary arteries are known as the aortic and piilnioiiary, respectively. The arteries are elastic, muscular tubes, which stand open when cut across, and arc without valves except at their exit from the heart. The elastic tissue in their walls allows them to expand when blood is forced in from the heart, and by subsequent contraction to maintain a uni- form pressure between heart- beats. It is this expansion, caused by the heart forcing mure blood into the already full arteries, which consti- tutes the pulse. The mus- cular tissue allows of a local regulation of the circulation under nervous influences such as occur in blushing or the pallor of fear. Thoracic Jorf, Fig. 36. — The Heart. The arteries freely communicate with each other by the anasto- viosis of small branches, so that when an artery becomes blocked by a clot, or is tied, the blood goes around the obstruction by means of the communication between the small branches given ofif on either side and the collateral circulation is established. It is by reason of the freedom of this collateral circulation that both ends of a cut artery spurt, and but for it gangrene might ensue when an artery is tied. By the constant giving off of branches the arteries become smaller and smaller until they finally terminate in the capillaries. 1 ic;. 34- DIAGRAM TO SHOW' THE COURSE OF THE BLOOD IN PASSING FROM A GIVEN POINT THROUGH THE TWO SETS OF CAPILLARIES TO THE STARTING POINT. THE BLOOD AXi) THE CIRCULATORY SYSTEM 75 The capillaries, so called because of their resemblance to minute hairs, though they are much smaller than the finest hairs, dilier from the arteries in being of a uniform size throughout, and in having only a single thin celular coat through which the ultimate interchange of materials takes place between the blood and tissues. The smallest veins start from the capillaries and constantly join each other, growing larger and larger, until finally all the venous blood in the body enters the right side of the heart through the superior and inferior vena cava. The pulmonary veins, unlike other veins, return arterial blood from the lungs to the left auricle. Veins dififer from arteries in the following particulars: Veins: The contained blood is dark red ; it flows in a continuous stream without spurting; it flows toward the heart. The veins have thin walls so that they collapse when cut across ; bleeding occurs only from the far end of th-e cut ^ ^ ^ vein, because the valves (Fig. 37) with which all veins 1 V /' (except those of the rectum) are supplied prevent a backward flow of blood from the near end. Many veins pjj^ va,v« are supercial and may be seen under the skin. of ^ ^'^in. Arteries: The contained blood is bright red ; it flows in waves, and spurts from the vessel when cut ; it flows away from the heart. Arteries have thick walls and stand open when divided, like a piece of hose ; bleeding occurs from both ends, owing to the absence of valves and the freedom of the collateral circulation. The large arteries are deeply placed near the bone and are usually on the inner or protected side of a limb. The circulation of the blood in the arteries is effected by the pumping action of the heart. In the viens the action of the heart is only one factor, the other two being pres- sure of the muscles in exercise and the aspirating power of the chest in inspiration. When the muscles contract they press on the thin- walled veins, and, as the blood is prevented from going backward by the valves, it must go toward the heart. When any obstruction exists in the course of a vein it is apt to become enlarged or varicose; such enlargements we see in the leg, constituting varicose veins, in the scrotum, called varicocele, and about the anus, called hemorrhoids or piles. All the arterial blood leaves the left ventricle of the heart by means of a large artery, called the aorta (Fij^ 38 ) ; this vessel arches back- 76 ANATOMY AND PHYSIOLOGY ward over the root of the lung, to the left side of the spinal column, down which it passes to the fourth lumbar vertebra, where it divides into the common iliacs. From the arch of the aorta are given off three large vessels, the innominate, the left common carotid, and the left subclavian; the innominate soon divides into the right common carotid and right subclavian, so that at the root of the neck the two sets of arteries are symmetrical. The common carotids on each side pass up alongside the trachea, or windpipe, where they can be felt, to the upper border of the thyroid cartilage, or " Adam's apple," where they are divided into the internal and external carotids. The internal carotids supply the interior of the cranium; they lie just behind the tonsils on the inside of the throat. The external carotids supply the exterior of the cranium and face, and the tongue ; the front edge of the sterno-mastoid muscle is the guide to this artery; the external carotid, or better, the common carotid, may be com- pressed against the vertebral column. The facial, a branch of the external carotid, curves over the lower jaw about an inch in front of its angle and can be compressed there; the temporal, another branch, passes up just in front of the ear and divides into an anterior and posterior temporal branch. The superior and inferior coronary branches of the facial unite with those from the opposite side to form a complete arch in each lip. The subclavian artery passes across the rsi rib just behind the clavicle, then beneath the clavicle to the axilla, where its name changes to axillary ; in the hollow behind the clavicle the subclavian can be felt and compressed against the rib. The axillary artery, where it passes beyond the armpit, is caled brachial; the brachial extends from the lower margin of the axilla down the inner and anterior aspect of the arm, and terminates about a half inch below and in front of the bend of the elbow, where it divides into the radial and ulnar. The course of the brachial artery is roughly indicated by the inner seam of the coat sleeve, or by a line drawn from the armpit along the inner border of the biceps muscle to the front of the elbow ; it may be compressed against the humerus. The radial artery passes down the radial side of the arm to the wrist, where it winds around the outer side and then passes forward to the palm between the thumlj and index finger; the ulnar artery in like manner passes down the ulnar or inner side of the arm and divides into two branches which anastomose with two similar THE BLOOD AXl) THE CIRCULATORY SYSTEM 11 branches from the radial, forming the superficial and deep palmar arches. Both the radial and ulnar are deeply buried under the muscles until just above the wrist where they become superficial; it is at this point that the beating of the radial is felt for in taking the pulse. The position of the palmar arches is important, because, owing to the fact that they receive branches from both the radial and ulnar arteries, bleeding from them is profuse and requires for its control pressure on both vessels. The superficial palmar arch is on a line witli the lower border of the extended thumb, while the deep palmar arch is a half inch higher up. The digital arteries, which supply the fingers, are branches of the palmar arches and pass along both sides of each finger. In the thorax the aorta gives ofif the intercostals, which run along the inner surface of the upper and lower borders of each of the ribs; in the abdomen it gives off important branches to all the abdominal viscera, and divides into the common iliacs. The common iliac on each side passes downward and outward to the margin of the pelvis where it divides into the external and internal iliac. The internal iliac goes to the interior of the pelvis and supplies it together with its viscera and the generative organs. The external iliac passes down- ward and outward to the fold of the groin, where it enters the thigh and becomes the femoral. The femoral artery commences at the center of the groin and passes down the front and inside of the thigh to the back of the knee, where it is known as the popliteal ; its course may be shown by stretching a string from the center of the groin to the back of the knee; just below the groin it may be compressed against the head of the femur. The popliteal artery extends from the termination of the femoral to just below the knee where it divides into the anterior and posterior tibial ; it is so tightly held down under fascia and tendons that it is hardly accessible for compression. The anterior tibial passes for- ward between the tibia and fibula to the front of the leg and then down deeply beneath the muscles to the front of the ankle, where it becomes the dorsalis pedis which is distributed to the back of the foot. The posterior tibial gives off a large branch, the peroneal, and then passes down the back of the leg beneath the deep muscles to the inner ankle, whence it passes to the sole of the foot and divides into two branches, the internal and external plantar, which supply the toes with digital arteries having the same distribution as those of 78 ANATOMY AX I) IMIVSIOLDGY the fingers. Bchiiid the inner ankle tlie i)osterior tibial may be felt and compressed. The veins may be divided into three sets, the pulmonary, the systemic, and the portal. The pulmonary I'cins dififer from all others in that they convey arterial blood from the lungs to the left side of the heart ; conversely, the pulmonary artery conveys venous blood from the right ventricle of the lungs. The systemic c'cius (Fig. 40) are arranged in two sets, deep and superficial ; the deep 7'cins accompany their corresponding arteries, each of the large arteries of the leg, forearm, and arm having two veins ; the deep veins communicate with the superficial set. The superficial veins lie just under the skin where they can, in many localities, be plainly seen ; those of the lower extremity are the internal saphenous, which starts on the top and inner side of the foot, runs up the inside of the leg and thigh and terminates in the femoral just below the groin, and the external saplicnous starting in like man- ner on the outer side of the foot and emptying into the popliteal behind the knee. Those of the upper extremity are the radial on the outer side, the ulnar on the inner side, and the median in the middle ; opposite the bend of the elbow the median splits into two veins, the one. known as the median cephalic, joining with the radial to form the cephalic, and the other, the median basilic, uniting with the ulnar to form the basilic; the basilic and cephalic both empty into the axillary. The median cephalic is the vein ordinarily opened in bleeding. The great superficial vein of the neck is the external jugular, which passes down from the angle of the jaw to the middle of the clavicle ; it may be brought into view by pressing with the finger just above the mid- dle of the clavicle. The portal system is composed of four large veins which collect the venous blood from the viscera of digestion. The trunk formed by their union (vera porta) enters the liver and breaks up into cap- illaries from which another set of veins, the hepatic 7rins, arise, which terminate in the zrna cava. This circulation is for the pur- pose of subjecting the products of digestion contained in these veins to the special action of the liver before they go into the general circulation. Fig. 38. — 'riie Circulation, N'etions ami Arterial CHAPTER VI TTTR RESPIRATORY APPARATUS The respiratory apparatus consists of the larynx, trachea, bronchi, and lungs ; the thyroid gland, which lies upon the trachea, may be conveniently considered in this connection (Fig. 39). The larynix, or Adam's apple, is the organ of voice, and is situated in the middle line of the neck, where it may be felt and seen mov- ing up and down in the act of swallowing. It lies between the trachea and the base of the tongue, and its upper opening is closed during swallowing by a cartilaginous flap called the epiglottis; when the tongue is drawn well forward, especially if the patient gags, the epiglottis may be seen as a white cartilage curving forward over the root of the tongue. When one chokes in swallowing because the food is said to have " gone the wrong way," it means that the epiglottis has failed to close efficiently the opening into the larynx, and food has gotten in, causing coughing for its expulsion. The larynx is composed externally of cartilage ; internally two white fibrous bands stretch from front to rear, and are known as the vocal cords; it is the vibration of these vocal cords that produces sound. The trachea or windpipe is a cartilaginous and membranous tube which extends downward about four and one-half inches from the larynx to its division into the two bronchi, one of which goes to each lung. The cartilages of the trachea and bronchi are arranged in rings, and serve the purpose of keeping the windpipe open. The right bronchus is larger and shorter than the left, and foreign bodies which get into the windpipe usually lodge in this bronchus. The bronchi divide and subdivide and give of¥ branches like a tree, at the same time gradually losing their cartilages and getting thinner and thinner until the little bronchioli terminate in a sack the walls of which are studded with air cells, a terminal bronchus and its air cells resembling a bunch of grapes. The termination of the broiichi together with the air cells con- stitutes the lung tissue proper. \\'hen the larynx becomes obstructed by disease so that air cannot 6 (81) 82 AXATUMV AXl) I'liVSlULUGY get into the lungs and death is otherwise imminent, a tube is intro- duced into the larynx between the vocal cords, intubation, or an open- ing is made into the trachea and a tube inserted there, tracheotomy. The lungs are the essential organs of respiration ; they are com- monly known a-s " lights," and with the heart between them fill the entire chest cavity (I'ig. 35). Each is covered by a smooth, shining serous membrane which also lines the chest cavity and is called the pleura. Ordinarily the lungs are everywhere in contact with the chest walls, but when an open- ing is made in the chest, as by a shot or stab wound, or when inflain- mation of the pleura occurs and fluid is poured out, a space is formed between the lung and the chest wall, known as the pleural caz'ity (Fig. 40). The right lung has three lobes, the left lung two, and each is com- FiG.39.-The Larynx, Trachea, Right and Left Bron- pOSed of bronchi aij-chu3,andtheLunf;s. The latter have been cut open to show ,, , , ,. .' . the method of division and subdivision of the Bronchi. cells, and the divisions and subdivisions of the pulmonary arteries and veins. In the ultimate air cells the venous blood of the pulmonary arteries circulating in the capillaries is brought in contact with the air in the cells, and the interchange takes place which results in the blood receiving a supply of oxygen and becoming arterial, while the air becomes charged with carbonic oxide, waste organic matter, and watery vapor. In inflammation of the lungs, pneumonia, these air cells become filled with liquor sanguinis containing some red blood cells, so that air can no longer enter and that portion of the lung is temporarily useless. In laryngitis and bronchitis mucus is pcurcd out into the THE RESPIRATORY APPARATUS 83 bronchi and coughed up, but the air cells are free ; hence those affections are much less serious. Breathing or respiration consists in the alternate expansion and contraction of the chest, by which air is drawn in and forced out ; the drawing in is known as inspiration and the forcing out as expira- tion. The number of these movements in health is about eighteen to the minute. In ordi- nary quiet respiration the principal muscle concerned is the diaph- ragm, wliich in its re- laxed state is arched up- ward into the cavity of the chest; in its con- traction tlie muscle is flattened out, largely in- creasing the capacity of the chest, so that the air rushes in through the larynx to fill the vacu- um ; inspiration com- pleted, tlie diaphragm relaxes, the chest walls collapse, and expiration occurs. When respira- tion becomes more ac- tive the intercostal muscles, which raise the ribs, come into play, and when still more effort is required all the muscles attached to the chest come into action, and even the nostrils are dilated to allow the entrance of- more air. Ordinary outdoor air contains about twenty-one parts of oxygen. seventy-nine parts of nitrogen, and four hundredth parts of carbonic acid, or four parts in ten thotisand. The oxygen is the element of the air which is necessary to sustain life; it serves the same purpose as it does in a fire, maintains the Fig. 40. ' — Chest, sliowing Pleura*. 84 ANATOMY AND I'llVSJULOGY combustion by which heat and force are produced. If you shut off the supply of air (oxygen) to a furnace the fire goes out ; if you shut off the supply to the lungs life goes out. The nitrogen has no other value than to dilute the oxygen. When air is breathed it loses a portion of its oxygen, is raised in temperature, and has added to it in the lungs carbonic acid, organic matter, and the vapor of water; the amount of contained carbonic acid is increased a hundred times, to about four per cent. As the air in a confined space is breathed over and over again, headache and drowsiness are experienced, and even death may result. A notable instance of this character occurred in India in the year 1756, when one hundred and fifty-six British prisoners were confined in a dungeon eighteen feet square ; the next morning one hundred and twenty-three of them were dead. The causes of these results were formerly supposed to be de- ficiency of oxygen, increase of carbonic acid, and organic matter. Now we believe that the real causes are increased temi>erature and humidity, and stagnation of the confined air; just how these factors act, we do not know, but experience has demonstrated that when the air is kept in motion, and the temperature reduced, the unpleasant symptoms do not occur. The inflow of fresh air to take the place of that which has been breathed is known as ventilation. The heat which is produced in the body by the burning or oxida- tion of carbon, the resulting carbonic acid escaping throiigh the lungs, would raise the temperature of the i^ody too high were it not that provision is made for its regulation. The evaporation of water is the principal cooling agency, the evaporation taking place from the lungs and skin ; this is going on all the time, thougii the vapor from the lungs is only visible in cold weather. So with the skin, the water is only visible in hot weather, when so much escapes that tbiC unevaporated portion becomes visible as sweat or perspiration ; the harder we work, the more heat is produced, and the more evaporation of water is required to reduce the body temperature. If the skin stops action the body temperature rapidly rises, and we have the condition of heat stroke, in which the hot, dry skin is a familiar symptom. CHAPTER VII THE EXCRETORY APPARATUS We have already seen that in all life processes waste products and poisons are produced, which, if not gotten rid of, are finally fatal even to the life which produced them. The yeast fungus growing in sugar solution produces a poison, alcohol, which when it reaches a certain proportion destroys the life of the yeast; so with the human body, it produces very deadly poisons which must be thrown ofif if the body would live, and the apparatus by which these poisons are eliminated is known as the excretory apparatus. The skin, lungs, large intestine, and urinary apparatus all take part in excretion. The excretory functions of the skin, lungs, and rectum have been fully described elsewhere. It remains to give a description of the urinary apparatus, whose practically sole function is excretion. It consists of the kid}ieys which secrete the urine and the ureters which convey it to the bladder, where it accumulates until it is convenient to discharge it through the urethra. The kidneys (Fig. 32 ), one on each side, are situated in the loins, at the back of the abdomen, behind the peritoneum, on either side of the spinal column, and just below the last rib. They are about four inches long by two and a half inches wide, by one and an eighth inches thick, and w'eigh about five ounces each. They are covered by a fibrous capsule which may be stripped off, and consist of two portions, a cortex and a medullary portion. The cortex is the secreting part, while the medulla is largely an aggregation of urinary tubules on their way to the pelvis of the kidney. Each urinary tubule, after many twists and loops, terminates in a little sack, in which is a bunch or tuft of tortuous capillaries ; the veins emerging from these capillaries are smaller than the arteries that empty into them, so that the blood in passing through is sub- jected to some degree of pressure, and under the pressure water and salts escape from the vessels. Farther on down the tubule the secreting epithelium with which the tubule is lined takes from the (85) 86 ANATOMY AXD PHYSIOLOGV blood the urea and oilier waste products necessary to [)urify it and complete the urine. On the inner side of each kidney is a deep depression containing a funnel-shaped sac, the pciz'is, which receives the terminations of the urinary tubules, and is itself the starting point of the ureters. The ureters are two musculo-membranous tubes, about the size of a goose quill, and sixleen inches long, extending from the pelvis of the kidneys to the urinary bladder (Fig. 41). When a stone formed in the pelvis of the kidney finds its way into one of these ureters, in its passage to the bladder, it naturally has a hard time in getting through such a small canal, and the result is the excruciate ing pain experienced in such a condition which is known as renal colic. The bladder is a muscular bag which serves as a reser- voir for the urine and in a moderately distended condi- tion holds about a pint. When empty or containing only a small amount of urine it lie- wholly within the pelvis, and behind the pubis; when full it rises into the abdomen and can be felt and percussed above the pubis. To deter- mine whether the bladder is full we tap on the finger placed just above the pubis : if we get a hollow sound we know that it cannot be distended (Fig. 42 V As the bladder rises into the abdomen it leaves exposed in front a small area not covered by the peritoneum and through which it can be aspirated without opening the peritoneum. Likewise there is a similar area behind, where the bladder rests on the rectum and through which it can be reached. The neck of the bladder is em- braced by the prostate gla}id which in old men becomes enlarged and makes a bar to the passage of urine. Fig. 4 — ■ Section of the Kidney. A,Corlex\B, medulla; C, pelvis; D, ureter. THE EXCRETORY APPARATUS 87 The urethra is eight or nine inches long and extends from the neck of the bladder to the meatus: when the penis is held up that portion of the urethra under the pubis describes a curve with the concavity upward, hence the curved shape of catheters and sounds. Urine is a watery solution of urea, uric acid, coloring matter, and salts, mostly urates, phosphates, carbonates, and chlorides. The MulC- iriani Prosta teqiarui CLlanS Fig. 42. — Section of Bladder and Urethra. average man passes about fifteen hundred cubic centimeters or three pints of urine a day, and this urine contains about fifty grammes or one and one-half ounces of solids. Normal urine is yellowish in color, acid in reaction, and has a specific gravity of from 1015 to 1025. The urea is the most important constituent, a little more than an ounce being excreted daily. Healthy urine when passed is ordinarily clear, but it may quickly become cloudy and a sediment form without indicating disease. H such cloudiness disappears when the urine is heated it is due to 88 ANATO.MY AND PHYSIOLOGY urates; if the cloudiness disappears on the addition of a few drops of acid it is due to phosphates. Among abnormal constituents of the urine, indicating disease, are albumin, sugar, bile, blood, and pus. Just above the kidney on each side is a small triangular ductless gland known as the suprarenal gland. It has nothing to do with the excretion of urine but is considered here for convenience. That these little glands add something important to the blood is shown by the fact that their removal in animals is quickly followed by death, and that their diseased condition in man is the cause of a fatal malady known as Addison's disease. Their function appears to be to sustain muscular tone, especially in the blood-vessels, and a substance known as adrenalin has been isolated from them which has a very powerful effect in that direction. PART III FIRST AID CHAPTER I EMERGENCIES, CONTUSIONS, AND WOUNDS One of the most important of the many duties of the hospital- corps man is to render first aid ; m time of war it becomes his most important duty. In order that this duty shall be performed promptly and efficiently and without excitement or hesitation he must be taught what to do until he possesses the confidence born of knowledge. If called upon for assistance in an emergency under other con- ditions than those of an action his first duty is to send word to a medical officer ; in action this often can not be done. The next step is to see that the sick or injured man is not crowded about so that he can not get air ; then the nature of the case must be ascertained as quickly as possible. Look for bleeding; if it is at all profuse it must be stopped at once ; if there is shock lower the head and give a little aromatic spirits of ammonia in water; if there is a wound protect it by a first-aid dressing, ripping up the clothing if necessary to get at it. but not attempting to clean or handle it in any way; if there is a fracture immobilize it before moving the patient a foot, so that a simple fracture may not be made compound. Then remove any equipments tlie soldier may have on. unbutton his collar, and loosen the clothing about his chest and abdomen. In action the amount of first aid to be rendered will depend on circumstances ; perhaps the arrest of severe hemorrhage is all that can be attempted. The clothing must be preserved as far as possible, for it is often impossible to replace it. On reaching the hospital the clothing must be very gently removed. To remove a shirt, pull it up from the back, (89) 90 FIRST AID then draw it over the liead to the front, and lastly disengage the arms; if one arm is injured disengage the well arm first, then draw the shirt over the head, and lastly free the injured arm; if necessary rip up the seam on the injured >ide. A co)ttitsio)i or bruise is a suhcutaneous or closed wound: a lacer- ation of the deeper tissues without a division of the skin. Contusions \ary in extent from an ordinary " hiack and blue "' spot, to the almost complete ])ulpihcation of a limb with laceration of the blood-vessels and nerves such as sometimes occurs in railway or other accidents, 'ilie tirst evidence of contusion is usually rapid swelling of the part ; every one knows that w'hen one is struck a hard blow on the eye the swelling closes it almost immediately, or a blow on the head is jjromptly followed by a " bump." There is only one thing which could cause such rapid swelling, and that is bleeding caused by the laceration of the subcutaneous tissues and vessels, the blood not being able to escape. At first there is no discoloration, but after a few hours or a. day, the blood makes its way toward the surface, and the part looks black and blue and. as changes later take place in the blood, greenish or yellow. Another symptom is pain. If the injury is severe there is shock ; the more shock the less pain usually. SliQck is a condition of nervous depression like fainting, only shock is due to physical causes, while fainting is due to mental impressions. The symptoms of shock are anxiety, pallor, dilated pupils, trembling, chilly feeling, nausea, clammy skin, very weak pulse, sighing respira- tion, often a subnormal temperature. The amount of shock will depend upon the part of the body injured and the gravity of the in- jury; it is much more marked in injuries of the trunk than in in- juries of the extremities ; injuries of the testicle are apt to be attended with marked shock. Shock may be so severe as to terminate fatally without reaction. The treatment of shock consists in the use of heat externally and stimulants internally ; hemorrhage must be carefully looked for and controlled if present. In severe shock on the field it is often safer not to attempt to move the j^atient until there are signs of reaction ; give him some stimulant and leave him temporarily. If he can be moved get him in bed as quickly as possible : wraj) him in hot blankets and surround him with bottles of hot water : gi\c him hot coft'ee or hot beef tea; keep him perfectly quiet with the head low. For the treatment of the contusion itself the indication is to stop EMERGENCIES, CONTUSIONS AND WOUNDS 91 the subcutaneous bleeding; this can be done by very hot or very cold applications; if the injury is in a limb, firm, even pressure of a band- age may be effective. Later when the bleeding has ceased the ab- sorption of the extravasated blood may be hastened by hot fomen- tations and massage. A ivound is a division not only of the tissues but of the overlying skin. Wounds are classed as incised, lacerated, contused, punctured, and poisoned ; gunshot zcounds are usually considered in a class by themselves. An incised iconnd is one made with a sharp cutting instrument, the class of wounds commonly known as cuts, such as cuts with a razor or knife. A lacerated wound is a torti wound, such as is made by barbed wire or a piece of shell ; it does not differ practically from a contused or bruised wound made with a blunt instrument such as a club or stick. A punctured wound is deep and narrow ; stabs are punctured wounds. A poisfoned zvound is one in which some poison has been intro- duced by the same agent which made the wound ; any of the above- named classes of wounds may be poisoned. Gunshot z^'ounds are both punctured and contused; they may also be lacerated. Incised wounds are especially apt to be attended by bleeding: lacerated and contused wounds are less apt to give rise to dangerous hemorrhage because the vessels are torn and twisted; a limb may even be entirely torn off without serious bleeding, but shock in this class of wounds is apt to be severe. Punctured wounds are dangerous because, while the external ojjening may be small, they often penetrate so deeply as to seriously injure important organs, or cause internal hemorrhage. The immediate dangers of wotuids are hemorrhage and shock; if these are removed the one great danger is infection; if that can be prevented the most serious wounds may be recovered from unless of course there is irreparable injury to some important organ. The healing" of wounds takes place in two ways; if there is no in- fection and no loss of tissue and the parts are brought into proper apposition healing occurs by first intention ; otherwise by granulation with or without suppuration. 92 FIRST AID 2^Iost incised and small-arm bullet wounds are originally aseptic or germ free, and if kept so will heal or grow together under one dressing, without heat, redness, severe pain or swelling, and without fever. The bullet itself after it has lodged is usually harmless and may be ignored as far as the treatment is concerned. If the wound becomes infected with pus cocci, inflammation occurs with its attendant symptoms of heat, redness, pain and swelling, and usually more or less fever; suppuration follows, and if the pus can- not escape freely some of the poisons produced by the growth of the pus cocci are absorbed, septic toxemia, or the cocci themselves 'get into the blood-vessels, septic infection; the septic infection ma}- result in the formation of abscesses in the ditTerent parts of the body, pyemia. All these blood poisonings are attended by chills, or chilly feelings, fever, headache, a peculiar waxy appearance of the skin, and perhaps delirium and stupor. Unless arrested the process terminates in death. Recent war experience, with its constant trench fighting, has shown that under the new conditions many wounds, especially those caused by shrapnel, shell, and hand grenades, are primarily infected. and not only with the bacteria of suppuration but often with those of gas-gangrene and tetanus. If infected with the germs of gas- gangrene, the wound quickly becomes foul and sloughy, and full of gas, so that it crackles under pressure. The first-aid treatment of wounds consists in the arrest of hem- orrhage — and by hemorrhage must be understood serious bleeding, and not the moderate bleeding which accompanies most wounds and only requires the pressure of a dressing — the relief of shock and the prevention of infection. To prevent infection is all-important and may be accomplished by following a few simple rules : do not touch the wound with the fingers or anything else; do not attempt to wash it or remove particles of dirt or clothing; if the intestine is protruding do not attempt to replace it ; if the sharp end of a broken bone is sticking through leave it undisturbed ; remove the soiled and bloodly clothing about the wound, paint the wound and surrounding skin with tincture of iodine, allow it to dry, and apply the contents of the first-aid packet, handling the gauze with the waxed paper so as if possible not to touch any part of the dressing with the fingers. Each soldier in the field is issued a first-aid packet for his in- EAIERGENCIES, COXTUSIOXS AND WOUNDS 93 dividual use ; it has a hermetically sealed metal cover, and contains two compresses of absorbent sublimated g-auze, each sewed to the center of a sublimated-gauz© bandage, each bandage being wrapped in parchment or waxed paper and two safety pins wrapped in waxed paper. The first-aid packet is carried by all officers and enlisted men. To protect the extensive wounds often caused by shell fire the ordinary first-aid packet is not large enough, so that these packets are now supplied in two sizes. The larger or " sheU-wound dressing " is wrapped in tough paper with directions for application printed thereon, and each contains I square yard of absorbent sublimated (i:i,ooo) gauze so folded as to make a pad six by nine inches , stitched to the back of each end of this compress is a piece of gauze bandage three inches wide by forty-eig'ht inches long. The dressing also contains one absorbent sublimated-gauze bandage three inches wide by live yards long, and two safety pins. If a first-aid packet is not at hand, the dressing may be of ordi- nary sterilized gauze, or any other thoroughly clean material, dry if possible. JVoHiids of the skull if penetrating are usually accompanied by injury to the brain which will, be Dianifested by unconsciousness. paralysis, unequal pupils, etc. No special first-aid treatment is re- quired. Wounds of the chest if penetrating are usually attended by injur}'- to the lungs. The signs of penetration of the chest cavity are the presence of air bubbles in the wound, difficult breathing, cough, and spitting of blood. The treatment consists in laying- the patient on the injured side and firmly bandaging the chest. Wounds of the abdovicn. ma)' or may Tiot he penetrating, and there may or may not be injury to the viscera. Tlic signs of hijury of the intestine are the escape of gas or feces through the wound and the passage of blood in the stools. Tnjurv to the stomach may be attended with the escape of its con- tents and by vomiting of blood. No special first-aid treatment is required in these conditions, except that the patient should be placed in such a position as may favor the escape externally of the contents of the intestinal tract. Injury of the bladder is shown by the escape of urine through the 94 FIRST AID wound and ihe passage of blood in the urine; if these signs are present the urine .Nhould be drawn frecjuently to prevent its escape into the abdomen. In all cases of injury to the abdominal viscera the signs of shock are usually well marked. Poisoned icoiuids may be divided into those in which the poison is chemical^ including the bites and stings of insects, scorpions, ta- rantulas, centipedes, and snakes ; and those in which it is bacterial, including the biles of man and other animals not rabid, the bites of rabid animals, and wounds infected with tetanus or anthrax. The bites and stings of inseets cause considerable smarting and if in loose tissues often much swelling; relief may be afforded by the application of ammonia, soda, or even wood-ashes; the sting if left in the wound should be extracted. The bites of the tarantula and centi- pede and the sting of the scorpion may cause great pain, considerable shock, and much local swelling and inflammiation, but are seldom or never fatal. The treatment is the same as for the bites of other in- sects, but in very severe cases it may be necessary to incise the wound and suck out the poison. Stimulants may be given if neces- sary and morphine for the pain. \Mien a person is bitten by a poisonons snake, of which the rattle- snake and copperhead are the principal varieties 'in this country, prompt action is required. If the wound is in the extremity tie a bandage or handkerchief tightly about the limb above the wound ; incise the wound freely and suck out as much of the poison as possible ; then with a hypodermic syringe inject a two-per-cent solution of permanganate of potash into and about the bite so as to destroy any poison which is left. Jf a hy- podermic syringe and permanganate solution are not available, the bite should be cauterized with a lighted match, a hot coal, or a lit- tle gunpowder rubbed in and ignited. Meanwhile give stimulants freely but not to the point of intoxication. The ligature should be loosened about every half-hour so as to allow restoration of the cir- culation, but should be immediately tightened up if symptoms of general poisoning occur. The bites of man and other animals not rabid are always more or less poisonous from the presence of the bacteria constantly found in the mouth and on the teeth ; sometimes they are fatal ; ^uch wounds should be thoroughly disinfected and wet antiseptic dressings applied. EMERGENCIES, CONTUSIOXS AND WOUNDS 95 Rabies or hydrophobia is a very fatal disease caused by the bite of a rabid animal or " mad dog.'' The effect is not immediate like that of snake bite, but may be delayed weeks or months. The treatment of the bite when the animal is known to be rabid i> exactly like that of snake bite, but no ligature need l)e used. Tetanus or lock-jazc is a disease the result of a wound infected by the bacillus of tetanus. It is especially apt to occur after toy-pistol wounds or any wound in which dirt has been carried deeply into the tissues. It has been very common in wars where the fighting occurs in trenches made in cultivated fields which have been enriched with stable manure. The tetanus germ grows best in the absence of air; hence it thrives in deep, punctured wounds. The germs are found in the soil especially about gardens, stables, and in the streets. Wounds of such a character should be opened up freely, disinfected, and drained. If available, tetanus antitoxin should be injected into and about the wound. Anthrax or malignant pustule is sometimes caused by the bite of an infected fly. It starts as a very hard swelling like a carbuncle, often on the lip. If its nature is recognized it .should be at once ex- cised. In warfare with savage peoples the latter often used poisoned zveapons. especially arrows. Many different poisons are used, vege- table, animal, and bacterial. The local treatment is the same as that of snake bite : the general treatment must be symptomatic, unless the nature of the poison is known. CHAPTER II HEMORRHAGES In capillary hemorrJiaye there is a steady oozing of red blood from all over the wounded surface ; nature's method of arresting such a hemorrhage is by the coagulation or clotting of the blood in the mouths of the tiny vessels, and by the contraction of their cut ends. In treatment we imitate nature. The part should be ele\"ated and very hot or very cold water applied to the wound ; the effect of either one is the same as the other, the result being the contraction of the vessels, coagulation of the blood, and arrest of hemorrhage. After this, uniform pressure applied to the wound by means of a gauze compress an4 bandage is all that is required. Epistaxis or nose-bleed is a form of capillary hemorrhage which is sometimes difficult to control ; the arms should be held by an assistant vertically above the head, and a sponge dipped in cold water applied to the back of the neck between the shoulders, and another over the root of the nose ; very cold or very hot water should be snuffed up the nose; if this fails an astringent should be added to the water — alum or tannic acid. Should the bleeding still continue, plug the nostrils with absorbent cotton; but if the blood then runs into the throat from the back of the nose, the assistance of a surgeon w'ill be required. Capillary bleeding from a tooth socket is sometimes excessive ; plug the cavity with a narrow strip of gauze, place a compress over the gauze, and bandage the lower jaw firmly against the upper. In venous hemorrhage there is a rapid flow of dark blood, a welling up as it were, without any spurting. In the treatment the first step is to elevate the part ; so little velocity is there in the venous current that elevation alcne will often stop the bleeding; if it does not, pressure must be made directly over the wound, and hot or cold water may be applied if necessary ; if in an extremity, the limb should be bandaged from the toes or fingers up to the bleeding point, in addition to the pressure over the point. (%) HEMORRHAGES 97 In arterial hemorrhage tlie l)lood is bright red in color and escapes in jets. Nature's method of arresting such a hemorrhage is by the formation of a clot, the contraction of the muscular coat of the artery lessening the caliber, and the retraction of the middle and anner coats affording an obstacle to the escape of the blood and favoring clot for- mation, and the diminished force of the blood flow caused jjy the weakening of the heart's action, the result of the hemorrhage. When fainting follows the loss of blood the hemorrhage often ceases at once because the heart's action is so weak th.it it cannot force out the clot which forms in the mouth of the vessel ; in such a case, however, the bleed- ing is apt to start again when reaction takes place, or when some sudden movement dis- places the clot. The recurrence of bleeding with reaction is known as intermediate hemor- rhage to distinguish it from primary hemor- rhage, that which occurs immediately on receipt of the wound, and secondary, that which occurs at a still later period from the reopening of the artery by the slipping of a ligature, or from an extension of sloughing or ulcera- tion to the vessel. In the treatment of arterial hemorrhage prompt action is required ; bleeding from a large artery like the femoral may cause death in a minute or two ; as a matter of fact a large proportion of the deaths on the battlefield are due to hemorrhage. The thing to be done is to compress the artery between the wound and the heart, or if that cannot be done then in the wound itself ; the point selected for pressure should be where the artery crosses a bone because there it can be made most eft'ective. If a hose connected with a hydrant breaks we stop the flow of water by putting a foot 7 Fig. 43. — Comifiessioii of the Femoral Artery. 98 FIRST AID upon the hose between the broken part and the hydrant ; we apply tlie same principle in arterial hemorrhage. The pressure should be made with the fingers, preferably the thumbs, and should be firm enough to arrest the bleeding ( Mg. 43) ; it should be made over the clothes, as too much time may be lost in removing them. You will know that you are pressing on the right place by feeling the artery beat- ing beneath the fingers and by the arrest of the bleeding: if you cannot find the artery make pressure directly over the bleeding point. As pressure with the fingers soon becomes tire- some, get an assistant to slip his thumb over yours, and take your place while you prepare a tourniquet. The principle of all tourniquets is a pad over the artery to Ijring the pres- sure on the artery and take it oft' the veins, a band around the limb and over the pad, and some means of Fig. 44. -Compression of the Femoral tightening the band. There are a Artery by a Rubber Bandage. \. . number of special tourniquets, but as they are not usuall}' at hand a suitable one must be improvised ; an excellent tourniquet may be improvised with a rubber bandage ; a number of turns are made about the limb and the rolled ])ortion of the bandage then placed under the last turn in such a position as to press directly upon the artery (Fig. 44). The most common improvised tourniquet is the Spanish windlass: in this arrangement any rounded, smooth, hard object, such as a stone, a cork, or a roller bandage, is used as a compress : for the band a handker- chief, a suspender, a waistbelt. a bandage, or anything of the sort may be used ; to tighten up the band a stick or bayonet, scabbard or some- thing of the kind is passed under the band and twisted until the fic. 4-.— Spanish WinJiass. HEMORRHAGES 99 bleeding ceases, when the ends of the stick are tied to the limb to prevent the band from becoming- untwisted (Fig'. 45). A tourniquet applied tight enough to stop arterial hemorrhage causes pain and swelling of the limb, and if left long enough may cause gangrene of the part ; it should therefore be watched and loosened up from time to time, say every half-hour or so. H on loosening the tourniquet the bleeding starts again tighten it up , if there is no appearance of bleeding leave the loose tourni- quet in place with an attendant watching to tighten it up should the hemorrhage recur. The surgeon arrests the hem- orrhage permanently by tying or twisting the divided ends of the artery. Fig. 46 shows on the skeleton the points at which the various arteries may be compressed to tlie best advantage. for bleeding anyichere in the npfcr extremity below the mid- '^^ii:K^ Coinpression of the Rrachial Artery. Fig. 46, — Skeleton with Rlack and Dotted Lines Showing the Course of tlie Arteries and a x Indicating the Pressure Points. die of the arm compress the brachial in the manner shown in Fig. 47 and then apply a tourniquet a little higher up. If th.e wound is 100 FIRST AID low do\yn in the palm of the liaiid. it may not be desirable to arrest the circulation in tlie entire liml:), in which case the pressure may be made in the pahn by a roller bandage over whicli tlie fingers are doubled and tied in place with a bandage (Fig. 48); or we Fig. 48. — • Arrest of Bleeding from the Palm. may put a ])ad in the elbow and bend the forearm on the arm and tie the two together (Fig. 40). If the wound is in the axilla, pressure must be made on the sub- clavian a2:ainst the first rib and in the hollow behind the clavicle Fig. 49.- — ^ Flexion of the Elbow to .\rrcst Bleeding Below. Fn;. 50. — Compression of the Sub- clavian .\rtery. (Fig. 50 ) ; as a tourniquet cannot be applied here the fingers may be relieved by making the pressure with the handle of a large key, or the end of a jiocket knife well wrajtped. In bleeding fro)ii any part of the lozccr extremity compress tlie HExMORRHAGES 101 femoral against the head of the femur just below the middle of the groin, with both thumbs, as shown in Fig. 43, then apply a tourni- (|uet to replace the thumbs. If the bleeding is from the foot another method is to put a pad be- hind the knee and flexing the leg forcibly, tie the leg to the thigh as Fig. 51. '• — Arrest of Bleeding by Flexion of the Knee. shown in i^'ig. 51 ; if from the top of the foot a tourniquet may be placed over the anterior til)ial in front of the ankle, or if from the sole of the foot over the posterior tibial behind the inner ankle. ■Fig. 52. — Compression of the Carotid. Fig. 53. — Compression of the Temporal Artery by Knotted Bandage. Hemorrhage of the iicclc from the branches of the carotid is con- trolled by compression of the carotid with the thumb against the ver- tebrae (Fig. 52) a tourniquet cannot be applied here. 102 FIRST AID Bleeding from the tongue may be controlled in the same way, or by rinsing; the mouth out with ice water, or holding pieces of ice in the mouth. Bleediuij; froin the lips may be very severe ; it is controlled by grasping" the lip l)etween the thumb and fingers; as the arteries of the lip come from both sides, pressure must be made on both sides of the woimd. Bleeding from the face may be arrested by pressure on the facial in front of the angle of the jaw. Bleed in (J from the scalp is easily arrested by pressure with a com- press on the bleeding point, the pressure being made by a knotted bandage as shown in Fig. 53- In bleeding from the lungs the blood is bright red, frothy, perhaps mixed with mucus, and is coughed up. Listen over the chest and where. rattling is heard apply an ice bag; give the patient pieces of ice to swallow, and keep him perfectly cjuiet in the recumbent posi- tion ; he should neither talk nor move. In bleeding from the stomach the blood is vomited, is usually dark in color, and may be mixed with food. It is always well to remember that vomited blood does not necessarily indicate hemorrhage from the stomach ; the blood may have been swallowed, coming from the back of the nose or throat ; inquire whether there has been any nose- bleed. The treatment is the same as for hemorrhage from the lungs, except that the ice bag is applied over the stomach. In bleeding fr'om the bowels the blood is bright red if fresh ; black and tarry if old. All that can be done is to apply cold applications to the abdomen and keep the patient quiet. CHAPTER III DISLOCATIONS AND SPRAINS A dislocation is a permanent slipping away from each other of the bones whicli form a joint, with locking of the bones in the new posi- tion ; the joint is out of place. Necessarily the dislocation is attended with tearing- of the ligaments and often with rupture of the muscular attachments as well. The cause is usually indirect violence especially falls and twists. In attempting to save one's self from falling the hand is thrown out and the weight of the body coming on it causes a dislocation of the shoulder ; or the thigh in falling is bent backward, resulting in dislo- cation of the hip. The symptoms of dislocation are as follows: The patient has fallen and cannot move the affected joint ; there is pain of a sickening char- acter, often with numbness or tingling in the limb below from pres- sure on the nerves and blood-vessels ; on attempting to move the joint we find that it is locked and cannot be moved ; on uncovering and examining it, it will be noticed that there is marked deformity in the joint, and that the limb is fixed in an unnatural position, and appears longer than the corresponding limb on the other side. A dislocation must always be carefully distinguished from a frac- ture or a sprain. In fracture there is unnatural movement between the joints instead of immobility at the joint, and the movement is attended with a grating sensation and sound ; the deformity is be- tween the joints and there is usually shortening of the limb. In sprains there is absence of any of the signs of dislocation except swelling and pain ; the joint can be moved, though the patient will resist on account of the pain. Always uncover the limbs and com- pare the corresponding joints on the two sides. If the services of a surgeon can soon be obtained nothing should be done for dislocations except to loosen the clothing about the in- jured part and support it as comfortably as possible in the new po- sition. If the patient must be moved the limb should be supported in a sling, or by splints and bandages. (103) 104 FIRST AID When, however, a physician can not be reached for some time, there are certain dislocations which a hospital-corps man may attempt to reduce. He must always remember that no force is to be employed, as it may do serious damage to the important vessels and nerves near the joint; the secret of success lies in the skillful manipulation with a clear understandini,^ of the anatomy of the joint. Dislocation of the shoulder occurs more fre- quently than dislocation of all the other joints in the body taken together ; the reason of this has been explained on page 43 ; the most common dislocation of the shoulder is downward (Fig. 54). The symptoms are those described for dis- locations in general ; there will be a hollow under the point of the shoulder which will be very con- spicuous when compared with the convexity on the other side and the head of the l)one can be felt in the arm pit where it should not y Fig. 54. — Subgle- noid Dislocation of the Shoulder. Fig. 55. — Reduction of Dislocation of the Shoulder by the Foot in the A.xilla. be. To reduce this dislocation place the patient on his back on the ground; sit beside him; remove one shoe from your foot and place that foot in the patient's axilla; then using the foot as a fulcrum, draw the arm downward in the direction of its axis, then outward, and finally carry it across the chest (Fig. 55) ; or Kochcr's method IJISLUCATIOXS AXl) SPRAINS 105 may be tried as follows : Flex the forearm to a right angle, bring the elbow to the side ; carry the hand and forearm outward ; then lift np the elbow and sweep the forearm across the front of the chest. If successful the humerus will suddenly slip into place with a click; the arm should then be bandaged to the side for a week or two to give the torm ligaments a chance to heal. If unsuccessful after a few minutes" trial further attempt should be postponed. A shoulder once dislocated is usually permanently weak, and the dislocation is apt to recur from slighter violence than at first. In dislocation of the lower jaw (Fig. 56) the patient can not speak or close the jaws, and is in great distress. This dislocation is usually re- duced without much difficulty, but there is great danger of the thumbs of the operator being bitten. Wrap the thumbs well with a handkerchief or band- age ; stand in front of the pa- tient, and while jiressing with the thumbs in the mouth just t?l back of the last lower molars at ^'*^- S^-— Dislocation of the Lower Jaw. the same time with the fingers lift up the chin ; the jaw will usually at once snap into place, and the thumbs must be quickly withdrawn to prevent them being bitten. After reduction bind the lower jaw to the upper with a four-tail bandage. In dislocation of the finger joints pull on the dislocated end. at the .same time bending it backward if the dislocation is forward, or for- ward if the dislocation is backward, and pushing the joint into place. After reduction strap or splint the finger. The patella or knee-cap may be dislocated outward or inward ; there is sickening pain, the knee cannot be moved, and on e.xamina- tion there is a hollow in front of the knee where there should be full- ness, and the patella can be seen and felt in its new position. Extend the knee as much as possible and flex the thigh so as to relax the muscles, when the patella can usually be pushed into place. In sprains the joint surfaces slip apart, tearing the ligaments, but slip back into place again ; a sprain is really a momentary dislocation. The tearing of the ligaments causes hemorrhage into and around the 106 FIRST AID joint, and as the blood can not escape externally the joint is immedi- ately swollen; that the swelling" is due to the bleeding is shown by the black and blue discoloration of the skin over the joint which begins to appear after a day or two as the blood comes to the surface. The treatment consists in stopping the hemorrhage, causing the absor])tion of the blood already poured out, and supporting the joint until the ligaments heal. A sprained ankle, the most common of all sprains, may be taken as a type. The patient twists his foot stepping on a stone, there is sharp pain in the ankle, lameness, and prompt swell- ing of the joint, but the joint is movable, thus excluding dislocation, and there is an absence of the signs of fracture. To control the bleeding put the foot at once into a pail of hot water, as hot as can be borne, and keep it there ten minutes; or if there is no water hot enough use ice water. Next shave, dry and powder the foot and then strap the joint firmly with rubber adhesive plaster, using strips about an inch wide and fifteen to eighteen inches long (Fig. 57). The first strap should form a stirrup of the heel, closely following the tendo Achillis on each side : the second should cross the first at a right angle, extending along the border of the foot from the root of the little toe to the root of the great toe or vice versa: the third strap covers one-third of the first and the fourth one-third of the second and so on until the entire ankle is covered except a narrow strip in front which is left open to allow of free cir- culation. Each strap is drawn tight and the crossings are made strongest over the swelling. When the strapping is completed a bandage is applied over all until the plaster is firmly adherent, when Fig. 57. — Strapping the Ankle. DISLOCATIONS AND SPRAINS 107 the bandage is removed, the sock and shoe put on and the latter finnly laced, after which the patient should begin to walk, commenc- ing with a crutch or cane. The walking is at first very painful, but must be persisted in, as the plaster takes the place of the torn ligaments and the movement of the joint in walking causes rapid absorption of the blood. As the strapping becomes loose it must be reapplied after thorough massage of the joint. CHAPTER IV 58. — Green-stick Fracture. l-RACTL'RES A fracture is a broken bone. There are two great classes of frac- tures, simple or closed and compound or open. A compound or open fracture is one in which there is a wound communicating with the broken ends of the bone ; the broken bones are open to infection. A simple or closed fracture is one in which the broken bones are closed to the air and to infection in that there is no wound communicating with the fracture. .\ fracture is coniniinuted when the bone is broken into more than two pieces; complicated when there are also injuries to the adjoining vessels, nerves, or muscles; impacted when the broken ends are driven into each other so that they can not move ; green stick when the bone is bent and only partially broken as a green stick is broken (Fig. 58). Fractures are caused by direct violence, as when a wagon wheel passes over a limb and breaks it; indirect violence, as when a man falls on his hand and breaks his collar bone; muscular action, as when one breaks his arm throwing a ball. How will you know that a fracture has occured? First there is a loss of power in the part ; if the leg is broken the man has fallen and can not get up ; if it is the arm he can not use it. Then the limb is in an unnatural position : if you compare it with the uninjured limb you will see that there is a deformity between the joints, and that the injured limb is probably shorter. If you attempt to move the limb you find there is movement (108) Fig. 59. — • Union of a Fracture. FRACTURES 100 bctii-een the joints where there should be none, and you can both feel and hear the broken ends of the bone grating together — crepitus. The patient complains of great pain and tenderness at the seat of fracture and there is svvelhng there due to bleeding from the broken ends. There is a history of violence and often the patient will say that he heard the bone crack and give way. In tlie treatment of fractures the great point is to keep them from becoming open ; a closed fracture is a very simple matter, not danger- ous to life, and usually healing promptly if kept quiet in proper po- FiG. 60. — -Use of Wire Gauze as a Splint. sition ; an open fracture is quite another matter, always taking a long time to heal and often threatening loss of limb and even life from infection. Therefore never attempt to move a inan with a fracture until the fracture has been fi.xed so that the broken ends of the bone can not move. If a physician can be obtained at once merely make the patient comfortable with pillows and supports where he lies; if he nuist be moved apply splints, handling the broken bones very care- fully so that sharp ends may not come through the skin and make the fracture compound. If a physician can not be reached for a day or two set the fracture and then splint it. no FIRST AID The cause of deformity in fractures is muscular contraction, and this contraction must be»overcome in setting the fracture, wliich is merely getting the broken ends into proper position , this is done by extension and counter-extension; extension is pulling the far end of the limb, and counter-extension is merely holding the end next the trunk ; pull until the deformity and shortening disappear and the Fig. 6:. — Splints of Telegraph Wire. two limbs look alike, then hold them so while the splints are applied. When a fracture is properly set the blood which escaped into the tissues about the break is gradually absorbed and at the end of a week or ten days callus is thrown out or the limb begins to k)iit ; callus is a soft, cement-like substance which is poured out between the broken ends around them, and in the medullary cavity ; the callus gradually hardens intc bone. That which is around the break form- ing a sort of ferrule or splice, and that in the medulla forming a pin, are absorbed after many months ; but that between the bones remains FRACTURES HI permanently, knitting the bone together (Fig. 59). Sometimes the callus is not sufficient in quanity or quality and union fails to take place. When a fracture is already open or compound the object of treat- ment is to convert it into a simple fracture, or at least to prevent in- fection. The wound is first dressed and then the fracture is treated. A splint is merely a splice to hold the bones in proper position until nature unites them. Splints must be light but sufficiently rigid to prevent bending; long enough to fix the joints above and below the fracture ; broad enough to prevent pinching of the limb in band- aging; sufficiently padded to protect the part from undue pressure. Fig. 62 Fig. 63. There are many splint materials supplied, among the more com- mon being thin boards, cardboard, felt, leather, wire gauze (Fig. 60), etc. Often in the military service splints must be extemporized : one of the most useful and most accessible materials for preparing them is telegraph wire; the method of using it is illustrated in the figures (Fig. 61 ) . On the battlefield the various weapons may be employed : rifles, bayonets, swords, scabbards (Fig. 62), and tent pins; splints may also be prepared from blankets and straw, from hay. small 112 FIRST AID sticks, the bark of trees, barrel staves, broom handles, canes and umbrellas. Padding may be made of clothing, hay, straw, grass, leaves, excel- sior, cotton, crumpled paper, etc. The best things to hold splints in place are straps which can be readily buckled and unbuckled ; the next best is the loop bandage applied as shown in Fig. 64; roller bandages, triangular bandages, tape, and many other things may be used. Before the splints are applied permanently the limb is usually bandaged from the extremity up to the fracture in order to prevent swelling below ; after tlie ap- Fic.54.- — Loop Bandage to Retain Splints. plication of the splints another bandage is applied over all. Be careful not to make the dressing too tight, and always leave the tips of the fingers exposed so that the circulation may be watched. If the tips of the fingers are blue and cold, or if upon pressing the blood out from under the nails it does not quickly return the dressing is too tight. After splinting the upper limb it must be placed in a sling; if there are no materials available to form one. the coat sleeve may be FRACTURES 113 simply pinned to the coat, or the flap of the blouse may be turned up and pinned, ripping the seam if necessary (Figs. 65 and 66). Fractures of the skull and spinal column are chiefly of importance on account of the coincident injury to the important parts of the ner- vous system which lie immediately beneath the bone. In fractures of the skull, unless compound or depressed, all the usual symptoms of fracture are absent, or entirely overshadowed by the injury to the cua Fig. 6,. Fig. 66. bram. The most prominent brain symptoms are loss of conscious- ness and paralysis ; if the loss of consciousness is sudden it is probably due to the pressure of a piece of bone ; if it comes on slowly it is apt to be the result of hemorrhage from a torn vessel. In frac- tures of the base of the skull there may be bleeding from the nose or ears, or into the orbits and under the conjunctiva ; the escape of 8 114 FIRST AID Fig. 67. — Four-tail Bandage for Fracture of Taw. cerebro-spinal fluid — a dear, watery serum — from the ears is con- sidered a sure sign of fracture of the base Treatment: Keep the patient quiet in a recumbent position and apply an ice bag to the head : if the fracture is compound a dressing will be required. In fractures of the spinal column the spinal cord is generally in- jured or cut across, with resulting paralysis of all parts below the fracture. On ex- amination, irregularity of tlie spinous pro- cesses will be noted, usually with angular deformity. Handle the patient with great care so as not to produce or increase injury to the spinal cord. Before moving him apply splints on both sides, from his arm- pits to his feet, so as to make the body as rigid as possible, then work a blanket under him, and, drawing it as tight as possible, lift him on a litter. Fractures of the ribs and pelvis are also chiefly important on account of the injury to the contained viscera. In fracture of the ribs the sharp end of the bone is apt to stick into the lung every time the patient breathes ; hence in these cases the patient will often complain of a sharp sticking pain when he breathes. and there may be cough, with spitting of frothy blood. When the fingers are passed firmly along the ribs they may be felt to give at the broken point, which is also very tender. The treatment consists in confining the movements of that side of the cliest as mucli as possible, in order to give the broken bone an opportunity to rest and knit. This is done by circular bandaging of the whole chest or by strapping one side. The pelvis is so strong that the bones are broken only by the most severe direct violence, as when a heavy wagon passes over it. The symptoms are inability to stand or sit up, and crepitus may be felt when firm |)ressure is made. If there is an injury to the bladder the Fig. 6S. FRACTURES ii: urine contains blood. The treatment consists in the application of splints on both sides from the axillai to the feet; if the bladder is injured a catheter must be introduced and left in, so that the urine will not accumulate and escape into the peritoneal cavity. In fracture of the nasal hones there is usually considerable deform- ity, the bridge of the nose ,being caved in and pushed to one side ; crepitus is generally to be felt, and there is considerable nose-bleed. Check the bleeding by syringing with hot or cold water ; push the bones into place by means of a probe or slender, smooth stick in the nostril, aided by the fingers outside. Apply cold dressings over the bridge of the nose and warn the patient not to attempt to blow the nose. In fracture of the lo:cer /arc the line of teeth is irregular and there may be bleeding from the mouth ; the patient can not open his mouth, and the fracture can usually be readily felt. ^''- ^^' Push the bones into place and apply a four-tailed bandage (Fig. f'v ) or two narrow cravats. The patient can not chew and will have to live for a time on liquid foods taken through a tube. In fracture of the claz'icle the attitude of the patient is often char- acteristic ; the shoulder drops downward, inward and forward, and he attempts to support it by holding the elbow of the injured side in the hand of the sound side. The collar bone lying immediateh' under the skin, the fracture is easily made out. .\s a first-aid dressing, put the arm in a large sling, place a pad in the a.xilla, and bind the arm to the side. The fracture is put up permanently in a Sayre's dressing or a J'clpcau bandage. Fracture of the JuDiienis or arm hone has all the common signs of fracture and may ordinarily be recognized without diffi- culty. Two splints are required ; they should be placed on the inner and outer sides, except in fracture near the lower end of the bone, when the splints should be front and rear (Fig. 68). Fig. 70. — Colles' Fracture 116 FIRST AID If tlie fracture is near tlie shoulder joiut a shoulder caj) must also be used, and if near the elbow joint the inner s])lint should be rectan- gular and include the forearm. The wrist should be sui)ported in a sling, leaving the elbow hanging down so as to produce extension. If no splints are availal)le the arm -hould be at least bandaged to the side of placed in a sling. When both bones of the forearm are broken all the usual signs of fracture are jiresent. Place a splint on each side, from the elbow to the root of the fingers, and put the arm in a sling (Fig. 69). As a general rule, in all fractures of the upper extremity flex the elbow to a right angle, and place the forearm in such a position that the thumb will point up. The reason of this is, that should the elbow become stiff, the arm is more useful in that position than any other; the thumb should point up, that is, the forearm be midway between pronation and supination, for in that position there is the widest possible space between the radius and ulna, and therefore they are less apt to become fused together by the callus which is thrown out in the process of union. Fracture of the radius alone, just above the wrist, is very common and is known as Colles' fracture. It is attended by a peculiar silver- FlG. 71. fork deformity (Fig. 70), and as the bones are usually impacted, crepitus is absent. The setting of this fracture can only be j^roperly done by a surgeon ; meantime the arm should be placed in a sling. Fracture of the metacarpals — a broken hand — usually occurs in a fight. The most prominent signs are deformity and pain. Splints .should be applied on the back and front of the hand, reaching from the finger tips half-way up the forearm. Fractures of the fingers arc treated by the application of narrow finger splints, usually on the palmar surface only. In fractures of the femur all the common symptoms of fractures i-RACTURES 117 are usually present; the foot may be everted, lying on its outer side, and the leg is shorter than the other. Two si)lints must be applied; the one on the outside reaches from the armpit to beyond the foot ; the one on the inside from the crotch to the foot (Fig. 71). The splints should be tied on in five places: around the ankles, over the knees, just below the hips, around the pelvis, and just below the axilla. It is well also to tie the two limbs together. Fig. 72. — Dressing for Broken Knee-Cap. So powerful are the muscles of the thigh, constantly tending to make the bones overlap, that in the permanent treatment in hospitals it is customary to provide special arrangements for overcoming the muscular action-. These arrangements comprise what is called extension. A weight is attached to the foot by adhesive-plaster straps, and a cord run- ning over a pulley, and counter-extension is provided by raising the foot of the bed. thus utilizing the weight of the body. Fractures of the lower extremity are always put up with the entire Fig. 73. limb straight, so that if the joints get stiff the limb can be at least utilized for standing and walking. In fractures of the patcUo or knee-cap the patient can not stand or walk: the upper fragment is drawn up the thigh by the powerful muscles attached to it. and the gaj) can be readily felt. The joint swells up at once. A splint should be applied to the back of the knee 118^ FIRST AID so as to keep the liinb extended, and the upper fraijment should be brought down by figure-of-eight bandaging (Fig. "Ji). If bolh bones of the leg arc broken the fracture is very apt to be compound because fracture of the tibia is usually oblique with a sharp point that may come through the skin ; such a fracture should be handled with the greatest care. Apply splints from the knee to beyond the foot on the inside, outside, and behind (Fig. 73). Tie the feet together. Fracture of the fibula alone just above the ankle is called Pott's fracture , the signs are usually indistinct, but if the lower end of the tibia is fractured as well there is apt to be marked eversion of the foot. Treat in the same manner as a fracture of both bones, except that the posterior splint is not necessary. Fractures of the bones of the foot are best treated by a plaster-of- Paris dressing. CHAPTER V rOKEIGN DODIES In the eye: Foreign bodies such a> particles of dust, cinders, etc., may lodge under the lids, upon the conjunctiva, or upon the cornea. In the latter situation they are seen and removed with the greatest difficulty, and the removal should not ordinarily be attempted by other than a physician. To remove a foreign body from the eye the best impro\ised appliance and one that is nearly always at hand is a match. Light the match and after it has burned a moment blow it out; then with a clean handkerchief and a circular movement of the fingers wipe otT the charred end, leaving a soft, aseptic, splinterless point with which to remove the foreign body. Fig. 74. — Evcrsion of the Upper Eyelid. To examine the lower lid draw it down with the fingers, at the same time telling the patient to look up; if the foreign body is not found there, evert the upper lid (Fig. 74) by standing behind the patient with his head upon your chest and telling him to look down at his feet ; at the same time press a match or the end of the finger firmly against the outside of the lid about a quarter of an inch behind its margin, draw the lid down by the lashes and turn it upward and outward o\er the match or finger tip. If the particle is still not visible search the l^all of the eye carefully for it. and when it is found lift it oil gently by a cjuick movement with the point of the match. If the eye is very irritable it may be necessary to drop in a little cocaine solution. It is important to remember that even after a foreign body is re- (119) 120 1-lKS'l" All) moved from the eye, there is often for some time a sensation as if it were still there. /// the car: The foreign body here may be an insect, a pea, or grain of wheat, a pebble, a plug of hardened wax. etc. An insect in the ear by its movements and ])uzzing often causes the most intense annoy- ance. Hold the head over on one side with the ear containing the insect uppermost; fill the ear with warm water; this will drown the insect in a few minutes, and then by suddenly turning the head to the other side it may come out with the water; the maneuver should be re- peated several times; if the insect does not come away syringe the ear. If the foreign Ijody is vegetable; such as a pea. water should not be used as it may cause the pea to swell and thereby render its extrac- tion more difificut. If the pea is visible bend the loop end of a fine- hairpin, and try to get beyond it so as to hook it out. As there is always danger of injuring the drum when instruments are pressed into the ear, it sht uld be a guiding rule that no instrument should be passed beyond the point v here its tip can be seen. Hardened wax must be removed l)y syringing with a warm five- per cent solution of soda. Ill the nose: Children push peas and such things into the nose, and occasionally flies deposit their eggs there with the result that maggots develop in the nasal cavity. Foreign bodies are best removed by closing the free nostril w ith the finger and forcibly blowing through the obstructed side ; snuffing up a little powdered tobacco or pepjier will cause sneezing and aid in the expulsion ; if this does not succeed and the body can he seen it may be hooked out with the bent hairpin in the same manner as described for the ear; or finally a small, smooth stick or a slender pencil may be wrapped with a little cotton and used to push the foreign body gently back through the posterior nares into the mouth ; press straight backward, never upward. Maggots in the nose is a very serious condition which may result in death. Let the patient inhale through the nose a half-teaspoonful of chloroform, and while the maggots are stupefied syringe them out with warm normal saline solution. Foreign bodies in the tJiroot are usually bones or masses of food. If the bone can be seen and reached it may be removed by fingers or forceps; if not it may be carried down by eating dry bread. If the FOREIGN BODIES 121 obstruction is a mass of food it may be dislodged by forcible blows on the back between the shoulders, or the fingers may Ije i)assed into the throat to hook it out or to cause its ejection by vomiting. Foreign bodies in the air passages cause violent cough and difficult breathing; the case is urgent, and if a child he may be held up by his heels and shaken; if an adult inversion may also be attempted and blows between the shoulders given as in the case of foreign body in the throat. Foreign bodies are sometimes swallowed and reach the stomach and intestines. Such cases are not usually serious. If the body is angular or pointed such as a tack or a pin, feed the patient on sub- stances which leave considerable residue to cover and protect the sharp points; — potatoes, bananas, bread, etc. Do not give laxatives as they will render the movements liquid and thus leave sharp points exposed. //; the skin: Here we find splinters, thorns, needles, pins, fish- hooks, pieces of glass, gunpowder, etc. For splinters and thorns pass the point of the blade of a pocket-knife imder them, with the thumb- nail press the splinter against the blade and draw it out ; or use a pointed dissecting or dressing forceps. If the splinter is buried open up the skin a little with the point of a knife or a needle until it can be reached. If under a nail make a notch in the nail so as to expose it. If a needle or pin is broken ofif in the skin and can not be grasped with forceps, cut a small hole in the end of a cork and press it down over the point of entrance of the needle ; this may cause the needle to emerge so far that it can be grasped. The needle may he so situated that it is best to push it through and extract it on the other side. If the needle or pin is in the foot or hand and can not be extracted, the patient should be directed not to use the part, as muscular action will cause it to work in deeper. A fishhook or an arrow can not be drawn out on account of the barbs ; they must be pushed through, (lunpowder is best removed by a thorough scrubbing with soft soap and a stifif brush, the remaining grains being picked out with a needle. CHAPTER VI THE EFFECTS OF HEAT AND THE EFFECTS OF COLD The effects of heat may be general or local. The general effects of heat are manifested in two entirely ditterent ways, viz. : heat stroke and heat exhaustion. Heat stroke, sunstroke, or insolation is due to prolonged exposure to excessive heat, usually the heat of the sun. But heat stroke may occur in hot rooms, and in the stoking-rooms of steamships. Ex- haustion and improper clothing are powerful contributing factors, hence it is especially apt to occur to soldiers on the march. The premonitory symptoms are headache, dizziness, irritability, frequent desire to urinate, seeing things red or purplish ; with or without these symptoms the patient suddenly falls unconscious ; the skin is dry and intensely hot; pupils contracted; pulse full and strong; respirations snoring; there maybe convulsions; if the tem- perature of the body can be taken it will usually be found to be very high, 105° F. to 109° F. or higher. The condition is a very serious one and unless immediately re- lieved terminates in death. The treatment has for its object rapid reduction of the tempera- ture. The man should be brought to the coolest accessible spot, in the shade if out of doors, on deck if in the fire room of a steamer, his clothing removed and an ice bag applied to his head and cold water poured over him continually. At the same time the ])ody may be rubbed with ice, and if a tub is availa])le he may be immersed in cold water. The treatment should continue until the temjierature is re- duced. If the patient is able to swallow he should be given cold, not iced, water to drink, and this should be repeated as often as possible. Serious results are liable to follow a sunstroke, even when death dees not occur; the most common of these after-effects are perma- nent headache, paralysis, mental confusion, or even insanity. More- over, one who has had a sunstroke is ever after very susceptible to the action of the sun. (122) EFFECTS OF HEAT AND EFFECTS OF COLD 123 Heat exhaustion is a very much less severe condition, closely allied to fainting. It occurs among soldiers on the march and very frequently among soldiers standing for some time at attention on a hot day. The soldier suddenly drops his piece and falls ; he is not unconscious or may be easily aroused ; face is pale, skin cool and moist, pupils dilated or normal, pulse very weak ; respiration shallow,, perhaps sighing. Such a patient should be moved into the shade, his clothing loosened, equipments removed, head kept low, and a drink of water or some stimulant given. On removal to the hospital he should be kept perfectly quiet in l)ed and hot-water bags used if necessary. The local application of heat produces burns or scalds. Burns are produced by a flame, hot solids, or caustics. Scalds are produced by hot liquids, they differ only in that in the former the hairs are destroyed, in the latter they are not; the treatment is the same. Burns are usually said to be of the first, second, or third degree. Burns which merely cause redness are of the first degree ; if blisters are raised they are of the second degree ; and if there are charring and destruction of tissue the burn is of the third degree. The symptoms of burn are shock which may be profound, chilly sensations, and pain. The pain may be agonizing or slight. The result of the burn depend: more upon the extent of surface affected than upon its depth , a burn of the first degree is almost cer- tainly fatal if two-thirds of the surface of the body is affected, and one of the second degree if one-third of the body is burned; the chances for recovery are much less in children and elderly people. The danger in the first twenty-four hours is from shock ; after that from internal congestions and inflammations, suppression of urine, idceration of the duodenum, and intestinal hemorrhage; and finally from exhaustion, Ijlood poisoning, or tetanus. If the entire thickness of the skin is destroyed terril)le deformities are apt to follow the contraction of the skin which occurs in healing. In burns of the first degree, of which sunburn is a type, soft cloths dipped in a saturated solution of cooking soda should be applied, and this followed by any fresh oil or fat ; cream or olive oil answers excellently well. In burns of the second and third degrees the objects of treatment are first protection from the air which greatly aggravates the pain 124 FIRST AID and shock; secondly relief of shock, and third prevention of infec- tion. The quickest temi)orary means of excluding air is to immerse the part or the entire body in warm water ; then having gotten every- thing ready carefully cut away the clothing, leaving such as is stick- ing to the burned skin ; blisters should be left undisturbed unless they are very tense and painful, when they may be punctured by a sterilized needle and the contents allowed to escape. The wound should next be dressed with sterile gauze di[)i)ed in a warm solution of Ijoric acid, or a solution of picric acid ten parts in eighty parts of alcohol and a thousand parts of water ; the picric acid 'relieves the pain and has value as an antiseptic ; over the gauze place a thick layer of sterile absorbent cotton. When the burns are ex- tensive small portions only should be exposed and dressed at a time. When the first dressing is finished it should be left on as long as possible. Meantime stimulants and hot drinks should be given internally and morphine and strychnine injected hypodermically if necessary. When there has been skin destruction the parts should be re- tained in proper position by splints when healing is taking place. In burns from carrosive acids, such as sul^^huric and nitric acids, the parts should be thoroughly flushed with water and a solution of soda, after which the treatment is the same as for other burns. In burns from caustic alkalies, such as lye, vinegar diluted with water should be used to neutralize the alkali before applying the usual treatment for ordinary burns. When the clothing of a pers( n, usually a woman, is on fire she should be envelopec] in a blanket, rug, cape, or woolen coat and thrown upon the ground while the flames are smothered ; the reason she should be thrown upon the ground is to prevent her from running about and thus fanning the flames, and also because flames rise, and in the erect position would reach the month and throat. The effects of cold, like those of heat, may be general or local. In general freezing there is at first a very unpleasant sensation of cold with pain in the extremities, then numbness and stift"ness. and finally great drowsiness with an irresistible desire to lie down and sleep, which if yielded to is soon followed l)y death. When one is found in such a condition, life not yet being extinct, he should be taken into a cold room, all clothing removed, and the EFFECTS OF HEAT AND EFFECTS OF COLD 125 body rubbed briskly with sheets or towels wet with cold water. As soon as the stiffness is removed artificial respiration should be per- formed; and when the patient is able to swallow, warm drinks should be given. When there are signs of returning consciousness and circulation the body may be enveloped in a blanket and the temperature of the room gradually raised. The reason a frozen person must not be brought into a warm room is that the sudden restoration of the circulation gives rise to violent congestions and ofter to sudden death from the formation of clots in the blood-vessels. Local freezing is of two degrees, frost-bite and chilblain. Frost-bite is usually of the extremities, fingers, toes, nose, or ears, but a whole limb may be frozen. The part is at first red and painful, then livid, and finally white, hard, and painless ; the sudden cessation of pain in the freezing part is always a bad sign. The danger of frost-bite is that sudden thawing may cause such severe congestion as to result in gangrene. Therefore the patient should not go into a warm room or near a fire. Rub the part vigorously with wet snow or ice water, never with dry snow as the temperature of dry snow may be much below freezing, and rubbing with it would aggravate the condition. When the pain and redness return apply cold dressings. Cliilblain is a condition of acute or chronic congestion occurring especially in the feet, and due to bringing cold feet near the fire too suddenly, or merely following exposure to cold in persons with poor circulation. On the part affected are red spots, more or less swollen, which burn and itch intensely. The treatment consists in stimulating applications, such as liniments and tincture of iodine. Susceptible persons should wear woolen socks. , CHAPTER VIl INSENSIBILITY AND FITS Among conditions causing insensibility are fainting, shock, con- cussion and compression of the brain, apoplexy, Hghtning stroke, electric shock, heat stroke, freezing, epilepsy, Bright's disease, alco- holism, narcotic poisoning, and asphyxia or suffocation. Fainting is a condition due to too little blood in the brain, and is caused by mental impressions, exhaustion, heat, bleeding, over- crowded rooms, etc. The symptoms are sudden unconsciousness. pale face, cool, moist skin, weak pulse, shallow breathing, and dilated pupils. Treatment: Get more blood to the brain by laying the patient flat on his back with the head low and the legs raised ; sprinkle cc-ld water in his face and apply ammonia or smelling salts to the nostrils to make him breathe, get him out of a crowd into the fresh air, loosen the clothing about his neck and waist. If he is sitting in a chair and about to faint the attack can often be prevented by thrusting the head down between his own knees and holding it there until the face becomes flushed. Shock is a condition similar to fainting but due to physical injury. It has been fully dealt with on page 90. Concussion of the brain is the condition present when we say a man has been "knocked senseless" or "stunned." I't is a jarring and shaking of the brain due to blows or falls upon the head or falls upon the feet ; the brain almost stops working for a while. The symptoms are unconsciousness, pallor of the face, breathing so quiet and shallow that it can hardly be detected, pulse fluttering, pupils equal and usually contracted. The degree of insensibility varies ; sometimes the patient can be aroused but is irrital)le and lapses again into unconsciousness which may last minutes or hours. Vomiting and turning on the side are favorable symptoms. Treatment: Perfect rest in a dark, quiet room; warmth externally (I2r,) INSEXSliJlLITV AXU FITS 127 if the surface is cold; aromatic spirits of ammonia internally or by inhalation if there is much depression. Compression of the brain is as its name implies a pressure on the brain. This pressure is due usually to either a piece of bone or to blood from a torn vessel which has escaped inside the cranuim and as it can not get out must compress the brain, and this compression prevents certain parts of the brain from working. When the bleed- ing is the result of injury the condition is called simply compression of the brain ; when it is the result of the bursting of a diseased vessel without any violence it is called apoplexy; the result and the symp- toms are just the same. The symptoms of compression are profound unconsciousness; loud, snoring breathing; slow pulse; pupils usually unequal and not reacting to light, and paralysis on one side of the body. If the compression is due to a piece of broken bone the symptoms come on immediately after the injury, while if it is due to bleeding they may come on later and gradually. Treatnic}it: If the compression is due to a piece of depressed bone the bone must be raised. If due to bleeding, the bleeding must be stopped ; surgical relief can only be given by a surgeon, but meantime keep the patient quiet with his head slightly raised; apply an ice bag to the head, give him a hot mustard foot bath, and put a few drops of croton oil in a teaspoon ful of sweet oil on his tongue, so as to send the blood from his brain to the feet and intestinal tract. Lightning stroke may cause sudden death, insensibility, or severe burns. If the patient is unconscious but living, effort should be made to keep him alive; perform artificial respiration if the breathing fails; give stimulants if the heart is weak, and apply heat externally if the surface is cold. Burns must be treated like other burns. Electric shock is caused by coming in contact with a " live wire " ; spasmodic contraction of the muscles occurs so that the person can not let go. The condition and results are exactly like lightning stroke. The first thing to be done is to rescue the patient by setting him free from the wire, and this must be done with great care, as to touch him with the bare hands will cause the rescuer to get the same shock. Immediately break the circuit. With a single quick motion, free the victim from the current. Use any dry nonconductor (clothing, rope, board) to move either the victim or the wire. Beware of using 1J8 FIRST AID metal or any moist material. While freeing the victim from the live conductor have every effort also made to shut off the current quickly. The treatment of the shock is the same as in the case of lightning shock. The forms of unconsciousness due to heat stroke and to freezing have already been described. Unconsciousness from acute alcoholism is the condition known as "dead drunk." The patient is insensible, though he can usually be partially aroused, the face is flushed and bloated, eyes Ijloodshot, pupils usually dilated, skin cold and clammy, temperature sul)normal, respiration snoring, pulse rapid and weak ; there is no paralysis. Treatment: The case is one of acute poisoning by alcohol. The first thing to be done is to empty the stomach, by tickling the throat or by giving an emetic of mustard or salt and warm water. Then sprinkle cold water freely upon the face, but apply heat to the body ; a cup of hot coffee may help to clear the brain after the stomach is emptied. Usually an undisturbed sleep is necessary. It must not be forgotten that alcoholism and apoplexy are fre- quently confounded, the more so as a man who has been drinking and has the odor of liquor upon his breath may be stricken with apoplexy. In apoplexy there are paralysis, unequal or contracted pupils. some fever, slow pulse; in alcoholism no paralysis, equally dilated pupils, rapid pulse, subnormal temperature. In epilepsy there may be fits with insensibility, or a mere momen- tary unconsciousness with slight muscular twitching, Ijut in which the patient does not fall. In the severe form, with or without some premonitory sign, the subject suddenly cries out in a peculiar manner and falls in a fit ; at first the entire body is rigid, then there are general convulsions with jerking of the limbs, contortions of the face, and foaming at the mouth; after a few minutes the convulsions are followed by pro- found stupor, and this generally passes off in deep sleep. During the attack the eyeballs may be touched without the patient flinching, the pupils are dilated, he often l)ites his tongue, and there may be involuntary evacuations of the bowels and bladder. Ej)ileptic stupor may be distinguislied from other forms of un- consciousness by the history of the fit, and of other fits, by the foam IXSEXSililLlTY AND FITS 129 at the mouth and the bitten tongue, and by the absence of any paralysis. Treatment: You can do nothing to stop the fit or to control it; all that can be accomplished is to prevent the patient from hurting him- self and to make him as comfortable as possible; do not attempt to hold him, l^ut twist a handkerchief and passing it between the jaws tie it at the back of the neck to keep him from biting his tongue until after the tit is over; after which let him sleep as long as he wishes. Epileptic fits are frequently feigned by soldiers in order to secure their discharges. The feigned attacks usually occur at night when no one can see them ; the man does not fall so as to hurt himself, does not bite his tongue, flinches when the eyeball is touched ; the pupils are not dilated; the patient can be aroused; when there is foaming at the mouth a piece of soap will often be found inside. A pail of cold water suddenly thrown upon the man's head and shoulders usually makes the diagnosis ; it promptly revives the ma- lingerer, but has little or no efifect upon the epileptic. 1 he insensibility of Bright's disease is really an acute poisoning from the retention of the waste products which the diseased kidneys are not able to carry of¥. The unconsciousness is often attended with delirium and convulsions. The pupils are contracted, the pulse slow, and the breathing loud and snoring. The distinguishing characteristics are the history of Bright's dis- ease, the waxy color of the skin, sometimes dropsy, the equally con- tracted pupils, the absence of paralysis. Emergency treatment: Cold cloths to the head and a hot mustard poultice to the back over the kidneys. In of'iuni poisoning the patient may be very sleepy or deeply un- conscious, the pupils are minutely contracted, the respiration very slow, as low as eight or ten to the minute, and snoring, and the pulse rapid and weak. If the opium has been swallowed, empty the stom- ach by an emetic, and then give a half gramme of permanganate of potash dissolved in half a pint of water to destroy what opium is left. Next keep the patient awake by giving him strong, black cofifee, pinching him, talking to him, and walking him up and down if pos- sible, but not to the point of exhaustion. Asphyxia or suffocation is another cause of unconsciousness, to which it is necessary to devote a special chapter. CHAPTER V ASPHYXIA Asphyxia or suffocation is that form of unconsciousness due to the cutting ott of the supply of oxygen to the lungs. This may occur in several ways. The air may be so full of some other gas that the proper amount of oxygen cannot reach the lungs ; this is what happens in cases of poisoning from illuminating gas, the gases in mines, etc. When a person is buried up to his neck in a slide of earth or snow he may be asphyxiated as a result of the inability to expand his chest, even though the mouth and nose be free. The air may be cut oft' at the mouth as when one is smothered by a pillow ; in the throat by the lodgment of food in the larynx, or its obstruction with the mem- brane of diphtheria. Tlie supply of air may be shut oft' by the pres- sure of a rope or fingers when one is hanged or strangled. In drowning, water gets into the air passages and mechanically shuts oft' the ain Finally when anesthetics, such as ether or chloroform, are given, asphyxia may result from an insufficient admixture of air. The treatment of asphyxia consists first in removing the cause, second iu restoring the breathing ])y artificial respiration. If the patient is overcome by gas remove him to the fresh air, if he is taking an anesthetic stop it, if he is buried in a snow-slide dig him out as quickly as possible, if there is a piece of meat in the throat put your finger in and hook it out or beat him between the shoulders and jar it out. If the larynx is obstructed by membrane it may be necessary to make an opening into the trachea (tracheotoni)) and put in a tube ; if the patient is hanging cut him down ; if he has been drowned get the water out of his air passages ; do these things first, then perform the artificial respiration. Artificial respiration seeks to imitate the natural breathing. There are several methods, the following recommended by the " Com- mittee on Resuscitation from Electric Shock," is probably the best, as it can be done with the least difficulty by one man. Proceeds as follows: (a) Lay the subject on his belly, with (130) ASPHYXIA 131 arms extended as straightforward as possible and with face to one side, so that nose and mouth are free for breathing. Let an assistant draw forward the subject's tongue Fig. 75. — .\rtificial Respiration. Inspiration; Pressure Off. (b) Kneel straddling the subject's thighs and facing his head; rest the palms of your hands on the loins (on the muscles of the Fig. -6. — Artihcial Kespiration. E.\piration: Pressure On. small of the Ijack ), willi lingers spread over the lowest ribs, as in Fig- 75- (c) With arms held straight, swing forward slowly so that the weight of your body is gradually, but not fiohntl\\ brought to bear 132 FIRST AID upon the subject (see Fig, 76). This act should take from two to three seconds. Jnimediately swing- backward so as to remove the pressure, thus returning to the position shown in Fig. 75. (d) Repeat dehberately twelve to fifteen times a minute the swinging forward and back — a complete respiration in four or five seconds. ve^iiiration. Mar-liall llalTs niL-thoil. Exijivation. (e) As soon as this artificial respiration has been started, and while it is being continued, an assistant should loosen any tight clothing about the subject's neck, chest or waist. Continue the artificial respiration (if necessary, at least an hour), zi'itJiout interruption, until natural breathing is restored, or until a physician arrives. If natural breathing stops after being restored, use artificial respiration again. Do not give any liquid by mouth until the subject is fully conscious. Give the subject fresh air, but keep him warm. Pause for a moment occasionally to see whether the patient makes any effort to breathe; if he does, time your movements so as to cor- ASPHYXIA 1 3: respond to the natural inspiratory and expiratory efforts. Usually the first signs of success are a change in the color of the face and faint sighing. Meanwhile efforts should be made to excite respiration in other ways; apply snuff, tobacco, pepper, or smelling salts to the nostrils, and strike the chest with towels dipped in hot and cold water alternately. Marshall Hall's method: In this method the patient is placed on the floor or ground with the face downward, his forehead resting on Fig. 7S. — .\ruriL'ial Respiration. Marsliall IIall"s method. Inspiration. one arm. and a roll of clothing supporting his chest. While in this position the weight of the body compresses the ribs and expels the air from the chest — an artificial expiration which is deepening by mak- ing pressure on the l<~>wcr ribs (Fig. yy). Then the operator, with one hand on the patient's free arm, near the shoulder, and the other placed under or in front of the corresponding hip bone, rolls the body from face downward to its ^ide and a little beyond (Fig. 78). An assistant aids in this movement l')y handling the head and under- lying arm. When the body has been thus rolled somewhat more than 134 FIRST AID half round, the chest becomes relieved from superincumbent weight, and a certain volume of air enters. After resting a second or two in this attitude of inspiration, tJTc patient is returned to the prone position, and pressure made along the ribs to imitate the expiratory act. Droivning: There are wide differences of opinion as to how long a man may remain under water after drowning and yet be resusci- tated. It is pre bable that fi\ e minutes is the limit, but inasmuch as no record is usually kept of the time and it may be actually much less than what it appears under the influence of excitement, it is well to make an effort at artificial respiration unless the time is actually known to have been greater than a quarter of an hour. Fig. 79. — Getting \Vater Out of the Lungs. To clear the lungs of water preliminary to artificial respiration turn the patient on his face with his forehead resting on his wrist and a roll of clothing under his chest ; then getting astride the body press on the back to force out the water; next drop your hands under his abdomen and lift up his body with the head hanging down so that the water will run out ( I'ig. 7<)). Besides artificial respiration it is necessary to restore the heat of ASPHYXIA 135 the body, which is rapidly lost by immersion in the water, and to stimulate the circulation. While efforts at artificial respiration are going on remove the wet clothing, wrap the body in dry, hot blankets, apply hot-water bottles to the feet, and rub the limbs actively toward the heart, stimulants should be given hypodermically, by the rectum, and by the mouth when the patient can swallow. When respiration is estal^lished put the patient in a hot bath until the body heat and circulation are restored. Even when artificial respiration is successful after drowning, congestion of the lungs, bronchitis, or pneumonia is apt to result from the cold and the irrita- tion of the lungs by the water which has gotten into them ; to prevent these complications large mustard plasters should be applied to the chest. CHAPTER IX POISONING Poisons may be divided into two classes, those 7vhicli are taken intcnially or liypodeniiically and those zchich are apl>lied to the skin. Of those taken internally the caustic acids and alkalies may also be applied to the skin ; in either case they produce burns. When swallowed the burns are upon the lips, in the mouth, throat, and stomach. The stains are seen upon the lips, and the symptoms are intense pain and agony, and vomiting of bloody matter mixed with mucus and shreds of membrane. The treatment consists in trying to neutralize the poison, protecting the burnt surfaces by administering soothing substances such as oils, milk, white of egg, Hour and water, etc., and relief of pain by opiates. The caustic alkalies, such as lye, are best neutralized by vinegar or lemon juice and water, and the caustic acids, such as sulphuric and nitric, by magnesia, cooking or washing soda, tooth powder, or soap suds. The remainder of the internal poisons may be divided in three general classes : 1. Those zchose principal effect is upon the gastric-i)itesfinal canal, causing violent irritation or inflammation ; such as arsenic, corrosive sublimate, nitrate of silver, oxalic acid, croton oil, and sugar of lead. 2. Those wJiich produce little or no local irritation, but haz'e a pozverful general effect, especially upon the nerzvus system ; such as opium, chloral, belladonna, prussic acid, and strychnine. 3. Those zchich are both local and general poisons: such as phenol, cantharides, phosphorus, and aconite. In the treatment of cases of poisoning our first object is to empty the stomach and prevent the absorption of any poison that may be left in it ; then to relieve pain and obviate the tendency to death. An emetic is ordinarily used to empty the stomach, and those which are most readily available are warm water, mustard, salt, and ipecac; give a tablespoonful of mustard or salt or a half-teaspoon ful of ipecac dissolved in a half-pint of tepid water; encourage vomiting (136) POISCJXIXG 137 by running- the fing-ers down the throat or tickhng it with a feather; the water >honlcl be tepid to produce nausea, and vomiting should be repeated until the water returns clear. If a stomach tube is available the stomach should be washed out. To prevent absorption we give an antidote, that is something that will de.-troy the poison or its effects, usually rendering it insoluble. Antidotes are. general and special. The general antidotes are given when we do not know the exact nature of the poison ; thus tan- nic acid and substances such as tea which contain it are antidotal to the poisonous alkaloids and therefore to most vegetable poisons, and albumin and substances such as white of e'^g, milk, etc., which con- tain it are antidotal to most mineral poisons. The special antidotes should be used when we know the exact nature of the poison ; hydrated magnesia or hydrated oxide of iron is the special antidote to arsenic, salt to the nitrate of silver, chalk or tooth powder to cjxalic acid, soluble sulphates such as Epsom or Glauber's salts to phenol and sugar of lead, sulphate of copper to phosphorus, and permanganate of potash to opium. The antidote is given at the same time as or immediately after the emetic. The relief of suft'ering calls for soothing, bland liquids, such as olive oil or milk when there is burning pain in the stomach and bowels, and also for morphine hypodermically. To obviate the tendency to death observe in what wa}- life is threat- ened and endeavor to counteract that effect. If there is shock and collapse, use stimulants, warmth, and rubbing: if the heart is failing as in poisoning by aconite, chloral, or prussic acid stimulate it by hot coffee, strychnine, digitalis, etc.; if there is failure of respiration as in phenol poisoning use coffee, cold douching, and artificial respira- tion ; if there are violent convulsions as in strychnine poisoning use bromides, chloral, or chloroform : if there is tendency to sleep keep the patient awake by the administration of coffee, slapping the face and chest with a wet towel, and walking him about. To sum up: // yoii do not knoiv zvhat the poison is, but there are signs of burning or caustic action about the moiitli and lips, do not give an emetic, give a tablespoonful of bland oil, such as olive oil or cotton.seed oil. or castor or cod-liver oil ; get the patient to bed. relieve his pain, put mustard plaster over the stomach, and try to keep him alive. You do not give an emetic in such cases because the burned 138 FIRST AID stomach might give way in vomiting, and the caustic would burn as much coming up as it did going down. If you do not know what the poison is, but the lips and mouth are not burned, give an emetic followed by two or three raw eggs, a glass of milk, or tlour and water, and then a>cup of strong, hot tea, after which relieve pain and obviate the tendency to death. When you do know the ])oison give the emetic, and the antidote; then relieve pain and keep the patient alive. Among the substances which most conmionly cause poisoning are phenol, opium, wood alcohol, foods, chloral, arsenic, corrosive sub- limate, nitrate of silver, phosphorus, and strychnine. Phenol is usually taken in concentrated form, and may produce death in an hour or two. The symptoms are white patches on the lips, burning pain in the stomach, intense depression, cold, clammy skin, weak pulse, failing respiration, stupor, and death. The anti- dotes are the soluble sulphates, and albumen but they cannot be depended upon. Give emetics, then wash out the stomach thoroughly with water containing about two ounces of Epsom or Glauber's salts, then give two raw eggs or a pint of milk. Perform artificial respira- tion and use stimulants, heat, and rubbing. When phenol is dropped on the skin, alcohol, if used promptly,, will completely prevent any burning. Opium. — The treatment of opium poisoning has been described on page 129. Wood alcohol or methyl aleohol is a very dangerous poison used as a fuel, and in the manufacture of toilet preparations such as bay rum. The symptoms of poisoning by it are severe pains in the head and abdomen, dizziness, vomiting, delirium, partial or complete blindness, dilated pupils, great depression of the heart and respiration, some- times albuminuria, stupor, and death. If the patient recovers he is often left blind. The treatment consists in use of emetics, or washing out the stomach, emptying the bowels by cathartics and enema, active stimu- lation by whisky and coflee internally and strychnine hypodermically, artificial respiration if necessary, and external warmth. Ptomaine poisoning is usually due to the use of foods which have undergone partial decomposition, though there may be no change in their taste or odor. The poisonous decomposition is especially apt to occur in hashes, milk, or foods containing milk which have been kept rolSOXlXG 139 over night in warm weather. Sausage, cheese, and shell-fish some- times undergo the same changes. Many cases of poisoning of this kind have occurred at military posts; sometimes whole companies have been poisoned at the same time. The symptoms are much like those of wood-alcohol poisoning, only vision is not usually affected and there may be some fever and some purging. In treatment the first thing to do is to empty the stomach and bowels of the poison by the use of emetics and active cathartics. Then relieve pain and give stimulants W'ith heat externally and mustard plasters over the abdomen. Chloral is the drug usually employed to make "knockout drops." It causes deep sleep followed by insensibility, with failure of the heart and sometimes the respiration. Empty the stomach and keep the patient awake by the same means as in opium poisoning, except that on account of his weak heart the patient must not be made to walk about as in opium poisoning, and for the same reason strychnine must be freely used h}-podermically. In arsenic poisoning there is great pain in the abdomen, with vomit- ing and purging, tenderness, straining and perhaps suppression of urine, severe depression and anxiety, weak, rapid i)ulse. and cold, clammy skin. Use emetics or the lavage tube, give a tablespoonful of freshly prepared hydratcd oxide of iron every ten minutes for five or six doses. The hydrated oxide is prepared by precipitating the tincture of the chloride of iron with aqua ammonia, and wash- ing the precipitate to remove the excess of ammonia. Then give morphine, stimulants, and soothing drinks, with external heat and friction. Corrosive sublimate may be swallowed by mistake in the form of an antiseptic solution. The symptoms are about the same as in arsenic poisoning and the treatment is much the same except that the antidote is albumen instead of hydrated oxide of iron, and that the antidotal efifect is only temporary so that emetics must be used after the antidote. Nitrate of silver may be swallowed accidentally as when a piece of lunar caustic breaks oft' and drops down the throat. Common table salt dissolved in li'ater should be given freely ; it is at once a special antidote and an emetic. Phosphorus is sometimes taken in the form of match-heads. It 140 FIRST AID is an irritant poison like arsenic and corrosive sublimate. Sulphate of copper is the antidote and also an emetic ; it should be given one- fifth of a gram every five or ten minutes with tepid water. Phosphorus is the one irritant mineral poison for which oils should not be given because its absorption is favored by them. Strychnine causes violent convulsions with intervals of rest ; there are also pains and cramps in the abdomen. Death is the result of asphyxia in the convulsions or exhaustion following them. Use emetics or the lavage tube, bromides and chloral, chloroform. Substances zvliich produce poisoning zvhen applied to the skin are chiefly plants of the rhus family such as " poison oak," " poison ivy," and " poison sumac." Other plants such as the common garden parsnip produce poisoning occasionally. Some persons are not susceptible while other persons are so much so that they appear to be poisoned even without actual contact. " Poison oak '' is a stubby plant with three leaflets notched on the edge and downy on the under surface ; " poison ivy " climbs on rocks and trees ; it is distinguished from " \'irginia creeper," which it resembles, by having three leaflets instead of five and by having a hairy trunk and little clusters of white berries ; " poison sumac " is distinguished from the harmless variety by having white berries instead of red. The symptoms of rhus poisoning are an inflamma- tion of the skin closely resembling erysipelas, redness, swelling, burning and itching, sometimes vesicles ; it is especially apt to occur on exposed parts such as the face and hands. The treatment consists in dissolving off any remaining poison with alcohol and then applying alkaline lotions, such as a saturated solu- tion of bicarbonate of soda. PART IV NURSING Nursing in post and field hospitals is ordinarily done by mem- bers of the hospital corps. In general hospitals, base hospitals, and other fixed hospitals of active service it is done by the nurse corps (female) and the hospital corps. The conditions most essential to the recovery of the sick are rest, absolute cleanliness, and an abundance of fresh air, and these the nurse should always seek to secure. Not all hospital corps men are fit to become nurses, but all must receive training in this subject in order to show whether or not they possess the aptitude. Study and experience are both necessary and the two must go together. CHAPTER I TIIK WARD The wards of all post hospitals are arranged on the same general plan. The number of beds in each ward varies from twelve to eighteen and usually there is connected with each a toilet-room with baths, basins and water-closets, and a wardmaster's room. Near the ward is a room or cabinet for patients' eft'ects. and a linen closet sufficient to contain enough linen for current ward use. The beds are arranged in pairs between adjacent windows, with a space of three feet between the beds and three and a half feet between each pair of beds. About loo feet of floor space and 1,200 cubic feet of air space are allowed to each bed ; in the tropics this should be increased to about 150 square feet floor space and 3.000 cubic feet of air space ; in wards for infectious diseases the floor space should be the same as that allowed for the tropics. (141) 142 XL'RSIXG Between each pair of beds is a chair, and adjoining each bed a glass and iron bedside table ; this with a folding bed-screen con- stitutes the official furniture of the ward which is purposely made as free as possible from appliances which are not only useless but collecting places for dirt and disease germs. Usually, however, there is a table for the wardmaster or nurse, and an- other with a small cabinet to contain ward medicines. Field hospitals, which have an ordinary capacity of 216 beds, are for temporary use only, to supply shelter, food, and emergency treatment and arc, therefore, not supplied with cots or furniture; the patients are placed on straw, covered by blankets. The post hospital ward is heated by hot water or steam and ventilated by special openings for entrance and exit of air. These air shafts are calculated to introduce three thousand six hundred cubic feet of fresh air per hour per patient. The entering air is warmed by passing over hot-water coils beneath the floor, while foul air escapes through shafts artificially heated by hot-water pipes so as to produce an up Flc. So.— Win- dow \"entilation ; board below low- draught. er sash. \\'hen no special arrangements are made for ventila- tion the natural openings of the ward, such as doors and windows, are u>ed for the purpose. The object must be to introduce as much fresh air as possible without reducing the tem- perature of the ward below the normal standard of 68° to 70° F., and without causing unpleasant draughts. One of the simplest plans to secure ventilation when this is not specially provided for is to place a board under the raised lower sash, the air pass- ing in between the sashes (Fig. 80), or to pull down the upper sash and protect the opening by a sloping board (Fig. 81). In either case the cold entering air is directed upward. Occasionally it is necessary to flush out the ward by opening wide the doors and windows for a few minutes; in such cases the patients should be thoroughly wrapped up as if out of doors. Each ward is under the care of a noncommissioned officer or ^'~ Fig. 81. — Window ^'entilation; board above sash. THE WARD 143 private first class assigned as zvardmaster, who is responsible for the comfort, diet, and medication of the patients, the performance of their duty by the nurses, the preservation of the ward property, the regulation of the heat, lights, and ventilation, and the cleanliness of the bed linen and clothing, lavatories, baths, water closets, etc. One nurse is sufficient for a ward of twenty beds when the cases are not of an acute character, but two may be required under special conditions. The wardmaster or nurse accompanies the medical officer on his rounds, takes down his directions in the ward book, and sees that they are carried out. Each nurse has specified duties assigned to him, so that each may know exactly what is expected of him. He should from the first cultivate habits of observation, neatness, and system. Each time he passes about his ward he should observe the condition of his patients, the beds, chairs, tables, etc., and should at once correct anything that is out of order. There should be a place for everything and everything in its place. When anything has been used it should at once be cleaned and put l^ack where it belongs, so that when occasion for its use comes again no time may be lost in looking for it and cleaning it. When a medical officer unattended by a noncommissioned officer enters the ward the wardmaster should at once arise and call attention and at the same time approach the medical officer to render any assistance he may require; the same courtesy must be rendered the commanding officer of the post or other authorized inspector. When strangers enter the ward he should ascertain their business and show them proper courtesies ; they should not be allowed to wander through the ward by themselves. A wardmaster should never leave his ward without informing his senior nurse where he is going and for how long and placing the latter formally in charge. The tour of a nigJit nurse's duty usually extends from immediately after dinner until after breakfast the following morning. The day nurses serve the dinner to the patients and the night nurses the breakfa,^t ; each completes his own work and cleans up everything that has been used by him during his tour of service. The night nurse renders a written report of all that has happened during the night and turns over to the day nurse any instructions he may have received. 144 NURSING In each ward a book should be kept containing a complete inven- tory of all the ward furniture, bedding, and appliances ; when any of these articles become soiled, worn out, or l^rcjken they are ex- changed for clean or new ones, but the number of each should as far as possible be maintained unchanged. When a wardmaster is relieved in a ward he should turn over the articles to his successor and take his receipt in the book. Going on duty in the morning the nurse must begin at once to get things in order for the morning rounds, usually at nine o'clock. Chairs should be put in their places, bedside tables cleared of super- fluous articles, and beds made up. Bed patients should have their hands, faces, and teeth washed, and hair brushed. Convalescents who are able to do so may be required to assist in the ward work. The floors should be dusted with a floor brush covered with a cloth wrung out of five per cent phenol solution and quickly polished with the polishing brush, and if of tile scrubbed with soap and water as often as necessary, and the chairs, tables, beds, and windowsills freed from dust by a cloth dampened in the same solution. Hospital floors should be made as impervious as possible, so that they may not absorb germs and dirt. They ordinarily have a hard finish and are kept smooth and polished l)y using on them a solution of paraffin or paraffin and wax in turpentine, and frequent polishing with a weighted polishing brush covered with a piece of blanket. A commonly used preparation consists of six ounces of paraftin dissolved in a gallon of turpentine, with the addition of an ounce of soft soap just before using; this is applied with a mop, and when dry is rubbed in with the floor polisher. A floor so finished should not be scrubbed with water ; spots may be removed with turpentine. After the ward is made ready the lavatory should be attended to; all urinals, bed pans, and bottles should be thoroughly cleaned, shelves wiped oflf, closet-bowls and seats washed, and bath tul)s scrubbed. To clean brass, copper and nickel, a mixture of oxalic acid, alcohol and kerosene is very effective ; for enameled ware use soap and hot water, removing stains with chlorinated lime. For porcelain utensils never use sapolio. oxalic acid or strong alkalies ; they destroy the enamel ; warm water and soap, followed by kerosene, are best. THE WARD 145 In addition to this daily cleaning a more thorough preparation is made for Saturday inspection. The walls, window bortlers. and all projections and corners, should be brushed with a soft long-handled brush covered with a damp cloth. Windows and sills, tables, chairs, and unoccupied beds are washed, and cots and mattresses gone over for bed-bugs. To destroy bed-bugs a saturated solution of phenol, or kerosene oil is usually empk)yed, the solution or kerosene being freely applied in all cracks and cre\ices and along the seams uf mattresses. Hydrocyanic acid gas is very useful for the destruction of bed-bugs, flies, cockroaches, and other vermin which may infest hospitals. The gas is generated from cyanitle of potash by the addition of com- mercial sul])huric acid. An ounce each of cyanide of potash and sulphuric acid and two ounces of water are required for each hun- dred cubic feet of air space, and the apartment must be tightly closed for six to eight hours in the same manner as in fumigation with sulphur or pyrethrum. The objection of cyanide fumigation is the great danger to human life from breathing the fumes of the gas, which precludes its employment in any part of an occupied house, or in a house in a bleck separated from other houses by party walls only. Beds and mattresses, however, may be freed from insects by fumigating them in a tightly constructed chamber or box such as is used for disinfecting ol)jects with formaldehyde gas. The room having been made ready, the jiroper amount of sulphuric acid and water is placed in a porcelain basin or slop jar to whicii is quickly added a thin paper bag containing the corresponding quantity of cyanide of potash; the operator then ii)unc(iiatcly leaves the room and closes the door. After six to eight hcnirs the door is thrown open for the escape of the gas and the entrance of fresh air. and on no account must any one enter the room until the order of the gas has practically disappeared. It must never he forgotten that this gas is absolutely deadly to human life, and that even a momentary exposure to it may be fatal. Whenever a bed is vacated mattress and bedding should be thor- oughly aired and sunned, and disinfected if necessary. The same bed linen should never be used, without washing, for two consecutive patients. In addition to the daily and weekly cleaning there should be a 10 146 NTRSIXG thorough disinfection of the wards twice a year or whenever infected. To prevent the polkiticn of the ward air, all discharges, such as urine, feces, sputum, and vomited matter, soiled dressings and linen, and dirty vessels should be promptly removed. The vessel con- taining discharges should be covered at once, using a piece of rubber sheeting or a towel if the vessel has no cover, and should never be carried through the ward uncovered. Soiled dressings should be received in a covered [)ail or paper bag and promptly burned. Sputum cups in use should Ije frequently disinfected l)y l)oiling. and l)ed pans and urinals scalded with hot water after each use and always kept clean. CHAPTER 11 WARD M.WAGKMEXT A PATIENT may be able to walk to the hospital or he may be brought there in an ambulance or on a litter. In either case he should be examined at once by the senior noncommissioned officer present; if he has been seen already by a medical officer direction for his disposition should accompany him; if he has not been seen by a medical officer one should be notified promptly. Pending his arrival the noncommissioned officer should take the necessary steps, taking care that no contagious case goes into the general wards. Generally there is a standing rule in hospitals that all patients should be given a bath before being put to bed unless there are orders to the contrary or the patient's condition is such as to render a bath undesirable. After the bath the patient is given a suit of hospital clothing and put to bed. An inventory of his effects is made in duplicate and signed by the wardmaster, one copy in a book and the other on a name slip which is attached to the bundle.^ Take everv- thing out of the patient's pockets and place all valuables such as money, watches, jewelry, etc., in a separate package, on which should be written the name of the patient, number of the room and of the ward, the date, and a list of the effects ; the package should be at once sent to the office for safe keeping. The clothing is then in- spected and if it requires disinfection is at once sent to the disin- fecting chamber; otherwise the underclothing should go to the laundry and the remainder, tied securely in a bundle, to the locker corresponding to the patient's bed. \'aluables should be listed, placed in an envelope marked with the name, date, and contents, and at once turned over to the senior noncommissioned officer for deposit in the hospital safe. ^Meantime it is well to offer the patient a glass of water or milk to make him feel that he is being cared for. After the patient is comfortably in bed. his pulse, temperature, and respiration are taken and recorded ; the first urine passed is saved in a clean vessel for examination. 1 In the larger hospitals a property card is fillcii out by the wardmaster, and, together with one of duplicate tags, numbered serially, attached to the property; the other tag is given to the patient. (147) 148 XURSIXG Fig. 82.— Bed Tray. J'>cd patients should wear hos])ital clothing only : l)ut, on the other hand, patients allowed uj) should not be ])erniitted to wear hospital gowns or pajamas under their own clothes ; unless this point is looked to, hospital clothing- will often be missing. h'ood and medicines must l)e administered prumjitly and in a jiroper way. The nurses' hands must be kept clean and free from odors. Nothing is more dis- gusting to one who is already ill than to have food pre- sented from dirty hands. One of the most important duties about the hospital and perhaps the one most fre- quently neglected is the scr^'iiig of diets. The noncommissioned officer in charge of the mess is responsible under the senior noncommissioned officer and should be in the wards at meal times to see personally that the diets are promptly and properly served. Utensils should be clean, plates warmed, and no slopping over allowed. Food which is intended to be hot should reach the patient in that condition. Used utensils and unconsumed food should be promptly removed from the ward and all crumbs and debris cleaned up. Patients able to sit up in bed use the bed tray (Fig. 82), those unable to sit up must be fed by the nurse. To administer liquids the head and shoulders are raised and a feeding cup (Fig. 83) or an ordinary cup or tumbler is used. When the head should not be raised the liquid may be taken through a bent glass tube. When the sick man is uncon- scious, liquids must be given very slowly, taking care to avoid choking. Utensils used for patients with infectious diseases must be kept separate from others and separately washed. Especially is this im- portant in the case of syphilitics with mucous patches in the mouth, and in typhoid fever cases. Very ill patients on liquid diet should have their nourishment regu- FiG. 83. — Feeding Cup. WARD -MAXAUEAIEXT 149 larly at night as well as by day unless there are special orders that the patient shall not be awakened. Very often wakefulness is due to insufificient nourishment, and a glass of milk or a cup of beef tea will often secure several additional hours of sleep. Liquid diet includes only liquids, the most useful of which are milk, meat extracts, broths, gruels, albumen solutions, and, last, but not least, water. Milk by reason of containing a proper proportion of all the im- portant food principles is by far the most valuable single article of liquid diet. It may be given in many forms: Plain, peptonized, as buttemiilk, whey, or junket; a patient on milk diet alone should take from two to five pints in the twenty-four hours. Meat extracts have little value except as stimulants; it should never be forgotten that a patient fed exclusively on them would promptly starve ; the same remark applies, in a less degree, to broths and gruels. Albumen water is valuable when milk is not tolerated. In all diseases, but especially in fevers, water in large quantities is indispensable ; it flushes out the excretory organs, removing poison- ous substances, aids the circulation, and lowers temperature in its evaporation from the skin. In all fever cases the amount of water given should be noted on the clinical record. Medicines must never be left with a patient to be taken by him ; the nurse should give them himself and see that they are swallowed before he leaves the bedside. In giving medicines great care must be exercised to avoid mistakes. The label indicating the nature of the medicine and the dose must be carefully read, the bottle shaken, and the dose measured out by pouring from the side of the bottle opposite the label so as not to spoil the latter. After the dose is taken the fact should be recorded, never before. A graduated medicine glass should always be used to measure doses instead of spoons which vary so much in size. Medicines ordered to be taken before meals should be given about twenty minutes before, while those to be taken after meals should usually be given immediately after. Sour medicine should not be given within a half-hour of the time when milk is administered. Sleeping patients should not be aroused to take medicine unless the medical officer has specially so ordered. Pills are administered by putting them far back on the patient's tongue and givinc: him a swallow of water. 150 NURSING A powder if small sliould be i)laced on the back of the tongue and washed down with water or placed on a spoon and moistened with water; if large and bulky it should be stirred up with water in a tumbler and swallowed quickly before it settles. The Zi'ard medicine closet must be kejit locked and the wardmaster must take care to avoid an accumulation of medicines. When a patient for whom a mixture has been especially ordered leaves the ward his medicine bottle should be at once turned in to the dis- pensary, and the same rule applies to all medicines not in current use. To give medicines subcutaneously, the hypodermic syringe is used. Certain rules are necessary to prevent accidents with this instrument. The solution used must be freshly prepared; the needles must be clean, sharp, and aseptic ; the syringe freshly sterilized ; the skin where the injection is made must be cleansed. To render the needle aseptic boil it a moment in a spoonful of Avater, or draw phenol or cresol solution through it several times. Disinfect the syringe in the same way. or use 70% alcohol. Never attempt to use a needle the point of which is dulled or bent. In making the injection care must be taken to avoid blood-vessels, nerv'es, and bones ; for this reason a fleshy part should always be selected and the injection made obliquely; the outside of the fore- arm or the front of the thigh is usually chosen. Draw the medicine into the syringe, screw on the needle, hold the syringe vertically, needle up, and gradually press the piston until all air has been forced out as indicated by the escape of a drop of fluid; wash the skin at the point of injection w^ith a little alcohol or plain soap and water, draw the skin tight, and thrust in the needle quickly. When the needle has penetrated about half an inch, force out the liquid slowly, withdraw the needle, and press the finger for a moment on the puncture. Before putting the syringe a\vay draw a disinfecting solution through it, remove the needle, force out the last drop of fluid, and at once insert the wire. The bed pan .should be warmed before use by dipping it in hot water or placing hot water in it for a few minutes; as soon as re- moved from the patient it should be promptly covered, taken from the ward, emptied, and washed. Rubber sheets should never be folded, as to do so will crack them ; when not in use, hang by the edges or roll on a wooden roller. The patient's nails should be kept clean and .special attention should WARD MAXAGEMEXT 151 be paid to liis mouth and teeth. The teeth and mouth of helpless patients should be washed with a gauze si)onge dipped in a mild antiseptic solution. Dying patients should preferably be removed to a separate room; but if this is not practicable their beds should be surrounded by screens so that the other patients may not be unfavorably affected by the sight. A medical officer should always be notified. As soon as death occurs the body should be removed with as little disturbance as possible and given proper attention. The signs of death are cessation of respiration and of the heart's action, dilatation of the pupils with flaccidity of the cornea, and later coldness of the body, rigor mortis, and decomposition. When respiration can no longer be seen its complete cessation may be verified by holding a mirror over the mouth ; if there is any breathing at all the mirror will be clouded. When the heart and pulse can no longer be felt, tying a string around the finger will show whether the circulation has ceased; if it has not there will be some congestion of the end of the finger, while there will be no change if death has occurred. In hospitals the sign of death most relied upon is the sudden and permanent dilatation of the pupils with flaccidity of the cornea; the latter sign is elicited by touching the cornea with the finger, when, instead of being firm and resilient, it will be found soft and flaccid. As soon as the body is removed from the ward the rectum, mouth and nostrils must be packed with cotton to avoid post mortem dis- charges, a triangular bandage with an absorbent cotton pad applied to the perineum, and the limbs straightened out and placed in posi- tion before rigor mortis or stiffening sets in. A little cotton should be placed under the upper lids which are then closed. To prevent the jaw from dropping, a four-tailed bandage is applied to the chin, or a rolled-up bandage is fixed between the chin and .sternum. The body is then wrapped in a sheet wet with an antiseptic solution and in hot weather placed in an ice box. Should an autopsy be necessary preparations are made for it. The body is placed on a table in the dead-house : the post-mortem case is procured and the instruments laid out ; the other arrange- ments necessary are three pails, one containing water, another to receive discharges, and the third for specimens w'hich it may be desired to keep ; a large bath sponge, two pairs of rubber gloves, basin with water, towels, strong thread and needles. CHAPTER III REDS AXI) i:i:i)-.MAKING The regulation hospital bed is of white enameled iron with wire springs^, and is excellent in every way. The mattress is of hair in three sections fastened together hy straps, so that the soiling or destruction of one section does not necessitate the loss of the entire mattress ; further to protect the mattress each is supplied with a movable cover which should always be used. The bed covering should be warm but light; counterpanes being heavy and not porous are objectionable, and for occupied beds should be replaced by sheets. To prepare a hospital bed first see that the springs are in good condition and not sagging; then select a good mattress free from hollows, cover it with a mattress cover, and place on tlie springs. Over the mattress spread a sheet, tucking it in first at tlie head and foot and then at the sides. If the patient is liable to soil the bed a draw sheet comes next, otherwise it is omitted. The draw sheet consists of a rubber sheet about three by four feet, covered by a folded cotton sheet and spread across the bed where the hips will rest, and tucked in at tlie sides or pinned to the mattress. Over this is placed the upper sheet :;.nd blankets, and over the latter for their protection another sheet is spread ; to protect the upper edge of the blankets from soiling, tlie outer sheet or spread is folded over it, and finally the upper inside sheet folded back over the outer one. When a patient is placed in bed always pull out the covers a little at the foot of the bed, so that they may not press upon his upturned feet ; this is a little point, often neglected, but meaning much to the patient. All of the beds in a ward should be prepared in the same way so as to give a neat and uniform appearance. Patients are very fond of tucking things away under the mattress, a practice which should be carefully prevented by frequent search. The bed linen of an occupied bed may be changed easily by a (152) BEDS AND UED-MAKIXG 153 single nurse unassisted and that without seriously disturbing the patient. To change the lower sheet, first loosen all the bed clothes at top, sides, and bottom, remove all the upper covering except a sheet and blanket, and roll up the bottom sheet lengthwise together with the draw sheet into a tight roll close to the patient's body ; then in like manner make one side of the clean sheet and draw sheet into a roll and place it alongside the first roll, tucking the free edges under the mattress. Now stand on the other side of the bed and with both hands turn the patient on his side with his face toward yo-u ; tuck in the rolls under his back, turn him back on his other side on to the clean sheet, then withdraw the soiled one and pull the clean sheet into place. To remove the upper bedclothing the covers should first be loosened as before, then spread the clean sheet and blanket over them and tuck in at the sides, after which the soiled clothes may be drawn out at the foot. Bed linen should be changed whenever it is soiled, when a patient is discharged, and at least once a week, depending on the nature of the case; in the infectious fevers it may be necessary to change daily. Even when the sheets are not changed they should be drawn tight and straightened up daily. Sometimes it is more convenient to move the patient to a fresh bed so that the other may be aired and changed ; this may be done in several ways. The two beds may be moved close alongside of each other and the patient gently lifted over on the sheet by two attendants, one at the head and the other at the foot; the lifting may be facilitated by rolling the edges of the sheet around a pole on each side, thus forming an improvised litter. If there is only one attendant a rubber sheet may be pinned to the occupied bed and stretched across the interval to form, a smooth surface on which the patient is pulled over on his own sheet; oi- the mattress on which the patient is lying may be pulled a little way over the other and the patient then rolled over the edge or drawn over on his own sheet. Where there is only one bed and the mat- tress is to be changed draw the soiled mattress half way off. and then place the clean one alongside ; draw the patient on his sheet from the soiled to the clean mattress, remove the soiled one. and draw the clean mattress in its place. A bed is prepared for an operative ease the same as for any other •154 ]\'L']vSI.\(i with the following differences: The pillow is remo\ecI and a small rnl)ber sheet covered by a towel pinned to the mattress in its place, this because nausea is less apt to occur if the head is low ; in case there should be vomiting- a couple of towels are hung over tlie head of the bed and a basin, several mouth-wipes and a mouth-gag or tongue depressor placed on the bedside table. A number of hot- water bags are placed in the bed, and a blanket is put under the upper sheet; the object of these procedures is to diminish shock by having the bed as warm as possible. Before the patient is placed in tile bed the hot-water bags are removed lest the patient in his un- conscious condition should be burned without knowing it. The covers on one side of the bed should be turned back to the edge of the mattress in order that the bed may be quickly opened up for the reception of the patient. Beds for fractures of the lower extremities should be firm and solid so that the sinking in of the bed from the weight of the body may not cause displacement of apparatus and in order that the patient may be better handled ; this is accomplished by placing under the mattress a frame of slats or a number of separate wooden slats. A great variety of fracture beds and invalid beds have been invented, but they are all too complicated, and an extemporized bed is better. To move a patient from one side of the bed to another; standing on the left side, pass the right arm. well under'the patient's shoulder and back, so that his shoulder will rest upon that of the nurse, and pass the other hand over the patient's other shoulder; lift gently and move over the u])per half of the body; then place the right arm under the back lower down, and the left below the hips, and move the lower half of the body over. Whenever the hips are to be moved, always flex the patient's knees, and place the feet upon the bed: this enables the patient to help and lighten the weight. When lifting the shoulders support the head in the hollow of your arm. When mov- ing the patient to one side of the bed always move him toward you. To lift to the upper part of the bed pass the right arm obliquely under the patient's shoulder and back and the left below the hips and lift toward the head. If the patient is strong enough to clasp his arms around the nurse's neck he can assist considerably in the-^e movements. BEDS AND BED-.MAKIXG 155 To change the pillozvs one arm should raise the shoulders and head, while the other hand adjusts the pillows. To raise the patient to a semi-recumbent position a bed-rest may be used; or a straight-backed chair turned bottom side up and padded with pillows answers very well, or the support may be made of pillows entirely, the first being placed low down beneath the back and the others packed in above. Where there is a tendency to slip down in bed, a firm cylindrical pillow about eight inches in diameter is used ; this is ])laced beneath the patient's knees and firmly tied to the head of the bed by broad bandages fastened to the pillow at each end. Rubber cushions of various shapes and sizes are very useful about a sick-bed, and when there are involuntary discharges a " Kelly pad " or surgical pad is invaluable. In cases of paralysis or other cases requiring long confinement to bed oir mattresses and li'atcr mattresses are used. The air mat- tresses may be placed on an ordinary bedstead and inflated with a bellows or by the mouth. The water mattress requires a frame on each side of the bed to keep it from slipping off, and a rubber sheet must be spread over the springs to prevent sticking. After the mattress is in position it is filled with water by a hose or through a funnel ; the temperature of the water must be not less than 98° F., that is, the temperature of the body. No pins should be used about water and air beds lest puncture and leakage occur. When patients are confined to the bed for long periods of time and their vitality is at the same time very much lowered, as occurs in cases of paralysis, long-continued fever, and in old persons, bed- sores are very apt to form ; starting as an inflammation of the skin, ulceration and sloughing soon follow and the destruction of tissue is often very deep, even laying bare the bone in many instances, and this with very little pain so that the patient may be unaware of the existence of the ulcers. The causes of bed-sores are long- continued and uneven pressure, frequent wetting of the skin, such as occurs in incontinence of urine, and uncleanliness. Constant watchfulness is necessary to avoid them in chronic bed cases, espe- cially when the patient must remain in one position. It is much easier, however, to prevent bed-sores than to cure them. The beds must be kept clean and free from crumbs ; the sheets and the patient's 156 XL'RSIXG night dress must be drawn smooth and free of wrinkles and should be changed whenever they get wet or soiled. The parts of the body most liable to be affected are naturally those most subjected to pressure, the lower part of the back, the shoulders, elbows, and lieeis. These parts should be washed fre- quently with soap and water, thoroughly dried, and well sponged with alcohol, whisky, or a one-per-cent solution of tannic acid in whisky. After this lanolin may be rubbed in to make the skin supple, followed by dusting w'ith talcum or starch to absorb moisture. In addition, pressure should be taken ofif the threatened points by frequent changes of position or the use of rubber rings; in the absence of rubber rings ring-shaped cushions may be made of cotton batting rolled in a tight cylinder, formed into a ring, and then wrapped with a roller bandage. In very chronic cases a water or air bed is necessary. When the skin is reddened and apparently about to break, it may be protected by strapping with adhesive plaster or a thin layer of absorbent cotton may be placed over it and held in place with a coating of collodion. After the bed-sore has formed it is treated like any other ulcer ; wet antiseptic dressings are applied, and, after all sloughs have sepa- rated, balsam of Peru or other stimulating applications are used. CHAPTER IV BATHS AND BATHING Baths are given for several purposes, among the more im.portant of which are: 1. To promote cleanHness. 2. To produce sweating of rehixation 3. To reduce fever. 4. To stimulate the circulation. 5. To quiet the nervous system. 6. For counter-irritation. According to temperature baths may be : 1. Tepid; at temperature of the body; 98° F. 2. Hot; 100° to 110° F. 3. Cold ; 90° to 70° F. According to extent baths are classified as : 1. General. a. Tub. b. Sponge. 2. Local. a. Sitz or pelvic. b. Foot. Besides water baths, hot-air and steam baths are employed. The wet pack is a modified form of bath. To promote cleanliness tepid water is used either in the tub or b^-- sponging. To give a sponge bath in bed, cover the entire bed with a rubber sheet ; on this place a blanket upon which the patient lies with another blanket or sheet over him ; provide a pail of tepid w^ater, a slop pail, basin, wash rag. soap, towels, ammonia, alcohol, mouth-wash, orange stick, nail brush, cotton, and comb. The bathing should be quickly done in sections, the rest of the body being meanwhile protected from exposure. If the purpose of the sponge bath is to reduce temperature the water should be cold and the whole body may be exposed ; in such (157) 138 NURSING a case if the patient seems chilly after the bath a glass of hot milk or a little stimulant may be given. The scdatk'i' bath is for the purpose of quieting excitement and inducing sleep ; it may be continued for hours or even days ; the temperature of the water is usually just below that of the body — about 96° F. The arrangement is practically the same as for the Brandt bath, but to keep the water from cooling, the tub must be covered with a few pieces of board, on which are placed a rubber sheet and blankets ; hot water must be carefully added from time to time to maintain a uniform temperature. To produce siveating or relaxation, hot-water, hot-air, or steam baths are used. The hot-ivater hath is given in the tub in the ordinary way except that the head is kept cool by cold cloths or an ice bag. Care must Fic. 84. — Bed Cradle from Barrel Hoops. be taken not to continue the bath too long, to the point of fainting ; fifteen to twenty minutes is sufficient, after which the patient is taken out and, without drying, placed on hot blankets and covered by three or four more which are wrapped closely about him up to the neck. Hot weak tea or hot water is given freely to encourage sweating. After about an hour the blankets are gradually removed, and the patient sponged off under the last one with alcohol and water, this being followed by a brisk rub with dry towels. Hot-air and steam baths may be given in bed or sitting up. In the first method the bed is covered with a rubber sheet upon which is placed a blanket on which the patient lies stripped. Over his body are placed two or three bed cradles or extemporized bed cradles BATHS AXD BATHIXG 159 (Fig. 84). Bed cradles may be extemporized by tying together at right angles two half barrel-hoops. Over the cradles and tucked in about the patient's neck is another rubber sheet and blanket. At the foot of the bed is placed an oil, gas, electric, or alcohol heate<- with a section of stove pipe and an elbow to conduct the heat under the bedclothes, or, if steam is to be used, upon the heater is set a tea- kettle with a hose attached to the spout for the same purpose (Fig. S=^}. After the stpam or hot air has passed in long enough to get perspiration well started, the upper rubber sheet and the cradles are removed and the blankets tucked in closely around the patient's body, after which the case is managed in the same manner as the hot-water bath. To give these baths to a patient sitting up, after removing all clothing he is made to take his seat upon a chair with perforated bottom; under the chair is placed an alcohol lamp, an electric heater, Anangcmcnts for Hot-air or Vapor P.aths in Bed. or a pail of water in which are dropi)ed hot stones or bricks. The patient is then surrounded from the neck downward by a rubber sheet and blankets arranged in the manner of a tent ; this is a con- vient method in the field. Precautions to be used with hot air or vapor baths : 1. Be careful not to burn or exhaust the patient, or to set fire to the bed. 2. Keep an ice-bag on his head. 3. \\''atch the pidse. 4. Give hot drinks freely. 5. Wrap the jiatient in a hot dry blanket for an hour after the bath, then rub with alcohol. To reduce fever we use either the Brandt system of cold tub bath?. 160 NURSING cold sponging, or the cold pack. There are also various extempo- reneoiis methods for applying cold for this i)iirpose. The general effect of cold baths, besides reducing the temperature, is to allay nervousness, quiet the circulation, increase excretion, and induce sleep. The Brandt system of bathing is used chiefly in typhoid fever. A portable bath tub on wheels is generally employed. The tub is brought to the bedside half filled with water at a temperature of about 90° F. ; the naked patient is lifted from the bed and lowered into the tub feet first, and gradually, so as not to produce too much shock. For the purpose of lifting the patient from the bed and supporting him in the tub an open-work stretcher, a hammock, or a cotton blanket with loops sewed in the edges, is usually employed; in the absence of these a binder eighteen inches broad should be fastened across the head of the tub to support the head and shoulders. His head rests upon a circular air cushion and is kept covered with cold compresses; pieces of ice are added to the water so as to reduce the temperature gradually to about 70° F. To ascertain the tem- perature accurately a bath thermometer is employed. All the time the patient is in the bath the attendants should keep up a vigorous rubbing- of his body. The duration of the bath is ordinarily about twenty minutes, but it may be shortened if there is much shivering, and blueness of the lips and finger tips. When it is time to take the patient out, the tub is covered with a dry sheet which is wrapped about the patient as he is lifted out, and placed on a dry blanket. If shivering persists a hot-water bag may be applied to the feet and a hot drink may be given internally, but he should not be wrapped in blankets. The tenijierature is taken in the rectum immediately after leaving the bath and again an hour later. Ordinarily the bath is repeated whenever the tem- perature goes abo\e 102.5° to 103° F. Cold sponging has already been described under the sponge bath. When the patient does not stand the cold tub bath well or is too weak to bear the moving, the cold pack may be employed. In this method the bed is protected by a long rubber sheet, and two sheets folded one or more times and wrung out of water at 70° F. are used. One is placed under the patient and the other over him and tucked in closely about the body and neck ; or a single sheet may be used euA eloping the entire body except the head. The packs are BATHS AXD DATiilXG 161 changed about every fifteen minutes, and three or four of ihem generally produce the effects of a single tub bath. Bed tub-bath. To give a patient a bath in bed, pass under him a rubber sheet the size of the bed, a bed sheet, and over this a large rubber sheet about three feet wider and two and one-half to three feet longer than the mattress. Attach a small rope or cord to the head and foot of the bed, on each side, about six inches above the mattress, and stretch it firmly. Over this cord pass the large rubber sheet and fasten with clothes pins, thus forming a trough to carry oft" the water; direct the lower end of the rubber sheet into a pail at the foot of the bed, and raise the head of the bed a few inches on blocks. Remove the top covers and place a towel over the patient. The water, of desired temperature, may be sprmkled on with a watering pot, or from a pitcher or a syphon connecting with a pail placed above the bed. If the bath is cold, patient should be well rubbed during its administration. After it is. over, drain off the water, and with a towel wipe the rubber sheet dry, withdraw it from beneath, and dry the patient with the sheet on which he will then lie. Alcohol baths. The patient is usually rubbed with alcohol after an ordinary bath, or it may be given alone, for its soothing and quieting effect. Fifty per cent alcohol is ordinarily employed, and is wdl rubbed in by the hands of the nurse. The bedding covering patient, except the sheet, should be removed, and the lower sheet protected by bath towels ; the body is then gone over systematically, one portion at a time, using only enough alcohol to avoid wetting the bed. A pint w\\\ usually be sufficient for one bath. In the field when the folding field tub is not available, substitutes may be extemporized. An ordinary camp cot may be taken, the canvas bottom punched full of holes and a piece of rubber sheeting tacked across the frame below the canvas in such a way that it will form a gutter draining toward a pail placed at the foot. On this cot the patient is to be placed and cold water sprinkled or poured over him ; or an upright frame may be made, to the sides and ends of which rubber sheeting may be attached in such a way as to form an extemporized tub. Bakes. Small hot air cabinets for baking different parts of the body are furnished by instrument makers, and especially adapted for the part to be baked. 11 162 NL'KSIXG It is necessary, in the use nf these ap[)hances, to strictly follow the directions and to take good care to avoid burning the patient. Special protectors are supplied for this purpose, hut need to be closely watched. Electric light baths. Special ai)pliances are required for the.-^e baths, and directions for their use accompany them. Local baths. The foot bath may be given in bed. It is employed in sprains to control the hemorrhage about the joint, and in internal diseases to draw away the blood f rem the congested part. For the latter purpose mustard is usually added to the hot water. To give a mustard foot bath in bed turn up the covers from the foot end of the bed, place a rubber sheet across it, and en this a pail or foot tub full of water as hot as can be borne. Dissolve a couple of tablespoonfuls of mustard in a cupful of hot water until a uniform cream is formed and stir it into the pail of hot water. If the dry mustard is added to the pail of water without previous solution, particles of mustard will float around, adhere to the legs, and may produce blisters. When all is ready the patient, lying on his back, should flex his legs and immerse them in the hot solution until the skin is quite red. The legs are then withdrawn, dried quickly, and wrapped in a blanket. In the Sits bath the patient sits in a tub or deep basin of hot water, the feet rest on the floor. CHAPTER V ENEMATA, IRRIGATIONS. DOUCHES, CATHETERIZATION An enema is an injection of fluid into the bowels. When the injection is made into the rectum through a tube passed just within the anus it is known as a lozc enema or simply an enema ; when the liquid is carried high up into the colon through a soft-rul)ber tube introduced fifteen or eighteen inches it is known as a hiyh enema. Enemata are further classified according to the purpose for which given, into laxative, nutrient, and medicinal or therapeutic enemata. Laxative eticmata are of various kinds according to the special indications of the case. The one most commonly used is composed of two or three pints of soap suds made with any good soap and water, either hot or cold. To give such an enema the patient is placed on his left side with the hips raised and resting upon a folded towel placed upon a rubber sheet for the protection of the bed. A bed pan or commode should be at hand, and also a towel to control the anus if necessary. A rubl)er bulb or a fountain syringe may be used, the former being generally considered preferable on account of the intermittent pressure which it permits of; either, however, is et^ective and safe if properly used. A soft rectal tube is attached to the tube of the injector by a sh('rt ])iece of glass tul)ing, the rectal tul)e lubricated with soft soap and then passed in gently for eight or ten inches. The fluid is made to pass in slowly, the bag in the case of the fountain syringe being raised or lowered as necessary so as not to cause any pain. After the entire amount has passed in. the patient is directed to hold it for about fifteen or twenty minutes if possible, and may be assisted by pressing a towel firmly against the anus. The longer the fluid is retained the higher up the contractions of the bowel extend and the mc^re comi)lete the resulting evacuation. Should a more active enema be necessary thirty grammes of Epsom salts and fifteen Cc. of turpentine may be added to the soap suds, or sixty Cc. of castor oil and fifteen Cc. of turpentine may precede the suds by (163) 164 NURSING half an hour. Fifteen Cc. of glycerin diluted with an ctjual amount of water, and given with a small hard-rubber syringe, makes a very effective enema. I'he nutrient cucnia is always given high, as the rectum itself has very little absorbent power and still less digestive capacity ; if the bowels, are loaded they must first be emptied by a laxative enema. Nutrient enemata mu t c i . Fig. 87. — Irrigation of the Bowels. Second step. should be of body tem- P'orature so as to cause as little irritation as i)ossible. DOUCHES, CATHETERIZATION 165 A nutrient enema is given through a rectal tube or large catheter, warmed, well oiled, and introduced for about twelve to fifteen inches ; in the outer end of the tube a funnel is placed, and the liquid food shov/ly poured in from a pitcher. When nutrient enemata are given frequently the bowel should be gently washed out with warm water before each one : the tube and funnel are used for the washing:, the latter being alternately raised and lowered before all the water has run out so as to secure siphon action. Medicinal enemata may be given for their general effect as when chloral, opium, or stimulants are used, or for their local effect, on inflammation or hemorrhage, when astringents, emollients, or anti- septics are employed. The last class of medicines is, however, usually employed by irrigation instead of enema. The most common emollient enema is the well-known starch-and-laudanum mixture. To prepare it take a tablespoon ful of ordinary laundry starch, add enough cold water to dissolve it, and then sufficient boiling water to form a thin paste; into this stir fifteen to twenty drops of lauda- lumi, and inject while warm with a hard-rubber syringe. An irrigatioji differs from an enema in that it is desired that a considerable portion of the liquid introduced shall be absorbed and that the remainder shall be allowed to flow away at once. The irrigation may be given for cleansing purposes only, or disinfectants such as nitrate of silver or quinine may be employed. Before the funnel is lowered, enough fluid should be introduced to gently dis- tend the bowel without causing pain ; it is important to see that the funnel is lowered while some fluid is still visible; otherwise there is difficulty in starting the outward flow (Figs. 86, 87). The tubes and syringes used in giving enemata and irrigations must be kept thoroughly clean ; for this purpose, after use a stream of water should be allowed to run over and through them, after which the syringe should be hung up to drip and the tubes and nozzles placed in an antiseptic solution. When the tubes or nozzles have been used in an infectious case they should be boiled before being employed for another patient. Urethral injections are used in gonorrhea. In the hospital these injections are given under the supervision of the nurse, who should instruct the patient how to give them correctly. Having placed a basin on a chair in front of him or standing in front of the urinal. he should first pass his water to wash all the pus out of the urethra. 166 XLRSiXG The syringe is then filied and the nozzle inserted in the meatus and held there firmly with thumb and forefinger of the left hand, after which the piston is driven slowly home, the syringe withdrawn, and the urethra lirml}- compressed for a couple of minutes in order to retain the injection. At least two syringefuls are used each time. A douche is a stream or jet of water propelled with some force. Spinal, vaginal, nasal, pharyngeal, eye. and aural tlouches are em- ployed, the latter being the most frequently used in military hospitals. The spinal douche. The patient should sit on a board across the end of the tub furthest from the spigot and with his back toward the spigot. Use the spray as directed. If the spray is to be hot test it first on 3-our own arm. If the patient is unable to sit up the douche may be given in bed which is pre- pared as for a bed-bath. 'Vhe iiasaJ douche. Use a fountain syringe with a nasal tip. Incline the patient's head forward and to one side so that the nostril of entrance is ui)i)ermost : if one nostril is obstructed this should be the entrance ; tell the patient to keep the mouth open and breathe through the mouth and not to cough or swallow. this to jirevent the passage of tiie fiuid into the eustachian tube; use no force; hold the irrigator only two or three inches above the patient's Fig. 88.— Syringing the Ear. UOSC : have the water hot. The eye douche. Use warm boric acid solution. Arrange the patient so that the eye to be douched is lower than the other one; wipe off any secretion with a wet cotton sponge from wilhin out- DOUCHES. CATHETERIZATION 167 ward ; evert one lid and direct the solution over it from within out- ward, holding the basin in such a position as to catch the flow ; treat the other lid in the same way; if drops are to be put in afterward place them at the outer angle of the eye so that they will not imme- diately escape through the tear duct. The aural or car douche is used for cleansing purposes or to remove foreign bodies, especially hardened wax. Either a fountain syringe with a straight glass medicine dropper or a nozzle, or a hard-rubber syringe is employed. The former is to be preferred, as the pressure can be more easily regulated. To remove hardened wax a warm, five-per-cent solution of soda is employed ; the coat and collar of the patient having been removed and a towel placed about his neck, he sits in a chair with the head inclined toward the affected side ; a basin or bowl is held firmly against the neck just below' but not touching the lobe of the ear ; the ear is then drawn upward and forward to straighten the canal, and the tip of the nozzle placed against the upper wall, along which the jet of water is directed wath the object of passing behind the plug of wax and washing it out in the return flow along the floor of the ear (Fig. 88). A quart or more of water may be used at a time and repeated until the mass comes away in one piece or in fragments. When the wax is removed the ear should be dried out with a wisp of cotton, a little of which is left in the canal for a day or two until the sensitiveness has subsided. CatJictcricatioii is the art of drawing off the urine from the bladder by the aid of a catheter. The dangers of catheterization are injury to the urethra from undue force, and cystitis or inflammation of the bladder caused by the introduction of germs on an unclean catheter. The precautions to be taken are absolute cleanliness of everything which may come in contact with the catheter and avoidance of all force in introduction. The catheter to be used should usually be of soft rubber only ; failing with this a noncommissioned officer may use a silver instrument. To introduce a soft-rubber catheter it is first washed in running water, then wrapped in gauze or a towel and boiled five minutes ; the attendant wa.^hes his hands and the penis of the patient with hot water and soap, followed by an antiseptic solution, and surrounds the base of the penis with a clean towel ; the catheter is then lubri- cated with sterilized oil, held in a dressing forceps, and gently passed 108 - NURSING in until the escape of urine announces that it has reached the bladder. Should an obstruction be met with, the catheter is withdrawn a little, and again pushed on as before. After the flow of urine has ceased, the instrument is gently withdrawn, taking care to compress the end between the fingers as the last portion is withdrawn from the urethra in order to prevent the urine remaining in the catheter dripping out on the bed. After use the catheter should be thoroughly washed in running water and either hung up to dry or placed in a boric-acid solution. Irrigation of the bladder for cystitis and other diseases, is done in much the same manner as irrigation of the intestines, using either a single or douljle current catheter. Catheterization of the ureter is always done by the physician ; the nurse's duties are to see to the sterilization of the instruments, and that specimens of the urine from the two kidneys are kept quite separate, for this purpose he marks the urethral catheter as well as the necessary vessels " right " and " left." CHAPTER VI EXTKRXAI. APPLICATION'S Among the external applications most commonly used are heat and cold, lotions, counter-irritants, and caustics. The application of heat may be general or local ; the general application has already been described in Chapter 1\'. The local eli'ects of heat are to relieve pain, allay intiammation, and relax spasm. Dry heat is api)lied in the form of the various dry hot-air apparatus, electric heaters, hot-water bags, bottles, or cans, salt bags and hop bags, hot bricks, etc. The dry hot-air apparatus must be used with considerable care and according to the directions which accompany each appliance. Bags, bottles or tins of hot water should be inclosed in a flannel cover or otherwise wrapped to prevent danger of burning; when used about unconscious or paralyzed patients especially, the greatest care and watchfulness should be employed to prevent accidents. Hot-water bags should be filled a little more than half full and all the air expelled before the top is screwed on; this makes them lighter and more ea^ily adjusted. They should be examined closely before use to see that they do not leak. Hot bottles are not very safe, as they are apt to crack or burst. The great advantage of bricks is that they retain the heat a long time, but they are very heavy and awkward. Moist heat is more penetrating and more relaxing than dry heat. It is applied in the form of poultices or fomentations or stupes. Poultices are made of various materials : anything which will hold heat and moisture is adapted to the purpose ; flaxseed meal is the time-honored basis for poultices, and where the skin is unbroken answers very well ; but where a wound or abrasion exists such a poultice is a veritable culture-bed for bacteria, and should be re- placed by layers of gauze wrung out of a hot antiseptic solution and covered by a layer of cotton batting and oiled silk. To make a flaxseed poultice stir the meal slowly into boiling water until a thick paste is formed ; boil for a few minutes, then (169) 170 XL'KSIXG beat briskly witb a sjioon until the admixture of air makes it light; spread with a spatula or knife to the thickness of one- fourth or one- half inch upon strong- muslin, leaving a free border of an inch all the way round. Then cover the face of the poultice with gauze, or oil it with vaseline, and turn over the edges. Apply, and cover with a layer of cotton and oil silk. Such a poultice should be changed once every two or three hours. The fresh poultice sh// fever, while temperatures above 105° F. are denominated hypcr- pyre.via. .\ depression of temperature of several degrees is usually of much more importance than a corresponding elevation ; thus a depression of three and a half degrees would give a temperature of 95° F., or the temperature of collapse, a condition which means speedy death 176 NURSING unless prompt reaction takes place. On the other hand an elevation of three and a half degrees would only give 102° F., a temperature by no means alarming. Hyperpyrexia, however, temperatures 106° to 109° F., is very dangerous, although recovery has often followed prompt remedial measures. The instrument for measuring the temperature of the body is called a clinical or self-registering thermometer. The self-register- ing feature is secured by a break in the mercurial column correspond- ing to a constriction in the glass. When the mercury column has risen above the normal line, which is usually indicated by an arrow, it must be shaken down by a sweeping motion of the arm before the thermometer is used again. The Fahrenheit scale is usually employed in this country, but the thermometers issued to the army are generally graduated in the Centigrade scale also. The normal in the Centigrade is 2^7°, 40° C. corresponding to 104° F. To convert Fahrenheit degrees into Centi- grade subtract 32 and multiply by %. For example: 98.6 F. = [ (98.6 — 32) X ^/o] = 37° C. Conversely, to convert Centigrade to Fahrenheit multiply by ?5 and add 32 ; example : 37° C. = [(37 X %) + 32] = 98.6° F. When in doubt about a thermometer compare it with one of known accuracy by simultaneous observations on the same patient. Temperatures are ordinarily taken in the mouth, the bulb being placed under the tongue and the patient directed to close his lips, but not his teeth upon it. If the patient is very weak it may be necessary for the nurse to hold the thennometer in his mouth. W^ith modern thermometers three minutes is ample for mouth tempera- tures. When the patient is delirious or unconscious, or is a child, it is not safe to take the temperature in the mouth. In infants and children the temperature is usually taken in the rectum ; the bulb well oiled is introduced for about an inch and a half; one or two minutes' time is sufficient. To take a temperature in the axilla, the arm pit is first wiped dry, the bulb put in place and the arm carried across the chest so as to bring the opposing skin surfaces in close contact with the ther- mometer ; a little longer time is required than in the mouth or rectum — about fixe minutes usually. Thermometers when not in use should be kept in an antiseptic TEMPERATURE, PULSE AND RESPIRATION 177 solution and resting on a bed of cotton; bichloride of mercury is objectionable for this purpose as it soon removes the markings on the glass. Before using for another patient the thermometer should be rinsed in clean water and wiped dry. Fevers are classified as continued, remittent, or intermittent. A continued fever is one in which the temperature is continually above normal, and there is a difference of not more than about one degree between morning and evening-; typhoid fever in the second week is usually a continued fever. In remittent fever there is a decided drop some time in the twenty- four hours, but the temperature does not reach normal. In the intermittent fevers the temperature at certain intervals falls to or below the normal ; malarial fevers are apt to be remittent or intermittent. ■ In keeping a record of fevers charts or thermograpJis are employed. Temperatures are usually recorded morning and evening, but in typhoid fever and other serious fevers this is generally done every three hours or oftener. In marking charts a dot is placed on the point at which the temperature stands, and these dots are connected by straight lines drawn with the aid of a ruler. The normal pulse rate in the adult is about seventy-two to the minute ; it varies, however, from about sixty-five to seventy-five. In children it is much more rapid. In fevers it rises considerably. The condition of the pulse is very important, as it usually accur- ately indicates the condition of the heart and vital powers. The pulse may he taken by laying the fingers gently on an)'- super- ficial artery, but usually the radial artery is the most convenient ; the temporal is also frequently used for the purpose. The points to be noted are frequoicy. res^ularity. intermittence, fullness, tension and sfrensj^th. Frequency of the pulse is increased by exercise, food, excitement, and position : the pulse is more frequent in the standing position than when lying down or sitting. An irritable pulse is one which is easily excited : an intenniftotf pulse is one which drops a heat now and then ; a dicrotic pulse occurs in extreme weakness, as in typhoid fever, and consists of two waves to each beat so that the rate may appear twice as fast as the actual pulsations of the heart. The normal respirations occur at the rate of about eighteen to the minute. In disease there occur marked variations in the frequency and character of the respirations ; in narcotic poisonings the respira- 12 178 NL'RSIXG tions are very slow, while in penumonia and peritonitis they are very rapid. In taking respirations one should notice their frequency and regularity, whether difficult or easy, noisy or quiet, deep or shallozv and whether symmetrical, that is to say the same on the two sides of the chest. Clieyne-Stokes respiration is that peculiar type of breatiiing which occurs in certain diseases of the heart and kidneys. The respira- tions gradually increase in frequency and intensity up to a certain [)oint, then slowly decrease until they seem to entirely cease; after a short pause the same course is gone through with again. In stertorous breathing there is a loud snoring noise with inspira- tion. Dyspnea means ditiicult or painful breathing. In taking respirations it must be remembered that they are in a measure under the control of the will; therefore, they must be taken without the patient's knowledge, and this is done by laying the arm across the chest in taking the pulse, and then without remov- ing the fingers from the wrist taking the respiration while appear- ing to take the pulse. With a little practice a nurse should become so expert that he can take the pulse and respiration of a sleeping patient without arousing him. In the normal condition, the pulse, temperature, and respiration rates have a definite relation to each other, and the three factors should always be considered together in disease, as disturbance in the normal ratio may have the most important meaning. In health the pulse rate is about four times the respiration rate ; when the respiration rate is increased to a third or a half of the pulse rate it is usually an indication of disease of the lungs such as pneumonia. In fevers, when the temperature rises the pulse becomes proportionally more rapid; if instead of rising with the temperature the pulse slowly falls, an important sign of yellow fever is present; if on the other hand the pulse rate becomes more rapid than that which is usual with a given temperature, it is an indication of weak- ness and diminished vital powers. CHAPTER VIII SYMPTOMS AM) CLINICAL KECORD One of the most important duties of a nurse is to cultivate the habit of observing symptoms accurately and reporting them clearly and intelligently. The physician can only be with the patient a short time, and he must depend upon his nurse to inform him of everything that takes place in his absence; the nurse may thus obtain information of the greatest value in diagnosis and treatment. Syuiptoms may be divided into two classes : subjective symptoms, those which are only apparent to the patient himself, such as pain ; and objective symp- toms, those which are apparent to others, such as redness and swell- ing. Sometimes the symptoms are feigned, when the patient is said to be malingeriny , it is always safer to assume, however, that the symptoms arc real until the contrary is proved. Not only must the nurse cultivate the habit of observing symptoms, but he must learn how to attach to them their relative importance. Emergencies continually arise when he must determine what is to be done ; are the symptoms of sufficient gravity to cause him to call in the noncommissioned officer or send for the surgeon ? Shall he loosen a bandage or give a stimulant on his own responsibility? The observations should commence with the giving of the first bath or putting the patient to bed. Are there any scars, wounds, or eruptions upon the body? Is the patient emaciated or dropsical? Does he appear weak and ill? The attitude and expression are sometimes characteristic. In inflammation of one lung the patient usually lies on that side so as to give free play to the uninjured lung. In appendicitis cr peritonitis he is apt to lie on the back with one or both legs drawn up. Slipping down toward the foot of the bed means weakness and is therefore unfavorable. With colic the patient often lies on the abdomen with a pillow pressed against it ; but when the pain is inflammatory he can not stand the pressure. 180 XL'RSIXG When the patient can not breathe while lying down there is usually trouble with the heart or lungs. Great restlessness is often a bad sign. An anxious look is unfavorable, while a tranquil expression is of the opposite import. The pallor and pinched expression of seosis are characteristic, but can not well be described. Rattling in the chest, with shortness of breath and a bluish tint of the lips, is a sign of edema of the lungs and often indicates approach- ing death. The mental condition gives important indications : whether the patient is conscious or unconscious; rational or irrational; depressed or excited or muttering. The speech may be thick or clear or hoarse. The eyes are to be observed ; whether the pupils are dilated or contracted or unequal; whether there is any squinting; any yellow- ness or congestion of the conjunctiva. The hearing may be painfully acute or it may be defective; there may be a discharge from the ear. Bad taste may be complained of or offensive odors. The skin, especially of the face, may give important indications; it may be pale, flushed, livid, or jaundiced; hot, cold, dry, or moist. A moist skin with high temperature is usually a bad omen. A peculiar red spot high up on either cheek is often indicative of pneu- monia or consumption; pallor about the lips is a sign of nausea. Then we have the waxy hue of Bright's disease and the rashes of the eruptive fevers ; the sallow color of narcotic users, the pallor of anaemia, the blue tint of cyanosis, the bronzing of Addison's disease. Bluish spots about the size of a finger nail distributed about the trunk are a sure sign of body vermin. The tongue offers many valuable indications ; note whether it is dry or moist, clean or coated, large or small, bitten, or indented on the edges by the teeth. In malarial fevers and digestive disorders the tongue is apt to be heavily coated and indented by the teeth ; in typhoid fever it is at first moist and coated, but soon becomes dry and cracked ; when such a tongue becomes moist and begins to clean up from the edges it is a very favorable sign. In scarlet fever the bright-red papillse showing through the white fur produce the characteristic strazvberry tongue. In yellow fever the tongue is small, red, and pointed. SYMPTOMS AXD CLINICAL RECORD 181 Note at the same time the condition of the mouth and teeth; white shghtly raised patches on the inside of the hps and cheeks, at the corners of the mouth, and in the throat are frequently mucous patches, a sign of syphiHs. The dark accumulations which occur on the teeth in fevers are known as sordes; their presence indicates that the mouth has not been well cared for. The odor of the breath is often significant; sweet in diabetes, urinous in uraemia, fetid in disorders of the stomach, gangrene of the lungs, bad teeth, etc. The state of the appetite is of importance; it is usually lost in acute diseases, but occasionally is excessive. Observe with care how much food the patient actually takes. Nausea is often present with or without vomiting. The frequency of the vomiting, whether it is painful, and the character of the matter vomited should be noted. Usually the vomitus consists of fcod at first, but this may be followed by bile, mucus, or blood. When blood has been retained in the stomach some time it becomes brownish in color, like coft'ee grounds ; vomitus of this character is seen in yellow fever. Vomiting of fecal matter is a sign of great importance and indicates obstruction of the bowels. Great thirst is usually an indication of fever or hemorrhage. The number and character of the stools should be noted. Blood, unless fresh, gives the stools a black, tarry appearance; in jaundice they are generally clay-colored ; bismuth and iron color them black ; they may be liquid or solid, and may contain mucus, pus, blood, or worms. Tenesmus, a constant desire to evacuate the bowels, is present in dysentery. Belching of gas, rumblings in the bowels, and distention of the abdomen are signs to be noted. The urinary functions should be carefully noted, and in special cases the amount passed carefully measured. In both suppression and retention no urine is passed, but in the former, which is much the more serious condition, no urine is secreted ; it may be distin- guished from retention, which is caused by some obstacle to the escape of urine from the bladder, by the fact that in suppression the bladder may be shown to be empty by tapping with the finger just above the pubis ; a hollow sound is produced if there is no urine in the bladder. 182 Xl'RSIXG hicontincncc of urine, that is, the inability to hold it. may be associated with retention, so that the mere fact of constant dribbling does not preclude the possibility of the bladder being distended. The quantity of urine should be measured and the frecjuency with which it is passed noted. Useful information may also be oljtained from observation of its color and odor. Blood gives it a smoky or red hue, pus a milky appearance, and mucus a stringy condition. Bile imparts a greenish tinge, as does carbolic acid, whilt? santonin gives a bright-yellow color. Many drugs and vege- tables impart a characteristic odor to urine. Coityh is an indication of some irritation of the air passages; the matters coughed up are called sputa. A\'hen there is no sputum the cough is said to be dry. The cough may he tight, loose, or painful; then there is the hoarse, crowing cough of croup or diph- theria, the spasmodic whoop of whooping cough, the wheezing cough of asthma, the painful cough of pleurisy, and the peculiar rasping cough of aortic aneurism. The character of the sputum varies; in bronchitis it is white or yellow and mucous; in pneumonia it is reddish and very sticky; in tuberculosis it is at first mucous and frothy, later it is purulent with cheesy nodules, and sometimes stained with blocd. /// gangrene of the lung the sputum is unbearably offensive. Hiccough when it is persistent in the later stages of acute diseases is often a very grave sign. When a patient complains of feeling cold take his temperature ; a chill is nearly always accompanied by fever. Chills frequently accompany the onset of acute disease; when they occur in the course of infiammation they often indicate suppuration; in malaria, while severe, they are not usually dangerous. Hemorrhage from any part of the body is always significant; nose-ljleed is often one of the early signs of typhoid fever. Pain is one of the most valuable signs which we possess, as it often points toward the location of the disease. The kind of pain should be described and whether it is constant or intermittent, severe or slight. Exaggerated sensitiveness to touch is called hyperesthesia and diminished sensiljility anesthesia ; the latter is often associated with loss of muscular power or paralysis; paralysis of the lower half of the body is called paraplegia ; of a lateral half honiplegia. Disorders of motion include picking at the bedclothes, always SYMPTOMS AXD CLINICAL RECORD 183 a bad sign, twitching of the tendons (subsulfus), shght spasms, and local or general convulsions. In convulsions always note the parts affected and whether the attack is attended with loss of conscious- ness. Under disorders of consciousness are included delusions and hal- lucinations, delirium, stupor, and coma. The character of the delusions should be noted, whether occa- sional or habitual, quiet or noisy; in stupor note whether the patient can be aroused; if he can not, it is coma, a veiy serious condition. Coma vigil is a combination of sleeplessness with partial unconscious- ness and is also a symptom of bad omen. The amount and character of sleep should be recorded; patients' statements on this point must be accepted with caution. That nothing concerning the patient's condition may be forgotten, clinical records are kept. The blank forms for this purpose are of a uniform size, 33/2" by 8", perforated at the top so that on the com- pletion of the case the various sheets pertaining to it may be as- sembled and filed together. Collection of specimens. It is usually necessary to keep speci- mens of urine, feces, sputum or vomitus, for the inspection of the visiting physician. Ordinarily these are best kept in the vessel in which they are received. It should be placed in a cool place and protected from dust. If sterile specimens are needed, the vessel in which they are received to be kept, should be sterilized by boiling or otherwise. If specimens of urine are to be kept for any length of time, it may be necessary to add a few drops of formalin or chloroform to them, to prevent decomposition. 184 XUkSlXG CHAPTER IX Fig. 91. — Reef Knot. RAXD.AGIXG Bandaging must be taught practically, one-half of the class prac- ticing on the other half. Three general types of bandages are used in the army ; triangular, roller, and tailed bandages. The triangular bandage possesses special advantages for the mili- tary service in that it is quickly and easily applied and removed. The triangles are made by tak- ing a piece of cheese cloth 38 to 41 inches square and cutting it diagonally into halves (Fig. 90). The bandage is used in three general forms : as an open triangle, folded twice from apex to base as a broad cravat, and folded three times as a narrozv cravat. To fasten the ends together the reef knot (Fig. 91) is used, which is much more secure than the " granny " (Fig. 92). Applications of the triangular bandage. Head: Place the base ^^^ of the triangle just above the eyes —=— :^— -- and let the apex hang down over the occiput ; cross the ends below the occiput, bring them to the front and tie (Fig. 93") ; bring the apex up over the crossed ends and pin (Fig. 94). Eye: Use the narrow cravat, tying the ends behind (Fig. 95). Chin or side of head or face: Use the narrow cravat, tying under the chin or on top of the head. Or apply middle of handkerchief over front of chin and tie back of neck (Fig. 96). Neck: Use broad or narrow cravat. Place center of cravat over dressing, cross on opposite side and tie in front (Fig. 97). Chest: Apply the center of the open triangle over the dressing; (185) " Granny " Knot. 186 XL'RSIXG tie tlie ends on the opposite side, leaving one end long; l)ring the apex over the shoulder and fasten to the long end. If the end is i:ot long enough lengthen it by using a narrow cravat (h'igs. 98 and ^)(j). Pclz'is: Apply the center of the base of the opened triangle just below the navel; carry the ends around to the back and tie one Fig. 93. — Triangle or the Head; front. Fig. 94 Triangle of the Head; rear. Fig. 95. — Narrow Cravat of One Eve. end long ; luring the apex over the perineum and between the legs to the rear and fasten to the long end (Fig. 100). Buttocks: Apply the base of the opened triangle to the lower part of the back ; bring the ends around the sides, crossing them in front, and {)in ; split the ape.x and fasten in front (Fig. loi). Sliiujs: The large arm sliiuj is applied in three ditterent ways. Fig. 96. — Narrow Cravat of Chin and Face. Fig. 97. — Narrow Cravat of Neck. In the first method place one end of the triangle over the sound shoulder; the base should be in front and the apex in rear; bring up the front end over the shoulder of the injured side and tie on the side of the neck; bring the apex forward and pin (Fig. 102). When the collar bone is injured the second form is used ; it is applied in the same manner as the first except that the front end is carried under the arm pit instead of over the shoulder of the injured side BANDAGING 187 (V\g. 103). In the third form the rear end is carried over the shoulder of the injured side; otherwise it is the same as the second (Fig. 104). For the small sling the narrow cravat is used, carried over the shoulders and fastened be- hind (Fig. 105). Shoulder: Place the apex of the triangle on the shoulder ; carry the ends around the arm, crossing them and tying at the out- side ; fold the apex over a bling or neck cravat and pin (Fig. 105). EWozv: Use a broad cravat as shown in Fig. Fic. 98.- THangle .f the Chest; from vieNv. if)5. or a large arm sling ( Fig. 102). Hand: Place the hand, palm up. on the triangle, ends of the fingers toward the apex ; bring the apex up over the palm ; pass the ends around the wrist over the apex, which is then folded toward the fingers and covered by another turn of the ends ; tie the ends be- hind (Fig. 105). Hip: Apply a narrow cravat aroimd the waist. Carry the ends of the triangle, base down, around the thigh and fasten. Pass the apex under the cravat, fold over and tie (Fig. 106). Knee: I'se the broad cravat : cross behind and knot in front below the knee-cap: or vice zersa (Fig. 107). Foot: Place the foot tin the triangle, toes toward the apex ; bring Fig. 99. — Triangit ..t liit Che^t; rear view. 188 NL'RSIXG Fig. 100. — Triangle of the Pelvis. the apex up over the toes toward the ankle ; cro.ss the ends over the front of the ankle and over the apex of the bandage, then carry them back around the ankle, crossing them l^ehind in such a manner as to catch the base of the triangle ; next draw up the apex so as to tighten the bandage and fold it over toward the toes. Bring the ends forward and, crossing over the ankle and apex, carry them beneath the foot and tie on the in- side (Fig. 1 08). To fasten splints: Take a narrow cravat, double it upon itself ; place the loop on the outside of the limb ; carry the free ends around the limb and one of them through the loop ; then tighten as much as neces- sary and tie (Fig. 64). Roller bandages consist of strips of cloth of variable length and width. To ai^ply them properly requires care, time, and constant practice : hence they have con- siderable less value for first-aid purposes than has the triangular bandage. The chief materials from which rollers are made are mus- lin, cheese cloth, gauze, flannel, and rubber ; each has its own special qualities. The most general and useful sizes are as follows : For the head, 2 inches wide and 5 yards long. For the upper limb, 2j/> inches wide and 5 to 10 yards long. For the trunk, 4 inches wide and 5 to lO yards long. For the lo-a-er limb, 3 inches wide and 5 to 10 yards long. For the fingers, J4 of an inch wide and i to 2 yards long. Fig. ioi. — Triangle of the Buttocks. BAXDAGING 189 Fig. 102. — Large Sling Xo. Roller bandages .should be lorn, not cut. To prepare a number at one time take a piece of muslin of the required length, tear off the selvage, with the scissors split one end into the required widths, tear down for a couple of feet, separate the alternate slri})s, hand one set to one per.son and the other to another. Eacli now pulls firmly until the piece of cloth is torn through the entire length. Besides a machine for roll- ing bandages there are two methods of rolling by hand. Take a cijuple of feet of the end of tl'e bandage and fold repeatedly upon itself until a firm mass is formed ; then sitting in a chair cover the right leg, foot, and adjacent floor with a clean towel or sheet, place the small roll on the thigh, the loose part of the bandage extending down over the knee to the floor, and roll toward the knee ; when the roll reaches the knee draw it up to the groin and then repeat the motions (Fig. 109). After a firm roll is made in this manner it may be finished by hand if desired; in this method the bandage is grasped as shown in Fig. no and rolled by alternate movements of ])ronation and supination of each hand. Rules for bo)idagiiis[: i. Place the limb in the position it is to occupy. If the arm is bandaged in the straight position and then bent, the bandage will eut in at the bend of the elbow and stop the circulation. Fig. 103. — Large Sling No. 2. 190 NURSING 2. Begin at the extremity of the limb, the ends of the fingers for the iijiper extremity, the tips of the toes for the lower; if this rule is not followed, the parts below the bandage will swell. 3. Place a layer of cotton between opposed skin sur- faces, such as the fingers and toes. 4. Hold the roller in the riglit hand when bandaging the left liml), and rice versa. 5. Place the outer surface of the bandage on the in- ner side of the extremity and ^'°- '04.— Large sung No. 3. secure by making a couple of circular turns. 6. Bandage evenly and neither too tight nor too loose. Leave the tip of the extremities ex]->osed to ob- serve the state of the circula- tion in the part. If the blood when pressed out of the nails does not pronij^.tly return, the bandage is too tight and may cause gangrene. Roller ])andages may be ap- plied by circular turns, siiuMe spirals, reversed spirals. fiynre-ofS, spica, and knotted turns. Circular turns and rapid spirals are used chiefly to hold dressings in place ; the method of using them is clearly shown in Fig. III. The slo7c spiral (Fig. 112) is used where a Fic. 103. — .Small Sling, Triangles of the Hand, Elbow, and Shoulder. limb is nearly cylindrical in BANDAGING 191 shape; each turn is parallel with the turn below, which it envelops for about one-third of its width. For a limb increasing in size like the leg or forearm this bandage would not lie evenly, and it becomes necessary to resort to reverses. The method of making the reicrsc is shown in Fig. 113; the bandage should be held loosely to give slack ; tb.c re- verses should be in line and on the outside of the liml). i'or covering the joints the figiire-of-S bandage becomes necessary ; as the name im- plies, figures-of-8 are made in alternate loops above and below the joint; each loop covering" in one-third of that immediately below (Fig. 114). The spica is really a figure- of-8 with one loop much larger than the other, and is used especially at the hip and shoulder (Fig. 114). Tlie knotted turn is used where it is desired to make pressure, especially on the temple. Unroll about a foot of the band- , age and hold it against the temple ; then carry the roll around the forehead and occiinit ; on reaching the starting point, twist the roller around to a right angle and carry it down under the chin and over the vertex; then fa>ten the ends (Fig. 53). Special applications of the roller bandage: Recurrent of the head: Alake a couple of circular turns about the forehead and occiput; reverse in front and carry the ■ 11 roller back to the occiput over the middle Fig. 107.— Broad Cravat of the of the vcrtcx ; rcvcrsc again and bring for- Knee. Fig. 106. — Triangle of the Hip. 192 XURSTXG ward covering in one-third of the preceding turn, continuing to carry the roller backward and forward until the head is well covered, when all the reverses are held in place by circular turns and pins or sewing. Until the circular turns are made all the reverses must be held in place by an assistant (Fig. 115). Recurrent of a stiinip: Made in the same manner as the recurrent of the head (Fig. 116). Figure-of-S of the eye: Place the end ^J^ of the roller on the temple and make a Fig. 108.— Triangle of the FoQt. couplc of circular tums arouud the fore- head and occiput, from right to left for the right eye, and z'ice versa for the left. Reaching the occiput, pass from under the right ear up over the right eye, across the opposite temple and down again to the occiput: make as many of these turns as necessary, and finahy fix by circular turns (Fig. 117). Figure-of-S, of the jazi' (Barton's bandage): Place the end of the roller below the occiput; pass ob- liquely up over the right parietal bone, across the vertex, dow^n over the left temple in front of the ear, under the chin, up over the right temple in front of the ear, across the vertex, and back to the starting point. Then pass forward along the right side of the jaw in front of the chin and back along the left side of the jaw to the starting point. These turns may be repeated as often as necessary (Fig. 118). Fig. 109. — Rolling Bandage on the Knee. Spiral of the chest: Unroll about five feet of the bandage; let the free end drop down over the front of the chest to about the knees of UAXDAGIXG 193 the patient, carry the roller over the opposite shoulder to the base of the chest, then around the chest over the loose end. ascending by a slow spiral. \\'lien the fhest is bandaged as high as neces- sary fasten the last turn by a l)in. Then bring up the loose end of tb.e bandage over the other shoulder and down the back to the base of the chest and fasten to the lower and upper turns ; this prevents the bandage from slipping down. Velpcau (for fractured clavicle): Place the palm of the hand of the injured side on the sound shoulder, witli padding between the arm and chest wall. Place the initial end of a roller in the axilla of the sound Fig. 1 10. — Rolling Bandage by Hand. Fig. III. — Rapid Spiral. 13 Fig. 112. — Slow Spiral. 194 NURSING Fig. 113. — Steps in Making Spiral Reverses. side, carry the handat^e u]) across the back, over the slioulder of the in- jured side, down the out- siifc of the arm, under the outside of the ell)()\v, and across the front of the che>t to the starting point ; repeat this turn, but when the sound axilla is reached the second time make a cir- cular turn around the chest and ov^r the arm ; then repeat the first and third turns alter;iately, each layer of bandage covering in about two- thirds of its predecessor. Stitch or ])in the jioints of intersection of the turns (Fig. 119). Sc udder's modification of I'dpcaii: Commence in the axilla of the sound side as in the ordinary X'elpeau, but carry the first and second turns horizontal!}' around the front of the chest, the fir>t under and the second over the elbow. The third turn ascends over tlie front of the chest to and over the injured shoulder, down the back of the arm. un- der the elbow and up again over the same BANDAGING 195 Fig. 114. — Figure-of-8, or Spica of the Shoulder. Fig. 115. — Recurrent of the Head Fig. h6. — Recurrent of a Stump. Fig. 1 1 r.— Figure-of-8 of One Eye. Fig. 118. — Figure-of-8 of the Taw (Barton's Bandage). 196 XURSIXG shoulder, thence across the Ixick to the opposite axilla, and again horizontally around the chest, covering in one-third of the previous horizontal turn. These movements are repeated until the shoulder is reached ( l'"ig. 120). Finger bandage: Make two turns about the wrist, pass diagonally over the back of the hand to the root of the finger, descend by spiral turns to the tip, make a circular turn, then ascend by slow spirals Fig. 119. — \'clpeau of the .SliouUler. or reverses ; on again reaching the base of the finger cross the back of the hand to the wrist and finish with a circular turn about the latter ( h"ig. 121 ). Foot bandage: Make a couple of circular turns around the ankle ; descend obliquely over the dorsum, under the sole, and ])ack to the dorsum of the foot, up which the bandage must pass by several spiral turns, covering the instep; when this is reached, pass the BAXDAGIXG 197 bandage under the paint of the heel, thence to the dorsum, then down beneath the sole, then along the outer surface of the heel, next around the heel above its point to reach the instep, whence, Fig. 120. — Modified Velpeau. passing to the sole, a turn is made around and above the point of the heel on the inner side, again to pass the instep, when the roller must be carried by spiral and reversed turns up to the knee (Fig. 122). Fig. 121. — Finger Handage. Tailed bandages: Bandages of various widths split at each end are called 4-tailed and are very useful about the head. The methods of their application are shown in Figs. 123 and T24. 1"8 NURSING The T-bandage is especially useful in confining dressings to the perineum and pubic region; it is made by sewing a strip of bandage to the middle of another strip, the two forming a right angle. Caurjc bandages, sterilized, are usually employed in aseptic dressings. Fig. 12; Foot Randage. Flannel bandages are used when it is desired to produce a moderate degree of elastic pressure, or where warmth is necessary. They lie more smoothly than non-elastic materials. Rubber bandages are of special value when considerable pressure and support are necessary. They must be used with care and fre- quently adjusted and washed with soap and water. They are also Fig. 123. — Four-Tail F.andage for the \"ortex. Fig. 124. — Four-Tail Bandage for the Occiput. emj^loycd like a tourniquet to control bleeding and may be very quickly and effectually applied as follows : Make several circular turns about the limb above the bleeding artery, then lift up one of the turns and pass the unrolled part of the bandage under the turn and over the artery ( Fie:. 44 ) . Crinoline is used for fixed bandages, especially the plaster-of- paris ^a;/(/flr/t',- gauze may also be used for this purpose, but a stifTer BANDAGING 199 material is better. The bandages are prepared by placing on a paper a lot of freshly opened plaster and rubbing it into the meshes of the material with the hand while the bandage is being loosely rolled. \\'hen the bandages are not required for immediate use they should be wrapped separately in waxed paper and kept in a warm, dry place, preferably in tins. To apply, first cover the part with a flannel bandage or other protective, then place a plaster bandage, end down, in water sufficient to cover it ; when bubbles cease to escape, squeeze the bandage gently and apply like any other bandage. Each time a bandage is taken out of the water place another in so as to have one always ready. Usually several tliicknesses of bandage are required, especially over the joints ; when necessary the dressing may also be stiffened by strips of tin incor- porated in the bandage. The floor should be protected by sheets or newspapers and the clothing of the patient and operator by the use of sheets. The limb must be shaved, washed, dried, and powdered before the application of the bandage. To remove plaster from the hands after completion of the oper- ation, sugar or carbonate of soda should be added to the water, or, better, rubbed on the hands. To remove plaster dressings when they are no longer necessary is an operation requiring patience and care. If the dressing is thin plaster shears can be used, but if it is thick a strong knife or saw is necessary. The track of the knife or saw may be softened somewhat by dropping into it a little strong acetic acid or hydrochloric acid. The operation of removal is much facilitated if a strip of tin has been placed under the plaster, in the line of incision, while it was being applied ; the strip may be cut down upon without fear of wounding the patient. CHAPTER X INTECTIOX AXD DISI .\ Fl'XTION Bacteria are the minute vegetable organisms, so small that they can not be seen except with a microscope, many of which grow on or in the human body and cause disease. The terms microbes and germs are ordinarily used in the same sense as bacteria. An infectious disease is one which is capable of infecting other persons, causing the same disease in them ; smallpox and malarial fever are both infectious. A contagious disease is that form of in- fectious disease which is spread to others by contact with the person infected. Smallpox is a contagious disease. Malarial fever is not a contagious disease because no amount of simple contact with an infected person can produce the disease, the infection of which must be carried by a mosquito. Disinfection is the process of de- stroying the infectious germ or agent to prevent the spread of the disease. An infectious disease may be due to an animal or a vegetable organism ; in either case the parasite is so small as to be visible only under the microscope or not visible at all. Some of the diseases due to animal parasites are malaria, sleeping sickness, amoebic dysentery, and probably yellow fever and dengue. Sepsis or putrefaction is a particular form of infection; anti- septics are those substances which prevent putrefaction either by destroying the germs or preventing their growth. Sterilization is the process of killing disease germs ; it has the same meaning as disinfection, but is usually limited to disinfection by heat. In all disinfection work it should be constantly borne in mind that the agent employed must be used at the proper strength, for a definite length of time, and must be brought thoroughly in contact zvith all parts of the substance to be disinfected. The disinfectants commonly used by the medical department in addition to direct sunlight, are dry heat, boiling water, steam, cor- (200) IXFI'XTIOX AXL) DISIXFl-XTlOX 201 rosive sublimate, phenol, cresol, iodine, quicklime, chlorinated lime, formaldehyde solution, and suli^hur. Dr\ heat is seldom used, as the high temperature necessary in- jures falirics. and the heat has little penetrating pi-wer. l^loic'uig steam is used especially in the operating room for dis- infecting dressings. Boiling is a simple and effective method of disinfection for metallic or earthen utensils, and for cotton or linen fabrics. Woolen and leather substances are injured by steam or boiling water. The ad- dition of one per cent of carbonate of soda increases the disinfecting power of the boiling water and prevents instruments from rusting. Actual boiling for ten minutes is ordinarily sufficient. Corrosive subVunate in acid solution (0.2 per cent hydrochloric acid) is one of the most effective chemical disinfectants; for this purpose solutions of corrosive sublimate i :iooo are usually em- played. Its disad\ antages are that it is decomposed by albuminous matters, and by hard waters, and that it corrodes and rapidly de- stroys metals. Solutions should be freshly prepared, and in soft water, such as rain water or distilled water. When only hard water is available some other disinfectant should be used. Phenol is a valuable disinfectant in five per cent solution. It, like corrosive sublimate, coagulates albumin and thereby to some extent protects the inclosed germs from its disinfectant action. Cresol in one per cent solution has about the same value as phenol at five per cent. AUnmiinous fluids do not interfere with its action. Iodine in 3-5 per cent alcoholic solution is very valuable for dis- infecting wounds, or sterilizing the skin before operation. Quicklime is a somewhat uncertain disinfectant because of the fact that it is rapidly decomposed on exposure to the air and moist- ure. Milk of lime, a ten per cent solution of quicklime, is ordi- narily employed. To be effective the lime must have been freshly burned and be tmslaked. Chlorinated lime is used ordinarily in four per cent solution in water. Its activity depends on the amount of chlorine it contains, and, as it is rapidly changed on exposure to the air, it should have been freshly opened and prepared in order to be effective. Formalin is a solution of formaldehyde gas in water, its disinfect- ing ])owers depending on the dissolved gas. It is sometimes used in the form of a spray, but ordinarily the gas itself is employed. 202 XURSTXG The only apparatus rc(juircd is a large open vessel, protected by some non-conductive material to prevent the loss of heat from within. An ordinary milk pail, set into a pulp or wooden bucket, will answer every i)ur])ose, although a special container (Fig. 125) will be found of considerable advantage. This container or genera- tor consists of a simply constructed tin can with broad flaring top. Its full height is 15>2 inches, the height from the bottom to the flaring top being about 8 inches. The lower or round section is 10 inches in diameter, while the flaring top is 17^2 inches in diameter Fig. 125. Container for Generating I'ornialikhyde Cias. (Formaldehyde-potassium permanganate method.) at its top. The container is made of good quality of bright tin, is supplied with a double bottom with ^4 i"ch air space between the two layers, and is entirely covered on sides and bottom with asbestos paper. The asbestos paper and double bottom serve effectively to retain the heat which is generated by the vigorous chemical reaction occurring within, and which is essential to the complete production and liberation of the gas. This special container can be made by any tinner of ordinary intelligence, and costs but a few dollars. The following preparatory steps should be taken — (a) IIa\e all windows and doors (except door of egress) tightly closed. Securely paste strips of paper over keyholes, over cracks. INFECTION AND DISINFECTION 203 above, beneath and at sides of windows and doors, over stove holes and all openings in walls, ceiling and floor. If opening be large, paste several thicknesses of paper over opening. Carefully stop up the fireplace if there be one. There must be no opening through which gas can escape. (b) All articles in the room that can not be washed must be spread out on chairs or racks. Clothing, bed covers, etc., should Ije hung on lines stretched across the room. Mattresses should be opened and set on edge. Window shades and curtains spread out at full length. If there is a trunk or chest in the room, open it but let nothing stay in it. Open the pillows so that the gas can reach the feathers. Do not pile articles together. With the room thus prepared, as is essential in any form of gaseous disinfection, crystals of potassium permanganate ( i6 ounces to each 1,000 cubic feet of room space) are placed in the container. Over this is poured " formaHn," or the yjYz per cent aqueous solu- tion of formaldehyde (16 ounces to every 1,000 cubic feet of room space), the temperature of the room must not be below 60° F. The formaldehyde gas is promptly liberated by the vigorous reaction of the formalin and potassium permanganate, and arises from the generator in immense volume in the form of an inverted cone. It is consequently necessary that all preparations be made in advance, and that the operator leave the room at once on the combination of the two chemicals. The door or window of exit will be promptly closed and sealed and the room left closed for at least four hours. As in all methods of disinfection, success largely depends upon the care which is exercised and the attention which is given to every detail. Simple as the method is, neglect of any of the following points may result in complete failure : 1. The room should be sealed and prepared as described. 2. The potassium permanganate (16 ounces to every 1,000 cubic feet of room space) should be placed in the apparatus or generator. The permanganate must he put in before the formaldehyde solution. 3. The 2>7y2 psr cent formaldehyde solution (16 ounces to the 1,000 cubic feet of room space) should then be poured over the permanganate. 4. As the gas is given off in immense volume immediately after the mixture of the formaldehyde and permanganate, the operator 204 NL'RSIXG must leave the room at once. All preparations must have been finished in advance. 5. The door or window of exit must be promptly closed and sealed, so that there will be no escape of gas, and the room should be left closed for four hours. Whenever practicable, the special generator, previously described, should be used. In the absence of such a container, however, a milk pail may be used. The milk pail should be set. so as to fit snugly into a wooden or pulp bucket, or it may be wrapped tightly with several layers of asbestos paper. This is done to retain the heat within the generator and is very important to the proper genera- tion of the gas. Care must be taken not to place too much formaldehyde in a single container. The reaction is violent and there is great effer- vescence and bubbling. If the room is too large to be disinfected with one generator, use as many more as are required, and place in each only a reasonable amount. The following quantities may be used safely in the containers recommended : 10 or 12 quart milk pail. Formaldehyde 16 ounces; Permanganate, 16 ounces. 14 quart milk pail. Formaldehyde, 24 ounces; Permanganate, 24 ounces. Special apparatus described above. Formaldehyde, 32 ounces Permanganate, 32 ounces. Sulphur fumes are valuable as a disinfectant chiefly because of their power of destroying animal carriers of infection such as mos- quitoes, fleas, lice, and rats ; they also have some value as destroyers of bacteria but they injure metals, fabrics, fcod-stufifs and colors. Four pounds of rolled sulphur are required per i.ooo cubic feet of air space. The room must be tightly closed and all cracks and openings sealed; the sulphur broken in small pieces is placed in a pan and a small quantity of alcohol poured over it ; the pan is then placed on bricks in a tub of water, the tub placed on a table, not on the floor, and the alcohol ignited. The water serves two purposes : it increases the efficiency of the sulphur dioxide by virtue of the vapor liberated by the heat of the burning sulphur, and it also lessens the danger of fire (Fig. 126). INFECTION AND DISINFECTION 205 Sulphur candles can be used instead of crude suli)hur, but care must be taken to use sufificient candles. The average candle on the market contains one pound of sulphur. Three of these will be re- quired in the disinfection of a small room, loxioxio. Do not use a less number, no matter what directions may accompany the candle. The water-jacketed candle is preferable. Partly fill tin around candle with water and place candles in a pan on the table, not on the floor. Let one-half pint of water be vaporized with each candle. In the absence of moisture, the fumes of sulphur have no disin- fecting power. Keep the room closed for lo hours at least. The prevention of the spread of infections diseases requires abso- lute cleanliness^ free ventilation, disinfection, and isolation, and in the Fio. i-;6. — Ijurning Sulphur. case of diseases such as malaria, yellow fever, dengue, typhus fever, plague, etc., which are carried by insects, protection from the insect carriers. In the bacterial diseases the infectious agent is usually contained in one or more of the excretions of the patient, depending upon the particular disease. As the bacteria can not get into the air from moist excretions these should not be allowed to dry, but should be disinfected and removed at once. The dust of the ward becomes infected from excretory particles which have accidentally become dried ; hence every care should be taken to avoid raising dust. Flies and other insects may carry the infection on their feet or other parts of their bodies, therefore the discharges should be care- fully protected from insects. Spjttum should be received in covered cups containing a one per cent solution of cresol, or fiive per cent formalin. Sometimes paper cups are used, the cups and contents being burned together. Feces are best disinfected with milk of lime, ten per cent, or solu- tion of chlorinated lime, four per cent. 206 NURSING Urine should be sterilized by adding sufficient carbolic acid to make a five per cent solution, or enough corrosive sublimate to make a solution of i :iooo. In all cases the disinfectant solution employed should be equal in bulk to the material to be disinfected and should be thoroughly mixed with the excretion and allowed to stand at least an hour. The vessels which have been used as containers should be boiled. Infected clothing and bedding should be disinfected by steam, or formaldehyde gas in a tight chamber, but steam should not be used for woolens. If the infection is gross, as when the bed linen of a typhoid or cholera patient is soiled with feces, the articles should be soaked in a cold phenol or cresol solution containing two per cent of soft soap for several hours. Boiling is applicable to linen or cotton fabrics. Mattresses of which the hair is infected require steam under press- ure, the ticking having been opened up. Metal beds should be washed with five per cent solution of carbolic acid. Disinfection of rooms: The contents of the room should not be removed. Articles of bedding and clothing should be hung on lines or the l)acks of chairs so as to expose as much surface as possible. The room must then be made practically airtight by sealing windows, doors, ventilating openings, and all other cracks and open- ings with strips of paper and ordinary flour paste. Formaldehyde gas or sulphuric-acid gas is then introduced in proper proportion and the room kept sealed for twenty-four hours. The latest investigations indicate that this preliminary fumiga- tion is of little value and may be omitted ; the mechanical cleansing is the important feature. The treatment of the walls and ceiling will depend upon their nature; if hard-finished or painted they should be scrubbed with hot water and soap, and then with an acid solution of corrosive subli- mate, I :iooo, and repainted; a preliminary scrubbing of the walls with slices of stale bread is very effective for mechanical cleansing ; bread so used should be burned. If the walls are calcimined or whitewashed they should be washed with soap and hot water, fol- lowed by ten per cent solution of chlorinated lime or five per cent of INFECTIOX AXD DISINFECTION 207 phenol, and recalcimined ; sublimate should not be used because it is decomposed by the lime. If the walls are papered the paper shouW be removed, after which the treatment is the same as for calcimined walls. Especial attention should be given to the lower parts of the walls, the first six feet from the floor. All woodwork is to be scrubbed with soap and hot water, followed by corrosive sublimate ; painted or varnished woodwork should be repainted or varnished. Floors with hard finish should have the old finish removed with turpentine and a new coat applied. After the completion of the disinfection the room with all doors and windows open should be freely exposed to the action of sun and air for several days. Disinfection of tentage: Everything should be removed from the tenl for disinfection by the methods appropriate to each. The in- terior of the canvas, the poles, and the wooden floors, if any, should then be sprayed or washed with a two per cent solution of cresol or five per cent phenol. The tent is then removed to a new site, pitched inside out and exposed to the sun and air for twenty-four hours. The ground under the old tent floor should be policed and scraped, and sprinkled with a ten per cent solution of chlorinated lime or freshly slaked quicklime. CHAPTER XI INSTKUMENTS AXD Al'l'LIANCES The following is a brief description of those instruments and appliances which require explanation : Explanation of Figs. i2y to 135. Atomizer, hand: An instrument for producing a fine spray (Fig. 127). Bistoury: A long, narrow knife, which is either straight or curved, sharp or blunt pointed (Fig. 128). Bougie: An instrument used for dilating strictures (Fig. 129). Bougie a boule: An instrument used to locate strictures (Fig. 130)- Bougie, filiform: A hairlike bougie for passing through tight strictures (Fig. 131). Catheter: A tube for passing through the -urethra into the bladder to draw off the urine. Catheters are made of silver, glass webbing, or rubber, of various sizes, and sometimes contain a wire called a strict (Fig. 132). Catlin: A double-edged amputating knife (Fig. 133). Caustic-holder: A little case for holding caustic, usually made of gutta-percha or silver (Fig- 134). Curette: An instrument used for scraping bones and unhealthy wounds (Fig. 135). (208) Fig. 127. INSTRUMENTS AND APPLIANCES 209 Fig 129. Fig 130. Fig. 135. 14 210 NURSING Explanation of Figs. 136 to 139. Cutting shears: A strong scissors for cutting plaster bandages (Fig. 136). Clamp, pile: Ivory faced blades, to prevent burning of tissues while using thermocantery (Fig. 137). Clamp, towel: Employed to secure the towel of gauze protector to the edges of the wound (Fig. 138). Cooler, prostatic: For cooling and massaging the prostate gland (Fig. 139). IXSTRU.MEXTS AXD APPLIANCES 211 Fig. 136. Fig. 139. Fic. 133. Fic. 13; 212 NURSING Explanation of Figs. 140 to 145. Divuls'or, urethral: For rapid dilatation and diviilsion of strictures (Fig. 140). Director: An instrument with a groove in which to guide the point of a knife (Fig. 141). Drill, bone- An instrument for boring holes in bone (Fig 142). Endoscope, urethral: For examination of the urethra (Fig. 143). Forceps, bullet: An instrument with separate blades used for extracting bullets (Fig. 144). Forceps, dental: An instrumerrt used for extracting teeth (Fig. M5). INSTRUMENTS AXD APPLIANCES 213 Fig. 141. Fig. 140. 214 NURSING Explanation of Figs. 146 to 151. Forceps, dissecting: Plain forceps used for di3secting purposes (Fig-. 146J. Forceps, dressing: Forceps with scissor handles, tised for remov- ing old dressings from wounds and sores (Fig. 147). Forceps, bone holding: For holding bone during operations (Fig. 148). Forceps: Ear dressing (Fig. 149). Forceps: Nasal dressing (Fig. 150). Forceps, sterilizer: For removing instruments from sterilizer (Fig. 151). INSTRUMENTS AND APPLIANCES 215 Fic. 150. Fig. 147. 216 NURSING Explanation of Figs. 152 to 157. Forceps, tongue: For grasping and holding the tongue during anaesthesia (Fig. 152). Forceps, gouge: A strong forceps, cutting at the points, so as to gouge bone (Fig. 153). Forceps, hemostatic: Forceps for taking up arteries (Fig. 154). Forcet's, Listons bone: A strong bone forceps for cutting bone in operations (Fig. 155). Forceps, mouse-tooth: Forceps with fine, sharp teeth, used in dissecting (Fig. 156). Forceps, ncedJe-iiolder: A forceps to hold the needle in sewing wounds (Fig. 157). IXSTRUAIEXTS AND APPLIANCES 217 Fig. 152. Fig. 157. 218 NUKSIXG Explanation of Figs. 158 to 164. Forceps, scqiicstniin: A strong forceps' for pulling- away dead bone (Fig. 158J. Gay, month: An appliance for holding the mouth open (Fig. 159). Gouge and chisel: For gouging and splitting bone (Fig. 160). Head mirror: A round mirror worn on the forehead in the ex- amination of the throat and ear (Fig. 161). Jnfiator, Polit.zer: A rubber air bag with nozzle used in inflating the ear (Fig. 162). Inhaler, chloroform: A framework covered with gauze or flannel for administering chloroform (Fig. 163). Inhaler, ether, Allis: An appliance for the administration of ether (Fig. 164). INSTRUMENTS AND APPLIANCES 219 Fic. 162. Fig. 160. Fig. 164. 220 NURSING Explanation of Figs. 165 to 175. Knife, amputating: Used for amputating a limb; a large one is used for amputating the thigh, a medium size for the leg, a small one for the arm (Fig. 165). Knife, tenotomy. A small narrow knife for cutting tendons under the skin (Fig. 166). Lachrymal probes: Small silver probes for introducing into the tube or duct leading from the eye to the nose (Fig. 167). Lachrymal styles: Button-headed silver instruments for passing into the duct leading from the eye to the nose (Fig. 168). Lancet: An instrument used for bleeding, vaccinating, and open- ing boils or small abscesses (Fig. 169). Lavage tube, rectum: A large, soft-rubber tube for washing out the bowel (Fig. 170). Lavage tube, stomach: A large, soft-rubber tube for washing out the stomach (Fig. 171). Needle, aneurism: A curved, blunt instrument, with an eye near the end, used for passing a ligature under an artery (Fig. 172). Needles: (a) An ordinary suture needle; (b) a cervix needle; (c) an intestinal needle; (d) a perineal needle. Needles are made in a very large variety of styles and sizes (Fig. 173). Periosteotome: An instrument Jor separating the periosteum from bone (Fig. 174). Probe: A silver-wire instrument for probing wounds (Fig. 175). IXSTRL'MEXTS AXD APPLIAXCLS 221 i Fig. 170. Fig. 171. Fig. 165. Fig. 172. Fig. 174. 222 NURSING Explanation of Figs. 176 to 181. Retractor: An instrument for holding apart the edges of wounds in operating (Fig. 176). SaiK', amputating: A saw used for sawing the bone in amputa- tions of the limb (Fig. 177). Saw, Hey's: A small saw for cutting a piece out of a bone ; used in operations on the skull (Fig. 178). Sazv, metacarpal: A small, straight saw for dividing the meta- carpal bones (Fig. 179). Sazv, plaster of Paris: For breaking and removing plaster band- ages (Fig. 180). Scalpel: A short knife with a convex edge, made in different sizes and used for cutting and dissecting (Fig. 181). IXSTRLAIEXTS AND APPLIAN'CES 223 Fig. i8i. Fig. iSo. 224 NURSING Explanation of Figs. 182 to 189. Scissors: Straight (Fig. 182). Scissors, curved. Scissors having the blades curved (Fig. 183). Scissors, bandage: For cutting bandages, etc. (Fig. 184). Sound: A metal instrument for dilating strictures or examining the bladder (Fig. 185). Specidum, ear: A more or less conical cylinder for examining the ear. Usually in nests of different sizes (Fig. 186). Speculum, e\e: An instrument for holding apart the eyelids (Fig. 187). Speculum, nose: A valved instrument for holding open the nostril (Fig. 188). Sponge-holder: An instrument for holding sponges when operat- ing in cavities (Fig. 189). INSTRUMENTS AND APPLIANCES 225 226 • NURSING Explanation of Figs, igo to 194. Spectulum, rectal: For examination of the rectum (Fig. 190). Spud and needle, eye: For removing foreign bodies from tlie eye (Fig. 191 j. Searcher, stone: For ascertaining the presence of stones in the bladder (Fig. 192). Syringe, urethral: For applying solutions into the urethra (Fig. 193)- Syringe, ivound dressing: Also used for filling the bladder in con- junction with soft-rubber catheter (lig. 194 J. INSTRUMENTS AND APPLIANCES 227 Fio. 190. Fig. 192 228 NURSING Explanation of Figs. 195 to 197. Stethoscope: An instrument with which to hsten to the sounds of the chest (Fig. 195). Syringe, hypodermic: A graduated glass or metal syringe tilted with a hollow needle, employed in the injection of morphine and other medicines beneath the skin (Fig. 196). Tenaculum-Forceps: (Fig. 197). INSTRUMENTS AND APPLIANCES 229 Fig. 195. Fig, 197. Fig. 196. 230 NURSING Explanation of Figs. 198 to 200. Thermo-cautery , Paqurlin: A cautery in which the fuel is incan- descent benzine (Fig. i(j8i. Tongue depressor: An apphance for holding dQ\\n the tongue in throat work (Fig. 199). Tonsillotome: An instrument for removing the tonsils (Fig. 200). IXSTRL'-MKXTS AXD APPLIANCES 231 Fig. 198. Fig. 199 Fig. 232 NURSING Explanation of Pigs, soi to 205. Tourniquet : An instrument for makmg pressure on an artery to stop the flow of blood through it (Fig. 201). Tracheotomy tubes: Two curved silver tubes, one fitting inside the other, used for putting into the wind-pipe when it has been opened by an operation called tracheotomy (Fig. 202). Trephine: A circular saw used in operations on the skull (Fig. 203). Trocar and cannula: A sharp pointed instrument and sheath for tapping collections of fluid (Fig. 204). Truss: An appliance used in the treatment of rupture (Fig. 205). IXSTRL'MEXTS AXD APPLIAXCES Fig. 201. Fig. 203. Fig. 203. Fig. 204. 1"IG. 205. 234 NURSING Explanation of Pigs. 206 to 208. Beside the above there are certain special apparatus and cases : .-Ipparatus, compressed air: This consists of a metal air container, a force pump for compressing the air, tubing for connections, a cut-off for controlling the escape of the compressed air, and a set of spray tubes (Fig. 206). Apparatus, electric: This is issued in several forms. The essen- tial parts are the cells, which generate the current, the electrodes by which it is applied, the conducting cords, and the coil and inter- rupter in the case of a faradic battery (Fig. 207). Apparatus, restraint: This is contained in a locked wooden box, and consists of a bed strap which is firmly fastened to the bed before the patient is placed upon it ; a breast strap which fastens the patient to the bed strap and bed, anklets, wristlets, a muff, and a set of keys, by which the buckles of the apparatus can be locked (Fig. 208). IXSTRUMEXTS AXL) APPLIANCES 235 Fig. 208. 236 NURSING Explanation of Figs. 209 to 210. Apparatus, steam sterilimng: For instruments and dressings (Fig. 209). Apparatus, infusion: For saline injection (Fig. 210). INSTRUMENTS AND APPLIANCES 237 t . v.'- r^^ _• -^ 5 ^; CEW E^ ~''&i'l ' *; Fig. 210. 238 NURSING Explanation of Figs. 211 to 213. Apparatus, blood pressure: For determining the diastolic and systolic blood pressure in diagnosis of diseases of heart, arteries and kidney (Fig. 211). Bottle, drop: For chloroform and ether (Fig. 212). Case, aspirating: This consists of a rubber stopper containing a double current metal tube with stopcocks, a pump, aspirating needles, trocar and cannula, and tubing attachments. To use it a bottle in which the rubber stopper fits tightly must be supplied; the double current metal tube is connected on one side with the pump and on the other with an aspirating needle. The air is pumped out of the bottle, creating a partial vacuum, after which the stop- cock connecting with the aspirating needle is opened and the fluid drawn off into the bottle (Fig. 213). IXSTRLAIEXTS AXi) APPLIAXCES 239 Fig. -mi. Fig. 2i; I'iG. 213. 240 XL'RSIXG Case, cmcrgcucy: Tliis is a case for use of medical ofificers, con- taining a h}])odcrniic syringe, clinical thermometer, a few simple instruments, and tablets of the most useful medicines. In the field everything is made as light and portable as possible in order to reduce transportation. .Appliances and equipment are packed in certain chests, cases, etc., which require some description. Diagnosis Tags: A book of diagnosis tags with a pencil attached is contained in each orderly pouch. The diagnosis tags are made according to the following specifications : Size 2}^ by 5^/2 inches, provided with a copper wire four (4) inches long for fastening to the clothing. Material to be linen, faced with paper. All inks and colors used to be "fast." Twenty-five (25) or fifty (50) to be bound in a book with paste- board covers. Form to be as follows : Date and hour Not able to walk. ^ (White ) Xamc and rank Regiment or department Diae^nosis Treatment Ambulance station Field hospital Signature Fig. 214. The following directions should be printed on the inside of the cover: I. In any wound or disease not rendering the patient unable to walk, detach the white body of the tag, leaving the colored border attached to the stub. In a wound or disease rendering the patient imable to walk, detach the entire tag. including colored border. It will thus be always possible to ascertain by the number of colored borders left with the stubs how many of the patients treated were or were not able to walk. IXSTRUMEXTS AND APPLIANCES 241 2. Under " Diagnosis '' note all essential facts, character of in- jury, parts involved, fracture, etc. 3. Under "Dressing Station" and "Field Hospital" note any additional treatment applied. If at either place it is deemed best net to evacuate a desperately sick or wounded patient any further, write the words " not transportable," or the initials " N.T." 4. Under " Remarks " on the back may be noted any important fact for which there is no room on the face, whether operation or treatment is urgently needed, the amount of stimulant or anodynes already administered, etc. 5. I'asten to button on clothing of patient over sternum or as near it as possible (Fig. 214). Field desk: This is an iron-bound oak chest, with padlock, in a hinged case. It contains waiting materials, blank books, and blank forms ; their are two sizes, Nos. i and 2. Food box: Contains hospital stores or containers for the same. Commode chest: A box containing a bed pan. chamber pot, urinal, spit cup, and toilet paper. .Icctylenc chest: A chest completely equipped with apparatus for illumination with acetylene gas. The regimental combat equipmoit includes a medical and surgical chest, a water sterilizing bag. a box of surgical dressings and other necessary articles enumerated in par. 866 M. M. D. Mess chests: This contains equipment to serve 25 persons. Belt, web icith pouch: This takes the place of the old hospital cor])s pouch. The pouch contains dressing forceps, scissors, pencil and book of diagnosis tags, while the belt provides ten pockets for field tourniquets, dressing packets, iodine swabs, bandages, sub- limated gauze, adhesive plaster, pins and aromatic ammonia. Chests, field laboratory. Nos. i and 2. Chest, medical and surgical, supplementary. Chest, tablezcare. Saddle, pouch. Venereal prophylaxis unit. 16 cii.\in"i<:R XII Tin: or'iiKAi ixt. room and strcical nursing Ix llie chapter on infection and disinfection we have already spoken of bacteria in relation to disease ; here we must consider them with special reference to surgical infections. ^'V'^'« \'^^^ "'M^'^ Fig. J15. — \'arioiis Types of Bacilli c/ '' V ^ ^ •% V Bacteria may be divided into two general classes, bacilli or rods, (Fig. 215), and micrococci or spherical bacteria ( Fig. 216 ) ; it is these latter that are specially concerned in wound infections. Mi- crococci may also be divided into two classes ; those which are ^%x)COCCC«Xtv 8 ^00 p ^ 08 Fig. 216. — Staphylococci and Streptococci. grouped in clusters like grapes, called staphylococci, and those arranged in chains, streptococci ; the former are concerned in ordi- (242) OFERATIXG ROOM AND SL'RGICAL XURSIXG 243 nary suppurations such as boils and abscesses, while the latter are the active agents in sej^ticemia and erysipelas. Some bacteria produce spores or seed which are much harder to kill than the bacteria themselves. We have already seen that sepsis means putrefaction; an aseptic wound is one that is surgically clean, that is free from all germs ; antiseptics prevent putrefaction by destroying the germs or prevent- ing their development. A wound otYers just the conditions neces- sary for the growth of bacteria — heat, moisture, and abundance of nutritive material, and the bacteria are everywhere present, on the skin, on the clothes, instruments, and fingers, and in the air, so that if we are to avoid infection minute care is necessary. All disease germs in the process of their growth produce certain poisons, the nature and action of which vary with the particular germ. Yeast, which is really a mass of germs, in its growth in sugar solu- tion produces alcohol, which when absurl)ed causes intoxication and, if in excessive amounts, death. The nux-vomica plant in its growth produces strychnine, one of the most powerful of all poisons. So with disease germs. The staphylococci in a wound cause inflam- mation and suppuration; if the poison is absorbed fever results, toxemia or blood poisoning. Streptococci have the same effect, and in addition frequently invade the blood themselves and grow there, producing septicemia, pxonia, and death. Pyemia differs from septicemia only in that abscesses form at a distance from the original infection, especially in the joints, muscles, and lungs; the abscesses are caused by the pus cocci which reach those points through the blood. The most important point in surgical nursing is absolute cleanli- ness on the part of the nurse ; a nurse with dirty hands and finger nails is an abomination and should not be tolerated for a moment. It sh(3uld be l)orne in mind that surgical infections are readily carried from one patient to another, and thorough cleansing and disinfection of the hands before dressing each case should be an invariable rule. The preparation of a patient for a major operation usually begins the night before, when a laxative is given followed by an enema early in the morning of the operation. About twelve hours before the operation the field of operation and the surrounding skin are shaved and then washed with hot water and soap ; about six hours before the operation the skin is 244 XrRSIXG willed dry with a sterile towel and then moistened with tincture of iodine, and covered with dry sterile gauze. If the operation is done in the morning no food is given after the light supper of the previous night, except perhaps an early cup of cotYee. The urine is passed or drawn the last thing before gfing to the operating room ; at the same time any false teeth are removed. Just before the operation a second application of iodine is usually made, but many surgeons do not consider this necessary. The iodine is applied with a sterile swab. In emergency operations the washing is omitted and the shaving done without soap because the iodine penetrates the skin better if it is perfectly dry. After-care: While the operation is being done the bed has been prepared in the prescribed manner ; when the patient is in bed a nurse is detailed to remain by him until the effects of the anesthetic have passed off. This is necessary as in his unconscious condition he may fall out of the bed, tear off his dressings, get up, or choke while vomiting, and be unable to help himself. Sometimes the patient may be in a condition of extreme shock, with cold, clammy skin, shallow breathing, and weak rapid pulse ; in such a case hot- water bottles should be freely used, stimulants given, and the foot of the bed raised. After shock the next dangers to be looked for are hemorrhage and infection. Infection usually first manifests inself by a rise of temperature and chilly sensations ; even aseptic cases, however, often have a temperature of about ioo° F. for the first day or two, constituting what is known as surgical fever. In aseptic cases there is little for the nurse to do beyond the adminis- tration of diets, as the first dressings are not changed for a week or ten days. The urine usually has to be drawn every six hours for the first twenty-four hours, or until the control of the bladder is regained. In surgical rounds the duty of the nurse is to have everything ready for any necessary change of dressings. Dressings may be dene in the ward, or there may be a special dressing room to which the patients are taken on a litter. In the former case a movable dressing table or ward carriage is usually employed. Besides a liberal supply of sterilized dressings in glass jars there will be required bandages, safety pins, an irrigator, antiseptic and sterile normal saline solutions, scissors, dressing forceps, dissecting forceps. OPERATING ROOM AND SURGICAL XLJRSIXG 245 basins, and a covered pail or paper bags for the soiled dressings, hot and cold water, soap, hand brushes, towels, and rubber sheeting. Dressings are of two general types, dry dressings and zvct dress- ings; the former are almost invariably used in aseptic wounds and consist of a pad of sterile gauze about half an inch thick, covered with a layer of absorbent cotton. Wet dressings are used in infected wounds and consist of a pad of sterile gauze soaked in a i :2ooo solution of corrosive sublimate or a two-per-cent solution of phenol ; over this a layer of absorbent cotton, and then a piece of oil silk, rubber tissue, or waxed paper. Antiseptics are used in wet dress- ings because we wish to destroy the germs which we know are already present, and the whole dressing is covered by a protective, as we call the oil silk, because we wish to keep the dressing moist and so allow a more uniform diffusion of the discharges which always occur in infected wounds. The operating room: The attendant in charge of the operating room must have a clear understanding of the technique of aseptic operating and must be a man of great carefulness and conscientious in details. He must remember always that surgical infections usually come from contact with something not surgically clean, and not from the air. The room itself must be clean and free from dust; it must be disinfected at frequent intervals and no dusting must ever be permitted there ; instead the floors must be mopped and the walls wiped with cloths moistened with an antiseptic solu- tion. The temperature of the room should be about y2° F., 80° F. in abdominal operations. Sterilizers: There are two general types of sterilizers in use, the essential difference being that in one steam is used under pressure, and in the other the steam is flowing. Of the latter kind of sterilizer, the Arnold is a type. In hospitals, steam under pressure is always used. The steam pressure sterilizer is known as an autoclave. It con- sists essentially of a metal cylinder with a tight fitting door, and pro- vided with a steam pressure gauge, safety valve, air vent, ther- mometer, and apertures for the entrance of steam. Outside the cylinder is a steam jacket, with a space between it and the cylinder, in which the steam circulates. In sterilizing dressings, a pressure of fifteen pounds of steam for twenty minutes is usually employed. i46 XL'RSIXG If glassware is used in tlie sterilizer, it is necessary to put a folded towel or something of that nature, between the glass and the metal, to prevent l)reakage, and if liquids are contained in the glass, the door of the chamber should not be opened until the pressure within is reduced to the normal, otherwise the liquid may boil over or the stopper may be blown out. The operating table is prepared by covering it with a folded blan- ket, over which is placed a rubber sheet and over that a sterilized sheet or a Kelly pad or surgical cushion may be used. On a small table by the head of the operating table are placed the appliances used in anesthesia. Instruments are usually sterilized by boiling from two to five minutes in one-per-cent solution of soda, the soda being used to pre- vent rusting. As boiling dulls sharp instruments, these may be better sterilized by soaking in 95 per cent alcohol for half an hour. Aluminum instruments are ruined by soda solution ; they must be boiled in plain water. Instrument trays, basins and pitchers, and rubber irrigators are boiled five minutes in plain water. Dressings cut in proper sizes, bandages and gauze, sponges, tow- els, sheets, and operating gowns are w-rapped in towels or sheets, pinned in small packages, and sterilized twenty minutes under fifteen pounds steam pressure. Besides the dry sterilized towels a number of damp towels sterilized by boiling should be ready to surround the field of operation and for other purposes. Gauze sponges are prepared of four or five thicknesses of gauze about six inches square with the end sides folded in or stitched so that there will be no loose threads to be left in the wound. Laparotomx pads are usually of several thicknesses, with the edges turned over and sewed, and with a tape fastened to one corner. Gauze for packing is cut in long narrow strips, folded inward sev- eral times from the edges, and the strips then packed in glass tubes closed with cotton, before being sterilized. In many hospitals gauze which has been used except in septic cases, is used over again after preparation as follows: Soak for several hours in cold water, with frequent stirring. Wash clean, under a running stream of tepid water. Boil for half an hour. Wring out dry. and then proceed as with new gauze. Iodoform gauze is frequently used, especially for packing sujipu- OPERATING ROOM AND SURGICAL XLRSIXG 247 rating wounds or abscess cavities ; it is prepared as follows : Sterilize five yards of gauze ; mix ten ounces of glycerin with an equal amount of water and boil fifteen minutes; add a half-ounce of iodoform to three ounces of alcohol and mix with the water and glycerin ; then, while stirring briskly, immerse the gauze in the mixture; wring out and keep moist in a closed glass jar. The sutures and ligatures ordinarily used are catgut, silk, silkworm gut, and silver wire ; the three last named are sterilized by simple Fig. ::i~. — Preparation of Gauze Sponges. boiling in plain water. Catgut is not made from the gut of a cat, but from that of the sheep ; being animal in nature it requires thorough sterilization, but will not stand boiling in water. Catgut in the army medical service is usually issued already sterilized, but m.ost surgeons prefer not to rely on trade processes, and prepare their own animal sutures. There are many different methods employed ; nearly all include as the first step the removal of the fat from the catgut by soaking forty-eight hours in ether which is changed daily. Among the methods are lx)iling in alcohol, the iodine method. and the cumol method. The iodine method is satisfactory and simple. The catgut without previous preparation is wound on glass spools in one layer and placed in a one-per-cent solution of iodine and iodide of potash in distilled water for one week ; the spools are then withdrawn and kept in alcohol. Boiling in alcohol. Wind the catgut on clean glass spools, soak in ether for twenty- four hours to remove grease, shaking several times during the period ; remove from the ether and soak twenty-four 248 NURSING hours in alcoholic solution of corrosive subHniate 1:500; remove from sublimate solution and bo'il in 95 per cent alcohol over a water bath for ten minutes. Keep in same jar until recjuired for use. Metal and (/lass syringes with rubber or asbestos packing may be boiled ; if the packini^-s are leather draw boilint^ water into the syringe, immediately force it out, wash out several times with five l)er cent i)henol. and soak in the same solution while full ; the needles are boiled with the wires in place. Rubber goods: Vulcanized rubber may be boiled for one minute; fountain and bulb syringes, drainage tubing, rubber bandages, rub- ber gloves and linger cots, soft-rubber catheters and bougies, may be boiled five minutes in i^lain water. Hard rubber is spoiled by boiling; soak in five per cent phenol. Rubber tissue (gutta-percha) will not stand boiling; wash in cold water with green soap, rinse, immerse twenty-four hours in solution of corrosive sublimate i :iooo. J!\^b catheters and bougies will not stand heat; disinfect in an antiseptic solution. Large quantities of boiled teater. both hot and cold, will be neces- sary, also sterile normal saline solution, and f re-^hl}' prepared antisep- tic solutions — two per cent phenol and i :2ooo bichloride of mercury. Normal saline solution is a 0.9 per cent solution of sodium chloride (common salt) in water. It is called "normal " because it has the same specific gravity as blood serum, which fact renders it less irri- tating than plain water. It is prepared by dissolving nine grammes of salt in a liter of boiling water and sterilizing in a glass flask, which is exposed to flowing steam in a steam sterilizer for a half-hour at a time on tb.ree successive days. This method of fractional sterili- zation is more successful than a single sterilization for an hour and a half because, while a single exposure of half an hour will kill all the adult bacteria, the spores or seeds are more resistant; the inter- vals of twenty-four hours allow the development of the spores which are then killed by the next sterilization. The mouth of the flask is closed with nonabsorbent cotton which is drawn over the lip of the flask and held in place by a piece of gauze. In the absence of normal saline tablets or exact means of measurement, the proper amount of salt may be approximated by using a scant teaspoon ful to a pint of water. In emergency the water is simply boiled five OPERATING ROO.M AXU SURGICAL NURSING 249 minutes instead of being subjected to fractional sterilization. When used for intravenous or subcutaneous infusion the solution should be filtered just before use. Drainage may be tubular or capillary ; for the former, rubber or glass drainage tubes are employed. Rubber drains are prepared for use by wasing with soap and water, rinsing, boiling five min- utes, and keeping in a tiiree-per-cent solution of phenol frequently changed. Glass drains are boiled. For capillary drainage we use a few strands of catgut or horsehair, or the so-called " cigarette drain." The " cigarette drain " is prepared by rolling a strip of gauze of the proper size in a piece of gutta-percha tissue, just as tobacco is rolled in a paper to make a cigarette. For capillary drainage we use strips of gauze about an inch wide and free from any loose threads, or a few strands of silkworm gut may be employed. The most important part of the whole preparation is the disin- fection of the hands and forearms of the operator and his assistants. !Many different methods have been recommended for this purpose, and, while none are capable of making the hands germ free, most of them give satisfactory results. In all the methods there are two steps ; first mechanical cleansing ; second, chemical sterilization ; the first is by far the most important. An excellent method of mechanical cleansing is as follows : After trimming the nails close remove all dirt from beneath them with a nail cleaner ; anoint the hands with soft soap or a liniment of soft soap, and rub thoroughly with a mixture of equal parts of corn-meal and powdered mustard ; wash in running hot water and thoroughly scrub for five minutes with a stiff brush recently boiled : pay especial attention to the edges of the nails : again clean the nails with a sterile cleaner, rinse the hands in boiled water, immerse in alcohol, and scrub five minutes, using gauze sponges. Most surgeons prefer to use freshly boiled rubber gloves, but evert with the gloves sterilization must be done just as thoroughly, as gloves are often punctured or leaky. The field of operation is prepared by painting it with tincture of iodine : only so much of the surface as is necessary is exposed, all the rest of the body being protected by a blanket covered with sterile sheets : immediately around the operating field wet antiseptic or sterile towels are used. 250 Nl'RSING The sterilization of the hands is usually done after the operating gowns or suits are put on, and (jnce done nothing should be touched which is not sterile ; this is the rule which is most fre(|uently broken by the inexperienced nurse; in his hurry or excitement he picks up something which is not sterile and then he must disinfect his hands again. Frequently during the operation the surgeon will wish to wash his hands to remove blood, so that a basin of sterile water must be kept ready at hand. After the operation the room must be immediately cleaned. All imused animal sutures which have been handled should be thrown away ; soiled or bloody towels, sheets, etc., placed to soak in cold water and the instruments cleaned, counted, and put away. 7'o clean the instriiineiits they are taken apart and washed in cold water to remove the blood, paying special attention to serrated parts, they are then washed in hot water and soft soap, rinsed, and thor- oughly dried. Instruments wdiich have been used m an infectious case must be sterilized before being cleaned. Scalpels and other cutting instruments must be cleaned separately, taking particular care not to dull the cutting edge. Needles should be dipped in alcohol, thoroughly dried, and placed in a box with lycopodium. Artery forceps which take apart usually have the same number stamped on the corresponding blades : if they do not. they should be cleaned one by one, so as not to get them mixed. Locks, screws, holes, and depressions must be carefully cleaned and dried with wisps of absorbent cotton. Rouge and pntz-pomade may be used to remove rust and stain. The leather packing and washers of syringes must be kept moist bv frequent use of water or glycerin, and such syringes should always be tested before use to see that they are in working order. Fountain syrim^es after washing should be himg bottom up to dry. after w^hich their mouths should be plugged with cotton to exclude dust. Rubber catheters after drying are to be kept in talcum. Rubber bandages in like manner are to be dusted with talcimi and rolled up. tapes, if any. inside; they must be protected from the air bv inclosure in a tin box \\\t\\ the top secured with a strip of rubber plaster. Rubber gloi'es should be thoroughly dried with a towel, dusted OPERATING RUU-M AND SURGICAL XGRSIXG 251 with talcum inside and out, and protected from the air in tin boxes. I'unctures may be closed with rubber cement, or patched with a piece of an old glove by the aid of the cement. In the field many of the conveniences of the operating room in the post hospital are absent, yet very excellent results may be ob- tained. The work must be done in a tent, or even with no more shelter than a fly ; under such circumstances dust is one of the great- est dangers to be guarded against. If possible no movement of troops or wagons should be allowed in the immediate vicinity ; the floor of the tent and the grounds around it should be thoroughly sprinkled to lay the dust, and wet sheets may be hung up so as to afl'ord further protection to the wounds. If no soda is available to boil the instruments, wood ashes may be used tied up in a bag to avoid clouding the water ; when steam sterilizers cannot be had the dressings may be boiled, or, in the absence of fire, saturated with antiseptics. When the water is very hard, muddy, or full of organic matter, bichloride of mercury is so rapidly decomposed that it should not be relied upon as an antiseptic ; phenol should be used instead. If there are no receptacles large enough to boil the trays they should be scalded with boiling water, and strong antiseptic solutions allowed to stand in them for a half-hour before use. In the absence of other suture material horsehair answers very well : it may be rendered aseptic by washing with soft soap and water, boiling ten minutes in 0.25 per-cent solution of soda and then ten minutes more in plain water, after which it is kept in a i :iooo alcoholic solution of corr(»sive sublimate. CHAPTER XITI NURSING I.\ Tlir: I. \ FACTIOUS DISEASES It is important that nurses should know something of the most common infectious diseases, especially how they are transmitted from person to person, the particular symptoms and special dangers of each, and how they affect the character of the nursing. We have already defined infectious diseases as those which may be transmitted to others ; it is the business of the nurse to prevent such transmission. It should be remembered that contact is the great source of in- fection in medical cases, just as it is in surgical cases, and therefore medical asepsis should be observed. All utensils and appliances used about the patient should be for his exclusive use, and kept within the room or barrier; nothing should be taken out of the room unless it be immediately sterilized ; the nurse should wear rubber gloves when handling the patient, or wash and sterilize his hands immediately thereafter, and should put on a special gown, to be kept in the room, whenever he comes in contact with the patient or his bed. Vaccines and antitoxins. Vaccines usually contain the dead or weakened germs of the disease against which they are used, while scrums and antitoxins contain the natural antidotes for the poison created by their germs. Both vaccines and antitoxins are used as well to cure diseases as to prevent them. The most common vaccines are those of smallpox, tyi)hoid, cholera, and plague, while the most common antitoxins are those of diph- theria, tetanus, and plague. Vaccinatio7i against typhoid. The site of the inoculation is the arm at the insertion of the deltoid muscle. If for any reason this site can not be used, the needle may be introduced in the back, over the lower portion of the scapula, or in the chest below the clavicle. The dose is to be given subciitaneously and not into the muscles nor into the skin. The arm should be cleansed as for any other operation. (252) IXFECTIOL'S J)1SEASES 253 Tincture of iodine painted over the dry skin, before and after the injection, has proven satisfactory. The ampule should be washed off in an antiseptic solution and opened after making one or more cuts near the top with a file. The vaccine can be drawn out of the container with a syringe, or it may be emptied into a shallow glass dish, such as a salt cellar, which has been sterilized by boiling. The syringe and needle should be sterilized by boiling in two-per- cent soda solution. To insure perfect sterilization, draw the piston out to its full length, or remove it entirely, so that the barrel is full of water during the boiling. A fresh needle should be used for each man, or, if one needle must be used on two or more men, it should be resterilized before each injection. Among the more common infectious diseases are gonorrhea, chan- croid, syphilis, typhoid fever, malaria, yellow fever, cerebro-spinal fever, dysentery, cholera, diphtheria, tuberculosis, influenza, ton- sillitis, mumps, erysipelas, and wound infections. Typhoid fever: This disease is due to infection with the typhoid bacillus, which always gains entrance to the ]:)ody through tlie mouth, and escapes from the body of the typhoid patient in the stools and urine and occasionally in the sputum. The germs are usually swallowed in infected water or food, but may get into the mouth indirectly as when one has been handling infected clothes, bedding, or other articles, and then handles food without washing the hands. The urine of the typhoid patient often contains typhoid germs for weeks after the patient is convalescent, hence the danger of urinating on the ground, w^here the germs grow readily and, getting on the shoes of the soldier, are carried into barracks. The initial lesion of typhoid fever is usually ulceration of the lower end of the small intestine, and this ulceration causes diarrhea and may go deep enough to cause hemorrhage or even perforation of the bowel. Sudden collapse in the course of typhoid fever is usually caused by either perforation or hemorrhage. The fever ordinarily lasts about four weeks. For his own protection the nurse should submit himself to pro- phylactic vaccination against typhoid and in addition must be care- ful to thoroughly w'ash and disinfect his hands every time after handling his patient, and again before eating. For the protection of others he must disinfect immediately all urine and stools, and every- 254 NURSING thing \Yliich may have been soiled by them, such as bedding, towels, nightclothes, etc. Even the water which has been used in bathing the patient must be regarded as infected; it should never be emptied on the ground, but into a sink which is afterward flushed with a disinfectant solution. Separate thermometers, feeding cups, etc., must always be used, but if this is not practicable they m'ust be disinfected before use with other patients. As flies carry the disease germs on their feet they must not be allowed to reach the patient or his discharges. Clothing and bedding must be disinfected. Dysentery: This occurs in two principal forms, amebic or tropical dysentery, and bacillary or epidemic dysentery. In both forms the germs are swallowed with water or food, chiefly the former, and in both they are thrown off in the stools. The disease is therefore spread much like typhoid fever, and the precautions to be taken are practically the same, except that the urine in dysentery is not infectious. Cholera: This disease is spread in the same way as dysentery, but is of short duration and very fatal. The only safety lies in eating and drinking nothing which has not been recently cooked. Clothing and bedding must be disinfected, and also of course the stools and vomited matter. Malaria: In this disease the infection is in the blood and cannot be carried from one person to another except by mosquitoes (the anopheliiia), which, after biting the malarial patient, then bite a person hitherto well. Therefore, the sick must be protected against mosquitoes, so that the mosquitoes can not get the disease, and the well must be also protected, so that if there are any infected mos- quitoes about they may not do any harm. Yellow fe^rr: This disease resembles malaria in that the infection is in the blood, and can only be carried by the mosquito (Aedes ealopiis) ; the precautions to be taken are the same. It is, however, a much more serious malady than malaria, and usually of much shorter duration. A curious feature of the disease is that it is not infectious, that is, cannot infect the mosquito, after the end of the third dav: but the mosquito once infected is capable of carrying the di'^ease to man probably as long as she (the mosquito) lives. Cerebrospinal meningitis: In this disease it is believed that the INFECTIOUS DISEASES 255 infective germ usually gains access to the body through the throat and nose and is frequently received from meningococcus carriers, or persons who have been in contact with other cases or themselves recently had the disease and still carry the coccus in their throats. This being the case, it is necessary to carefully disinfect all discharges from the throat and nose of the patient and also that nurses and physicians who come in contact with cases of this disease should frequently spray their own throats and noses with an antiseptic solution. Inasmuch as we do not know just how contagious the disease is, nor in what excretions the meningococcus leaves the bodies of the sick, all cases and their attendants must be carefully isolated, and all discharges from the patient and everything which has come in contact with him, including the room in which treated and its contents, must be thoroughly disinfected. Gonorrhea or clap: There is no danger of contracting this disease in its ordinary form except through sexual intercourse, but there is danger of getting some of the pus into the eyes and thereby induc- ing a very serious inflammation which often completely destroys vision. This may happen to the patient himself by bringing the unwashed hands, after handling the penis, in contact with the eyes, or more commonly to the nurse or other innocent person, from use of a towel on which the gonorrhea patient has managed to get some of the pus from his penis. Such a patient should be cautioned about the danger to his own eyes, and should not be allowed to use any toilet articles except his own. Chancroid: While this disease is nearly always venereal, a nurse with a hang-nail or other abrasion may inoculate himself while dressing the sore or the resulting bubo. Syphilis: Syphilis, though very contagious at certain times and under certain conditions, is not always so. The chancre, mucous patches, condylomata, and the blood during the first few years of the disease, are all contagious. The mucous patches, being often located in the mouth and throat where they are not visible, are espe- cially dangerous. All the table ware, toilet articles, instruments and appliances, and bed linen used by syphilitics should be kept entirely separate from those used by others, and should be frequently disin- fected. Should the nurse have any cut or abrasion on his hands he must be exceedingly careful in handling the syphilitic lesions, or the dressings which have been used on them. 256 XURSIXG Pulmonary tuberculosis: In this disease the infection is contamed in tlie sputum. As long as the sputum is moist the germs can not escape into the air, but they may be carried by flies whicli aHght upon it or in the fine spray which is thrown out when the patient coughs. The danger is in the dry sputum which becomes pulverized and mixed with dust; hence it must be kept moist and always received in a disinfectant solution. If paper spit cups are used, these with their contents are burned. Clothing and bedding must be dis- infected. Pneiuiioiiia, like tuberculosis, is infectious through sputum which must be treated in the same way as that of the latter disease. Cloth- ing and bedding must be disinfected. Iiifliienca; or " the Grip " : In this disease the sputum is infectious and also the nasal discharge when there is any. The sputum is to be treated like that of pneumonia and tuberculosis, the nasal dis- charges are to be received on small pieces of gauze or toilet paper and immediately burned. Clothing and bedding must be disinfected. In follicular tonsillitis the discharges from the nose and throat are infectious and should be handled in the same way as those of influenza. The same remark applies to diphtheria, but this disease is very contagious through particles of the membrane which is present in the throat and often in the nose, and may be coughed into the face of the attendant; minute portions of the membrane lodged in the eye, nose, or mouth of the attendant may reproduce the disease in him. Patients with diphtheria should always be isolated. Clothing and bedding must be disinfected. Measles belongs to the class of eruptive fez'ers, which includes also scarlet fever, smallpox, and chicken pox, all of which are con- tagious the infectious agent being inhaled or swallowed. Though there is reason to believe that they are all germ diseases, that sup- position has not been proven for any of them. The discharges from the throat and nose are highly infectious, as are also the skin lesions in smallpox. The modern belief is that this class of diseases, like erysipelas and other wound infections, is spread chiefly if not en- tirely by persons or things which have been in contact with other cases. The general rules for nursing infectious diseases are to be followed and all discharges disinfected. Before the convalescent iXl-ECTlUL'S DISEASES 257 is allowed to mix with well people he should be given an antiseptic bath, 1 :20oo bichloride, and the hair and scalp thoroughly shampooed. Mumps: In mumps the contagious agent is probably in the secre- tions of the mouth and throat. The disease is to be handled like eruptive fevers. Erysipelas may be carried from one wound to another on the hands of the nurse, on instruments, dressings, etc., and possibly also through the air. So very contagious is it that an erysipelas patient should be isolated and his nurse should not go near any one with a wound. Wound infections are readily carried from one patient to another in the same way as erysipelas is transmitted. A nurse who dresses infected wounds should not attend those whose wounds are aseptic. As hospital corps men serving in the tropics occasionally have to nurse cases of plague, it is necessary that they should know some- thing of that disease. The most prominent symptoms of plague are great prostration, high fever, and the development of buboes, most commonly in the groin ; but buboes are not always present. The disease is due to a bacillus which is found in the blood and all the discharges, including the pus from the buboes, the urine, feces, sputum, etc. It is con- tagious and everything about the patient becomes infected, especially the locality. It may be conveyed by dust, food, water and clothing, by rats, mice and flies, and probably by ants and mo.^quitoes. Often the infection occurs through some slight wound of the skin. Plague patients should be isolated and everything which comes in contact with them disinfected. Rats and vermin of every sort must be systematically destroyed, and the utmost cleanliness insisted upon. Xo one with a wound, sore, or even a scratch, should nurse plague patients or visit an infected locality. Nurses should wear leggins and s:hould frequently disinfect their hands, mouths, and nostrils. In typhus fever the infection is conveyed by the bite of the body louse ; probably also by the head louse and " crab " louse. The body and clothing of the patient nnist be thoroughly disin- fected in such a way as to kill all lice and their eggs ; then there will be no danger of catching the disease provided the surroundings of the patient are also clean and free from vermin. 17 PART V MESS MANAGEMENT AND COOKING CHAPTER I MESS MANAGEMExXT The management of the hospital mess is one of the most impor- tant duties pertaining to the hospital corps, as upon its success de- pends not only the welfare of the patients, but much of the content- ment and happiness of the men themselves. The noncommissioned officer selected for this assignment must be not only a man of in- telligence and business capacity, but also one who has had actual experience in the kitchen. The sources from which the mess is supplied are the rations issued for the hospital corps ; a variable money allowance per day for each enlisted man sick in hospital; the hospital fund; the products of the hospital garden, chickens, and cows, and. in the field, hospital stores. A ration is the allowance for the subsistence of one person for one clay. The garrison ration is intended for troops in garrison, and, in time of peace, for troops in maneuver camps; the ration to be issued to troops on the* march in time of peace will be prescribed by the commander, and will not exceed the allowances prescribed for the garrison ration : the travel ration is for troops traveling otherwise tiian by marching and separated from cooking facilities : the reserve ration is carried on the person of the men and in the trains, and con- stitutes the reserve for field service ; the field ration is the ration prescribed in orders by the commander of the field forces ; the Filipino ration is for use of the Philippine Scouts ; and the emer- gency ration for troops in active campaign for use on occasions of emergency or in the field for purposes of instruction. In time of war when Philippine Scouts are serving in the field they will be subsisted the same as are regular troops. W^hen im- practicable for Philippine Scouts to use the Filipino ration while traveling otherwise than by marching, on account of the lack of cooking facilities or for other reasons, the travel ration may be prescribed. The kinds and quantities of the component articles of the .\rmv (250) 260 MESS aiaxagI':m1":xt and cooking raiion and the sul)stitiiti\c c(iui\aicni articles which may be issued ill place of such cumpuuents are as follows: I. (Iarrison Ration. Component articles and quantilits. Beef, fresh jo ounces Flour 1 8 ounces Baking powder .. 0.08 ounces. Beans .'.4 ounces . Potatoes2 -'o ounces Prunes 1 . 28 ounces Coffee, roasted 1.12 ounces and ground. .Sugar 3.2 ounces. Milk, evaporated, jo. 5 ounce. unsweetened. | \'inegar 0.16 gill ... Salt 'o . 64 ounce. Pepper, black. ... 0.04 ounce r- ' Cinnamon 0.014 ounce I.ard o . 64 ounce. Butter ) . 5 ounce . . Sirup 0.32 gill. Flavoring extract, o. 014 ounce ' lemon. 1 Substitutive articles and iiuantities. -Mutton, fresh Bacon 1 Canned meat, when impracticable to fur- nish fresh meat. Hash, corned beef, when impracticable to furnish fresh meat. Fish, dried Fish, pickled Fish, canned Turkey, dressed, drawn, on Tranksgiving Day and Christmas, when practicable. Soft bread Hard bread, to be ordered issued only when the interests of the Government so require. Cornmeal 20 ounces. 12 ounces. 16 ounces. 16 ounces. 14 ounces. 18 ounces. 16 ounces. 16 ounces. 18 ounces. 16 ounces. 20 ounces. Rice 1.6 ounces. Hominy 1.6 ounces. ' Potatoes, canned 15 ounces. Onions, in lieu of an equal quantity nf potatoes, but not exceeding twelity peri cent of total issue. Tomatoes, canned, in lieu of an equal quantity of potatoes, but not exceeding twenty per cent of total issue. Other fresh vegetables (not canned) when they can be obtained in the vicinity or transported in a wholesome condition from a distance, in lieu of an equal quantity of potatoes, but not exceeding thirty per cent of total issue. r Apples, dried or evaporated i . 28 ounces. Peaches, dried or evaporated i . 28 ounces. Jam, in lieu of an equal quantity of; prunes, but not exceeding fifty per cent] of total issue. | 'Coffee, roasted, not ground 1. 12 ounces. Coffee, green 1.4 ounces. Tea, black or green 0.32 ounce. Pickles, cucumber, in lieu of an equal quan- I tity of vinegar, but not exceeding fifty I iicr cent of total issue. fCloves 0.014 ounce. •{ Ginper 1.014 ounce. i [ Xutmeg 0.014 ounce. jOleoniargarine 0.5 ounce. ^'anilla 0.014 ounce. 'In ,\laska, 16 ounces bacon, or, when desired, 16 ounces salt pork, or 22 ounces salt beef. - In .Alaska the allowance of fresh vegetables will be 24 ounces instead of 20 ounces, or canned potatoes, 18 ounces instead of 15 ounces. Note. — Food for troops traveling on United States -Army transports will be prepared from the articles of subsistence stores which compose the ration for troops in garrison, varied by the substitution of other articles of authorized subsistence stores, the total daily cost per man of the food consiuncd not to exceed 20 per cent more than the current cost of the garrison ration, excei)t on Thanksgiving Day and Christmas, when 60 per cent increase over the same current cost is authorized. MESS -MANAGEMENT 261 One day in each alternate month of the season of practical instruc- tion, not exceeding three days in each year, the use of the reserve ration with individual cooking will be required by all troops in the field for purposes of instruction. 2. Travel Ration. Component articles and quantities. .Substitutive articles and quantities. Koft bread |i8 ounces Hee*f, corned ii.j ounces Beans, baked (4 ounces. Tomatoes, canned. ]8 ounces. Jam 1.4 ounces. Coffee, roasted and i . 12 ounces. ground. Sugar 2.4 ounces. Milk, evaporated, O.J ounce. unsweetened. Hard bread 16 ounces. Hash, corned beef 12 ounces. Bacon 1:2 ounces. or meat canned. 16 ounces. Hard bread 1 16 ounces. Coffee, roasted and i . 12 ounces. ground. I .Sugar 2.4 ounces. Salt o. 1 6 ounce. 3. Reserve Ration. Component articles and quantities. Substitutive articles and quantities. 4. Field Ration. 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, supplemented by articles of food r..'quisitioned 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. 5. Filipino Ration. Component articles and quantities. Beef, fresl\. Flour Baking powder, when in field and ovens are not available. Rice, unpolished. , Potatoes Coffee, roasted and ground. Sugar 2 ounces. Vinegar ,> (,8 gill. Salt 0.64 ounce. Pepper, black 0.02 ounce. Substitutive articles and quantities r Bacon i Canned meat 1 Fish, canned I I Fish, fresh . ^ ounces \\ Hard brcaa . i Soft bread . . .32 ounce. 20 ounces. 8 ounces . I ounce. Onions •> ounces. S ounces. 12 ounces. 1 2 ounces. S ounces, ■f ounces. 8 ounces. 262 MESS MAXAGKMI'LXT AND COOKING Scout organizations will be recjuired to use the entire allowance of the meat comj)onent, and not more than i6 ounces of rice per day to be used for each ration. The purchase of 1.6 ounces of beans per ration in substitution of the portion of the rice ration not drawn will be made, and use of as large an extent as possible of native products, such as camotes, mongos, and squash will be required. 6. EMERGENCY RATION' The emergency ration is furnished, in addition to the regular ration, as required for troops on active campaign or in the field for purposes of instruction, and will not be opened except by order of an officer or in extremity, nor used when regular rations are obtainable. Ration returns upon which emergency rations are drawn will bear the certificate of the organization commander that such rations are required for the enlisted men of his organization and that the mone_y value of any rations previously drawn by him, and improperly opened or lost, has been charged against the person responsible. All articles of the garrison, travel, or Filipino ration due a com- l)any, or other military organization, will be retained by the com- missary and credit given to the organization for the money value of these articles at the current price of the articles ; and the commissary will pay as savings to the organization commanders any excess in value of the stores so retained over those purchased by the organiza- tion. The revenue from this source as well as that from the post bakery (savings on flour), the post exchange, and the care of patients other than soldiers in hospital constitutes the Iiospital fund, which may be expended as far as desirable in giving greater variety and abundance to the mess of the hospital corps. Variety in the mess is of much importance ai.d may be obtained through the use of the alternative issues, by purchases from the hospital fund, and especially by variety in cooking. Usually bills of fare are prepared by the noncommissioned officer in charge of the mess and submitted to the surgeon for his approval, and variety should be insisted on. It is the duty of the noncommissioned officer also to see that the meals are properly and promptly served in both the dining-room and wards. Wastage must be carefully avoided, grease and drippings should be jjreserved for use in cooking, and bones for the preparation of MESS .MANAGEMENT 263 soup. In the dining-room the rule should be small portions served as desired rather than large portions to be left on the plate. Different classes of diet are necessary in hospital because of the great variety in the nature and severity of the diseases treated therein. The arrangement of the diet tables is based upon our knowledge of the relative digestibility of the different sorts of food, and the part Vv'hich the dift'erent portions of the digestive tract take in the process of digestion. The diets usually found in military hospitals are full, light, liquid, and special. Full diet includes what is served at the table in the dining-room ; the other diets are ordinarily served in the wards. Light diet includes liquids and the simpler and more digestible articles of solid or semisolid food. Each surgeon usually has his own diet list ; the following table, which has been used at the U. S. Army General Hospital, Presidio of San Francisco, California, may be taken as an illustration of full and light diets. In addition to the regular diet tables a special diet hst is provided for the use of ward surgeons for cases requiring this kind of diet. Liquid diet: This includes liquids only, such as milk, strained soups, gruels, broths, albumen water, etc. The amount of each of these articles to be taken by a patient in twenty-four hours should always be stated. Special diet: This is usually a list from which special articles of food are prescribed for particular cases. As to which diet shall be given to a particular patient depends upon the nature of the case. In all fevers and grave disorders, while there is increased necessity for food to repair the unusual waste, there is unfortunately also diminished power of digestion and assimilation. Therefore we begin with liquid foods to save the digestive appa- ratus the labor of liquefying them, and we give them in small quan- tities and frequently. If there is irritation of the stomach and bowels we give those foods which have the least indigestible residue to irritate the bowels. From liquids we go on to jellies, custards, ice cream, light puddings, milk toast, lightly boiled eggs, chicken, rare steak, etc. 264 MESS MANAGEMENT AND COOKING FULL DIliT Breakfast. Dinner. Supper. Sunday. Cereal and milk. Vermicelli soup. Veal stew or boiled ham. Ham and eggs. Bread and butter. Fruit. Coffee. Roast veal, sage-dressing, or turkey, or chicken and dress- ing. Stewed peas. Mashed potatoes. l'"arina pudding. P>uit. Bread and butter, coffee. Apple sauce. Cake. Bread and butter. Tea. Monday. Cereal and milk. Beefsteak. Fried potatoes. Bread and butter. Fruit. Coffee. Roast beef. Mashed potatoes. String beans. Tapioca pudding. Bread and butter. Fruit. Coffee. Codfish balls or hash. Bread and butter. Pickles. Jam. Sweet crackers. Prunes. Tea. Tuesday. Cereal and milk. Sausage. F"ried potatoes. Bread and Ijutter. Coffee. Fruit. Vegetable soup. Baked pork and beans. Baked tomatoes. Bread pudding. Bread, butter, cocoa, fruit. Fried liver and bacon. Corn bread and syrup, or Biscuits. Bread, butter, tea. Fruit. Wednesday. Milk toast. Beefsteak. Bread and butter. Coffee. Fruit. Roast mutton with dressing. Mashed potatoes. Corn or fresh vegetables. Chocolate pudding, fruit. Bread, butter, coffee. Mutton stew. Pickles. Sweet crackers. Bread, butter, tea. Peach cobbler. Thursday. Cereal and milk. Hash. Bread and butter. Coffee. Fruit. Oj'ster soup. Corned beef and cabbage. Boiled potatoes. Radishes. Rice pudding. Fruit. Bread, butter, coffee. • Sliced roast beef. Macaroni and cheese. Preserves. Bread and butter. Tea. Friday. Cereal and milk. Bacon and eggs. Bread and butter. Coffee. Fruit. Baked fish with sauce. Plain boiled potatoes. Fresh salad. Farina pudding. Fruit. Bread, butter, cocoa. Salmon salad. Potato salad. Apple sauce. Ginger crackers. Bread and butter. Tea. Saturday. Cereal and milk. Beefsteak. Fried potatoes. Bread and butter. Coffee. Fruit. Roast beef, veal, or pork. Mashed potatoes. Hot slaw. Cauliflower. P>rcad pudding. Bread, butter, coffee. Baked hash or stew. Stewed prunes. .'Kssorted cakes. Bread and butter. Tea. MESS MANAGEMENT 265 LIGHT DIET Breakfast. Dinner. Supper. Sunday. Cereal and milk. Soft-boiled eggs. Milk toast. Cotif ee. Rice soup. I-arina pudding. Coff'ee. Milk toast. Cup custard. Tea. Monday. Cereal and milk. Milk toast. Boiled eggs. Coffee. Plain tomato soup. Bread pudding with lemon sauce. Coffee. Farina mush and milk. Sweet crackers. Jelly. Toast. Tea. Tuesday. Cereal and milk. Boiled eggs. Coffee. Barley soup. Tapioca pudding. Cocoa. Biscuits or corn bread. Maple syrup. Boiled rice. Milk toast and tea. Wednesday. Cereal and milk. Soft-boiled eggs. Coffee. Consomme vermicelli. Cornstarch pudding. \'anilla sauce. Coffee. Sweet crackers. Jam. xMilk toast. Tea. Thursday. Cereal and milk. Boiled eggs. Coffee. Oyster soup. Rice pudding. Coff'ee. Macaroni and cheese. Milk toast. Maple syrup. Tea. Friday. Cereal and milk. Boiled eggs. Milk toast. Coffee. I^'ish chowder. I-'arina pudding. Cocoa. Tapioca pudding. ^lilk toast. Ginger crackers. Boiled eggs. Tea. ' Saturday. Cereal and milk. Boiled eggs. Coffee. Vermicelli soup. Sago pudding. Coffee. Cereal mu.sh. .\ssnrted cakes. Jelly Milk toast. Tea. CHAPTER II (.UOKING Practical cooking can only be learned in the kitchen where each hospital-corps man must serve an apprenticeship, those who show aptitude being given an opportunity to develop into cooks. But the principles of cooking and diet cooking must be learned by all. Nearly all food is capable of prompt putrefaction; putrefaction is due to the growth of germs, and requires the presence of heat, mois- ture, and organic matter; if any one of these conditions is absent putrefaction will not take place. Hence meats will keep indefinitely when frozen (absence of a suitable temperature) ; when dried (absence of moisture) ; canned (absence of germs which have been destroyed by heat) ; or when pickled (absence of germs which have been killed by antiseptics, such as salt, vinegar, and sugar). A clean kitchen means the practical absence of germs ; in such a kitchen foods do not spoil or putrefy. The following extracts from an old work on " Camp Fires and Camp Cooking " are worth repeating here : " Cleanliness is net to godliness, both in person and kettles : Be ever industrious, then, in scouring your pots. Much elbow grease, a few ashes, and a little water are capital aids to the careful cook. Dirt and grease betray the poor cook and destroy the poor soldier, whilst health, content, and good cheer should ever reward him who does his duty and keeps his kettles clean. In military life, punctu- ality is not only a duty, but a necessity, and the cook should always endeavor to be exact in time. Be sparing with sugar and salt, as a deficiency can be better remedied than an overi)lus. " Remember that beans, badly boiled, kill more than bullets; fat is more fatal than powder. In cooking, more than anything else in the world, always make haste slowly. One hour too much is vastly better than five minutes too little, with rare exceptions. A big fire scorches your soup, burns your face, and crisps your temper. Skim, simmer, and scour are the true secrets of good cooking." (266) COOKING 267 Cooking improves the flavor of food and thereby increases the appetite ; it destroys all parasites and disease germs ; and it enables the food to be more thoroughly masticated and digested. It lessens the toughness of muscular fibres, gelatinizes the connec- tive tissue, coagulates albumin, breaks up the starch granules and practically converts them into glucose and dextrin, all of which per- mits of more thorough penetration of the digestive fluids and more rapid digestion. The ordinary processes of cooking are boiling, stcii'ing, roasting, baking, frying, and broiling or grilling. In boiling, the object is to cook the food and at the same time retain in it all its natural juices. To do this with fresh meat and vegetables the water should be salted, and the food in large masses dropped at once in boiling water ; this by coagulating the albumin in the outer layers forms a protecting coating which prevents the juices from escaping. Active boiling is continued for five minutes, after which the process should be one of simmering or very slowly boiling-. Salt meats, beans, and pease should be put on in cold water and the temperature slowly raised. Potatoes should be boiled in their jackets, but if peeled the water should be salted to prevent the escape of the vegetable salts. Fish and potatoes should be thoroughly drained after boiling. Beans, pease, rice, and other hard grains require a preliminary soak- ing ; the two former can not be cooked in hard water. Fresh meats require about fifteen minutes to the pound. In stezcing meats we do not mind the escape of the juices because the broth, as the water in which meat is boiled is called, forms a part of the food, all of which is to be eaten. Therefore the meat is cut in small pieces, placed in cold w^ater, and the boiling done very slowly ; vegetables are usually added. If the stew is made with meat which has already been cooked it is known as a Jiash. In soup making the broth is the part used, hence we desire to get out of the meat and bones and into the water all that can be extracted of their nutritive ingredients, and especially the gelatin which is a result of a prolonged boiling of the bone and connective tissues. The meat is cut in small pieces and the bones thoroughly cracked, and all placed in cold water in a covered pot which should simmer slowly and be frequently skimmed. The product when finished constitutes 268 MESS MANAGEMENT AND COOKING stock, and the various soups are prepared l)y adding vegetables cut into small pieces, and cooking for an hour or so more or until the vegetables are done. Soup stock should not be kept in an iron pot because the iron gives it an unpleasant flavor. In making meat teas or extracts by heat, the process is a little different from soup making; we do not wish any fat, hence lean meat is selected without bone, and all fat is removed after the broth is cold ; the water should never come to a boil so as not to coagulate the albumin which we wish to retain. Roasting is properly done in front of a clear fire with special arrangements for concentrating the heat and turning the joint. In this country the term roast is ordinarily applied to baked meats. Baking is done in an oven, and as the fat acids developed by high temperature can not escape, the flavor and digestibility are not so good as in roasting. As in boiling, our object is to expose the roast to a high temperature in order to coagulate the surface layer so that it may retain the juices ; when that is accomplished the balance of the cooking is done more slowly at a lower temperature. Frequent basting with the melted fat and meat juices is necessary in order to prevent the surface becoming too tough and hard, and to secure better penetration of the heat into the interior of the joint. The oven must not be too hot ; if the hand and arm can be held in the oven for fifteen seconds the temperature is about right. Baking ordinarily requires about fifteen minutes to the pound. Broiling or grilling is practically the same as roasting only the cooking is done over instead of in front of the fire, and a larger extent of surface is exposed to the heat. The meat is placed on a gridiron or broiler over a clear bright fire free from smoke. If the broiling is done before a fire instead of over it, the juices can be caught in a drip pan and used. Frying is properly done by dropping the meat or vegetables in boiling oil or fat at a temperature of about 500° F. and in a frying pan deep enough to immerse the article to be cooked. If the fat is hot enough the surface layer of the meat is at once coagulated as in boiling and roasting, and the grease does not penetrate. Frying is usually improperly done, the bottom of the frying pan being only greased enough to prevent the meat from sticking to it ; articles thus fried are saturated with grease and indigestible. The object of bread making is to convert an indigestible, tasteless COOKING 269 mass of flour into an appetizing, porous food capable of ready [)ene- t ration by the digestive juices and known as bread. The first step is to make the dough, which is done by thoroughly mixing or kneading the flour with salt and water ; the next step is to impart the necessary porosity by the introduction of carbonic-acid gas into the mass; this is done by either generating it within the dough or forcing it in from without. The first of the methods may be effected either by fermentation of yeast or by baking powders; the second constitutes the so-called aerated bread, a process little used in this country. The carbonic-acid gas is held in minute bubbles by the tenacity of the gluten, the nitrogenous element of flour, and the dough rises, becoming light and spongy. It is then kneaded over again, divided into loaves of suitable size, allowed to rise for about one hour in the forms, and then baked, by which the gas is still further expanded, the dough made lighter, and the porosity permanently fixed in the bread. By leavened bread we mean that which has been made by fermen- tation; yeast may be used directly, or we may use a portion of old fermenting dough or leaven ; the former is preferable. In the growth of the yeast fungus a portion of the sugar of the dough is converted into alcohol and carbonic acid ; the former is driven oft' by the heat in baking, and the latter is spread through the dough, making it porous. Usually a portion of the flour is first made into dough with yeast, salt, and water, and set aside in a warm place for a couple of hours, this constituting the sponge which is subse- quently thoroughly kneaded with the remainder of the flour and w'ater, and the fermentation allowed to proceed in the entire mass. The important point is to know just when it has gone far enough; if it goes too far the bread becomes sour; if not far enough it is heavy. The necessary carbonic acid may also be generated by the use of baking pozvders; these consist generally of bicarbonate of soda mixed with cream of tartar, acid phosphate of lime, or alum; in the chemi- cal reaction which takes place in the dough carbonic-acid gas is set free and certain more or less harmless salts remain in the bread. Alum baking powders are objectionable because the remaining salts are t)€lieved to cause indigestion. CHAPTER III RECIPFS The following recipes are taken from the valuable pamphlet on " Emergency Diet for the Sick in the Military Service," by Captain Edward L. jMunson, assistant surgeon, U. S. Army, and published with his permission. They will serve an excellent purpose in prepar- ing foods for the sick and also in the instruction of the hospital corps in cooking and diet cooking^: LIQUID DIET Sterilized Milk Pour the milk into a granite saucepan (or a double boiler) and raise the temperature of milk to about 190° Fahrenheit. Keep it at this point for one hour. Do not boil the milk. Any utensil used for this purpose must be absolutely clean. Milk Punch Three-fourths of a coffee cup of milk (six ounces) Two tablespoonfuls of brandy or whisky. One teaspoonful of sugar. Grated nutmeg to taste. Sweeten the milk (preferably sterilized) with the sugar. Stir into it the brandy. Shake it up well by pouring from one cup into another, or by the use of a milk-shaker, until a froth is formed. Grate a little nutmeg on top and serve. The term "cup" in this recipe, as in all others, means the ordinary coffee cup, holding eight ounces. Milk with Mineral or Aerated Waters Mix equal quantities of sterilized milk with seltzer, soda water, or lime water, and serve immediately. Albumenized Milk Beat up the white of an egg till light. Add a good-size pinch of salt, and four ounces of fresh, cool milk which has been sterilized. A little sugar may be added if desired. (270) LIOL'ID DIET 271 Peptonized Milk (Cold Process) into a clean quart bottle put two peptonizing tablets dissolved in four ounces of cold water. Add one pint of fresh cold milk, shake thoroughly, and place the bottle on ice. Use clean cotton to plug the bottle. In place of the peptonizing tablets, five grains of pancreatine and fifteen grains of sodium bicarbonate, to be obtained from tlie dispensary, may be employed. Peptonized Milk (Warm Process) Into a clean quart jar or bottle put the tablets above mentioned, dissolved in four ounces of cold water. Add one pint of fresh milk and shake the whole well. Place the bottle in a pan or kettle of hot water maintained at such a temperature that the hand can just be held in it without discomfort. Keep the bottle in the water for ten minutes. Put on the ice immediately after removing from the hot bath, to check further digestion. If ice is not available pour the milk into a saucepan and heat quickly to boiling. Whey Warm one pint of milk to about blood heat, or about ioo° Fahrenheit. Dissolve half a rennet tablet in one tablespoonful of cold water. Stir it into the milk and let it stand until the latter is curdled, which will be in a few minutes. Break up the curd with a fork and strain off the liquid (whey). This may be sweetened with sugar, and when cooled makes a refreshing drink for fever patient" Junket Heat one pint of fresh unboiled milk to about blood heat, or about loo^ Fahrenheit. Dissolve a full tablespoonful of sugar in it. Add half a rennet tablet which has been dissolved in one tablespoonful of cold water. It will set the milk in about fifteen minutes. Put in a cool place till ready to be used. It can be served plain, or with cream, sugar, and a little nutmeg. Farina Gruel One tablespoonful of farina. One pint of water. One teaspoonful of sugar. One-half teaspoonful of salt. Into one pint of water, raised to boiling, put a half teaspoonful of salt; then add the farina and cook for twenty minutes. I'^lavor with sugar and condensed milk, if fresh milk is not available. Strain and serve hot. In this recipe, as in others, condensed milk is used in a strength of one teaspoonful to the half pint of gruel. Rice Gruel Two tablespoonfuls of rice. Or one tablespoonful of rice flour One pint of boiling water. One-half teaspoonful of salt. One teaspoonful of sugar. 211 M1-:SS -MAXAGEMExNT AXl) COOKING Wash the rice thoroughly in two waters, after removing any specks that may be mixed in the grain. Have the cooking water boihng. Add the salt and then the rice. Boil for two hours, when the rice should be almost entirely di.-i.solvcd. Strain. Add condensed milk and sugar, if desired. Some persons prefer the use of salt alone. Jf ground rice or rice flour is used, it should be mixed with cold water before mixing with boiling water, and requires but thirty minutes' boiling. Flavor with sugar or condensed milk. Hard-Bread Gruel Toast hard bread thoroughly and grind it into a powder. To one pint of boiling water, to which one-half teaspoonful of salt has been added, add two tablespoonfuls of hard-bread powder. Boil ten minutes and then strain. Flavor with one teaspoonful of sugar and one teaspoonful of condensed milk to each cupful of the gruel. Koumyss Dissolve one-fourth cake of compressed yeast (Fleischmann's) in a little warm water. If Fleischmann's yeast is not obtainable, use one-fourth cake of ordinary compressed j-east or half a fluid ounce of bakers' yeast. Warm one quart of fresh milk to about 90° Fahrenheit, add one tablespoonful of sugar and the dissolved yeast ; thorough!}' mix and put into a stout bottle, tying a small piece of cloth firml}' over the cork to hold it in place. Shake well, and allow to stand for six hours at a temperature of about 70° Fahren- heit. Then put the bottle on ice upside down, and allow to stand for three days before using. Condensed milk may be used with as good a result as fresh milk. Use five parts of water to one part of condensed milk, and omit the sugar. Lemonade One small lemon or lime. One tablespoonful of sugar. Three- fourths of a cofifee cup of water (six ounces'). Wash and wipe the lemon or lime. Squeeze the juice into a glass or bow.. Then add the sugar, pour on the water, and strain. Serve at once. Boiled or sterilized water should be used. Orangeade One orange. One teaspoonful of sugar. Three-fourths of a coffee cup of water (six ounces). Wash and wipe the orange. Squeeze the juice into the sugar. Add the cold water, previously boiled. Strain and serve. Eggnog One egg. Two teaspoonfuls of sugar. Thrcc-fourts of a coffee cup of milk (six ounces) Salt to taste. LIQUID DIET 273 Beat the egg up till light. Add sugar and salt and then the milk, which is better when not too cold. With tlic addition of one' or two tablespoon fuls of brandy this makes a very strengthening drink for convalescents. Egg Lemonade One egg. One small lemon. Two teaspoonfuls of sugar. Beat up ihe white and yolk of the egg separately; add sugar to yolk. When both are light, mix them together and add the strained juice of the lemon. Pour into a glass and serve with a spoon. A little cold water may be added if the beaten egg is too foamy. Sherry and Egg One egg. One teaspoonful of sugar. Two tablespoonfuls of sherry wine. Break the egg into a bowl and add the sugar. Beat the two together until they are thoroughly mixed. Add two tablespoonfuls of sherry wine and an equal quantity of cold w'ater. Mix thoroughly, strain, and serve immediately. Toast Water Toast three slices oi soft bread till very brown, and dry throughout. Break up fine, add one pint of boiling water, and set aside for rifteen minutes. Turn into a strainer or piece of gauze and strain. The water thus obtained may be used plain, or a little sugar or condensed milk may be added. It may be served either hot or cold. Coffee To each cup of water allow one tablespoonful of cofTee, freshly roasted and ground. Have the Avater boiling. Mix the cofifee with a little cold water and pour it into the boiling water. Let the whole come to a boil, and then set aside for five or ten minutes to steep and settle before using If muddy it may be cleared by boiling with egg shells, or, in their absence, by a dash of cold water. Add sugar and fresh or condensed milk to flavor as desired. Tea To each half-pint of boiling water add one teaspoonful of tea. Let it steep or infuse for five minutes. Never let tea boil. Add sugar and fresh or condensed milk to flavor as desired. Beef Juice Cut a lean piece of steak, from the round or other good portion, about one-half pound in weight. Remove all fat and fibrous tissue. Broil over a clear, hot fire so that the meat becomes pink and full of juice. It should 18 274 iMESS ma.\agi:mi:.\"1" and cookixg not be merely done on the outside and raw inside. Cut into small pieces and squeeze out the juice. Add a little salt and it is ready to serve. If it is needed warm, place the cup holding the juice in a bowl of warm water. Do not let the temperature of this water exceed i6o° Fahrenheit. Beef Juice (Bottled) Choose a good, well-flavored piece of beef, half a pound in weight. Cut away the fat, leaving only the lean. Cut this up into small pieces. Put these into a clean glass jar and cover the latter. Set the jar in a deep sauce- pan of cold water and heat gradually for one hour. Then strain out the juice and press the meat. Add a little salt and serve. If the temperature of the water exceeds i6o° Fahrenheit the beef juice becomes brown and flaky. A half-pound of beef should give from three to four tablespoonfuls of juice. Beef Tea (Bottled) Select and prepare the beef as for bottled beef juice, except that to each half-pound of meat a cup of cold water should be added, pouring the water over the beef after it has been put in the jar. The liquid thus obtained will resemble the beef juice in every respect except strength. Add a little salt and serve. Beef Tea with Hydrochloric Acid Select and prepare the beef as above. Put into a bowl and pour over it one cupful of cold water, to which five drops of dilute hydrochloric acid have been added. Let the whole stand for two hours in a cool place. Strain, add salt to flavor, and serve cold. This tea may be heated ; but the albumin which coagulates and appears as brown flakes should not be strained out, for it is the nutritious portion of the tea. Beef (or Mutton) Broth One pound of lean beef (or mutton). One quart of water. One teaspoonful of salt. Soak the meat, previously chopped fine, in the cold salted water for at least two hours, in the vessel in which it is to be cooked, keeping it on ice or in a cool place during this time. Then expose to moderate heat. Keep the vessel covered and allow the broth to simmer, keeping up the original quantity of water, for three hours at least. Let it cool overnight, skim off the fat in the morning, and keep covered in a cool place until needed. Heat and serve as required. Chicken Broth Fowls are better to use for broth than young chickens. Pluck and pre- pare by singeing with a blazing newspaper, straw, or dry grass. Remove all refuse — entrails, oil bag, crop, lungs, etc. Wash well in cold water, then cut up and disjoint. To each pound of chicken add a quart of cold salted ■water and simmer for two hours: then l)oil for two hours. .A.dd rice or powedered hard bread or soft bread crumbs in the proportion of one table- SEMISOLID OR LIGHT DIET 275 spoonful to each quart of water. \'egetablcs, such as onions, garuC, carrots, celery, and parsley, may he also used, a taI)lesT)oonful to the quart, and should be put in when the broth is Hrst put on to cook. Strain, remove the fat, and serve hot. Canned Soups To render canned soups ready for eating, simply raise them to the boilin.i; point by immersing the cans in boiling water for half an hour to thoroughly heat the contents ; or empty and heat the contents in a granite saucepan. After diluting with the proper amount of water, following directions on the cans, they are ready to serve. Before heating any canned article a hole should be punctured in the upper end of the can. Clam broth (Canned) This may be served hot or cold. If the l)n)th is desired plain, add an equal quantity of water to the clam juice and heat to the temperature required. Do not boil. Clam broth can also be given iced. If fresh milk is available, equal parts of milk and clam juice may be heated up together. SEMISOLID OR LIGHT DIET Poached Eg-gs Pour sufficient boiling water into a clean cooking untensil and add salt in the proportion of one teaspoonful to the quart of water. Place it on the stove to boil. Break a fresh egg into a small dish, and when the water boils slide the egg gently into it. When the albumen or while is firm, or at the end of two minutes, lift the egg out of the water with a skimmer and place it on a piece of hot, nicely-browned toast or hard-tack. Sprinkle with a little salt and pepper and serve hot. Soft Cooked Eggs Put into a saucepan as many eggs as are to be cooked. Pour over them water enough to cover. The water should have been brought up not quite to the boiling point. Let the eggs stay in the water from seven to ten minutes, and the result is an evenly cooked egg throughout. When the water is poured on the eggs do not set the pan on the lire. Xo further heating is required, but the water should not be allowed to cool down too rapidly. Omelet Two eggs. Two tablespoonfuls of milk, cream, or water. One-fourth teaspoonful of salt. Pepper to taste. Beat up the yolks and whites of the eggs separately. Add the salt to the yolks. Mix the whites and j-olks together with the milk, cream, or 276 MESS MANAGEMENT AND COOKING water. Place a small piece of butter or l)acon fat in a pan or plate hot enough to melt it. Pour in the omelet, and with a sharp knife loosen the edges as they solidify and fold over the omelet into a half-circle. When done, turn out on a plate and serve hot. When milk can not be had, water may be used. Spanish omelet has minced onion added to the above. An excellent addi- tion to the plain omelet is a dressing made of canned tomatoes and boiled crumbled hard bread, strained, seasoned, and heated together. Never use flour in an omelet, as it can not be cooked sufficiently in the short time that should be given to eggs. Baked Custard One pint of fresh milk. Two eggs. One-third teaspoonful of salt. Two tablespoonfuls of sugar. Small piece of cinnamon. Put the cinnamon in the milk and pour into a saucepan to heat. Brea.^ the eggs into a howl with the sugar and salt, and beat until well mixed but not light. When the milk comes to a boil pour it over the eggs. Stir slowly to dissolve the sugar. Strain the mixture into cups, set them in a deep pan of boiling water, and bake for twenty minutes in a moderately hot oven. Dry Toast Cut the bread in slices one-thrid of an inch in thickness. Toast may be made either by drying bread in an oven and then placing on a toaster over the fire, or the bread may be allowed to dry and brown in the oven. Toast that is moist and soft in the middle should never be given to an invalid. Have it dry, crisp throughout, and of a golden-brown color. Serve hot, either dry or buttered. Milk Toast Put a cup of milk into a saucepan and let it heat to the boiling point. Have ready three slices of nicely browned bread. Put a little salt in the milk and pour it over the toast. A little butter may be spread on the latter, but it is a more delicate dish without it. Serve hot. Oatmeal Porridge Three tablespoonfuls of oatmeal or rolled oats. One pint of boiling water. One-fourth teaspoonful of salt. Dissolve the salt in the water, then add the oatmeal. Cook for two hours in a double boiler. Rolled oats require cooking only half an hour. Oat- meal is very appetizing when served cold in mold shapes, and it will frequently be eaten in this way when it would be refused if served in anj' other form. Variations may be made by using farina, browned rice (browned in the SEMISOLID OR LIGHT DIET 277 oven before steaming and molding), arrowroot, etc., giving further change by serving occasionally with sweetened fruit juices, fresh, dried, or canned, instead of cream or milk. Farina Mush or Porridge hree tablespoonfuls of farina One pint of boiling water. One-half teaspoonful of salt. The water must be boiling before putting in the farina. Boil for half an hour. It may be served with fresh milk, or condensed milk diluted one to four parts of boiling water, or with stewed dried fruit, such as prunes, peaches, or apples. Cold farina mush may be sliced and fried for the use of convalescents. Plain Boiled Rice One-half cup of rice. Two cups of boiling water. One-half teaspoonful of salt. Pick the rice clean. Wash thoroughly in two waters, pouring off the last when ready to put the rice into the boiling water. Add the salt to the water. Pour in the rice and boil steadily for half an hour. In order to see if the rice is done, take out some of the grains and crush between the fingers. If done, they will mash easily and feel perfectly soft. Do not stir the rice, as this will cause it to fall to the bottom and burn. Serve with sugar and fresh or condensed milk or with stewed fruits. Steamed Rice Wash the rice thoroughly in two waters. Use in same proportions as are given for boiled rice. Use a double boiler. Have the water boiling in lower boiler. Place the above mixture of rice, boiling water, and salt in the upper chamber, and let cook for one hour. Do not stir. Keep the rice covered while steaming, and keep the lower boiler well supplied with boiling water. Serve as with boiled rice. Milk Porridge The flour for milk porridge should be prepared in the following manner: Tie up in a muslin bag or towel as much fliour as desired and boil for four or five hours, then bake in an oven until dry. To make the porridge, grate two tablespoonfuls of the dried flour, mix it with cold water into a paste, and add to it one pint of boiling milk or boiling water. Boil for ten minutes. If water alone is used to make the porridge, condensed or fresh milk may be used in addition, in equal parts or diluted one-half with water. Condensed milk used in this recipe is made in the strength of one part of condensed mlk to four of water. Salt is added in proportion of one tea- spoonful to the quart of boiling milk or water. 278 MESS AlA\A(.l'..\Ii:.\T AXD LOOKING Lemon Jelly One-fourth box of gelatin (one-half ounce). One-fourth cup of cold water. One-fourth cup of fresh lemon juice (about the amount yielded by two lemons). Three tablcspoonfuls of sugar. One and one-fourth cups of boiling water. Put the gelatin to soak in the cold water, about twenty minutes being re- quired for this process. When dissolved, pour on the boiling water. Add the lemon juice and sugar. Stir thoroughly and strain through a fine-meshed cloth into a china or granite-ware mold, cooling in a refrigerator or by placing in a pan of cold water. Never use tin molds for lemon jelly. Coffee Jelly One-fourth box of gelatin (one-half ounce). One-fourth cup of cold water. One cup of boiling wafer. One-half cup of strong coffee. Two tablcspoonfuls of sugar. Soak the gelatin in the cold water for half an hour. Pour on the boiling water, then put in the sugar and coffee. Strain it through a cloth into a mold or dish in Avhich it may be cooled, either in a pan of iced water or in a refrigerator. Coffee jelly may be served with cream and sugar. Have the coffee strong, two tablcspoonfuls of coffee to eaclj cup of water. Where vanilla extract is available, one-half teaspoonful will be advanta- geously added to the above recipe. Wine Jelly One-fourth box of gelatin (one-half ounce). One-fourth cup of cold water. One-half cup of sugar. One-half cup of sherrj' w^ine. One and one-fourth cups of boiling water. One small piece of cinnamon. Put the gelatin and cold water together in a dish large enough to hold the whole mixture. Let it soak for half an hour, then pour the boiling water (in which the piece of cinnamon has been simmering) over the softened gel- atin. Add the sugar and wine, strain through a clean cloth into a china or granite-ware mold, and cool in a refrigerator or a pan of cold water. Stewed Dried Apples, Apricots, or Peaches Wash the fruit thoroughly. Soak for four or five hours in the cold water it is to be cooked in, using only a sufficient quantity of water to cover. 'Heat in a covered granite-ware saucepan, simmering slowly for two hours. Do not boil. If the fruit is allowed to simmer it will not burn or need stirring, which breaks it up and makes it look unsightly. Apricots need plenty of sugar, but this should not be added until five minutes before taking off the SEMISOLID OR LIGHT DIET 279 fire. Lemon juice or lemon peel may be added to poorly flavored apples, a tablespoonful of the juice or the peel of half a lemon to the pound of fruit, or spices may be used for flavoring. The use of brown sugar in stewing dried fruit is to be preferred, because of the better flavor which it gives. Baked Apples Select fair, sound, and preferably tart apples. Wash and wipe them and cut out the cores, removing all the seeds and husks. Cut off any dark spots on the outside. Put the prepared apples into a granite or earthernware dish. Put into each apple from one-half to one teaspoon ful of sugar, according to the acidity of the fruit, and a bit of lemon peel. Pour boiling water into the dish about one-fourth inch deep, and bake in a moderately hot oven. When perfectly soft all through, the fruit is done. The time for baking varies, according to the species of apple, from half an hour to two hours. Canned Fruit, Serving' of Remove from cans several hours before using and put in porcelain or granite-ware dish to cool. Canned fruit is much improved by cooling, being more palatable and refreshing than if served direct from the can. Never allow fruit to remain in cans when once opened. This applies par- ticularly to very acid fruit, and also to meats, fish, or vegetables. Baked Potatoes Have the potatoes of a uniform size, so that all may be done at the .same time. Wash them thoroughly and bake in a hot oven from forty-five to lifty minutes. They are recognized as being done by the soft, yielding sensation given on pinching. oasted Potatoes Bury under the hot ashes of an open fire (camp) for half an hour or more. The thoroughness of cooking is recognized as with baked potatoes. Break open by squeezing. Brush the ashes off first. Boiled Potatoes Wash the potatoes well. Pare carr fully so as not to waste. Put them on to cook in boiling salted water, enough to cover, and let boil for thirty minutes. It requires more time for large-size potatoes. When easily pierced with a fork they are done. Drain off the water, and dry them on top of the stove by moving the boiler back and forth for a minute or two. Serve as quickly as possible after they are cooked. Mashed Potatoes Prepare as for boiled potatoes. When cooked, drain off the water and mash in the dish in which they wore boiled. Add butter, pepper, and salt to taste, and lastly put in a little milk or cream. Whip up lightly and serve immediately. Keep the dish covered until served. 280 MESS AIAXAGEMEXT AND COOKING Scraped Beef Cut a piece of steak from the round, about half a pound in weight and about an inch thick. Lay it on a clean meat-board and with a dull knife scrape out the pulp until there is nothing left but stringy fiber. Season the scaped pillp with salt and make it into small cakes. Broil for two minutes either by direct heat over a clear tire, or b}- heating a clean pan or plate and, when hot, placing the meat on it. Have both sides cooked sufficiently. This is a safe food for a patient beginning to take solid nourishment. Scraped be<.'f uiaj- be prepared very easily- over an alcohol lamp. Scraped Beef Sandwiches Place a piece of round steak on a meat-board and scrape out all of the pulp with a dull knife; add to the pulp a little salt and pepper and enough raw beef juice to make it into a firm jelly. Have stale bread cut into very thin slices and spread the beef pulp on them ; cut the sandwiches quite small. Never use butter in making beef sandwiches. Broiled Beefsteak Have a clear, hot fire, either coal or charcoal. Put the steak on a broiler, place directly over the fire for about a minute, then turn and do the same with other side. Bj^ applying greater heat at the outset the juices are kept in the meat. It requires from five to seven minutes over a clear fire to broil a steak an inch thick. Season both sides with salt and a little pepper, but no butter. Serve hot. A baked potato is a good vegetable to serve with the above, as is also boiled rice. Another good way to broil steak is to heat a granite-ware plate on a stove till it is quite hot. Place the steak on it till one side is done, then turn it and do the same with other side. Stewed Chicken Boil a chicken, prepared as for broth, until tender. Set it away till it is cool. Skim off the fat ; take the meat and cut it up in cubes or small pieces, rejecting all skin, gristle, tendons, and bones. To one cupful of the meat add one pint of the broth, seasoning with salt and pepper. Mix one tea- spoonful of flour with a little cold water, blend it thoroughly, and add it to the chicken. Let the whole stew for ten minutes, and serve with toast or boiled rice. Minced Chicken on Toast Prepare the chicken as for broth. When cool, skim off the fat and mince up the meat fine, rejecting all .skin, tendons, gristle, and bone. Season with salt and a little pepper. Add enough broth, or better yet, cream, if available, to make it of the proper consistency, or about that of cream. Have ready some nicely-browned dry toast, pour the minced chicken over it, and serve hot. THE RATIONS 281 THE HOSPITAL STORES Beef Extract (Liquid) To four ounces of cold, sterilized water add half a teaspoonful to one teaspoonful of the liquid extract. Mix thoroughly; season with salt and pepper to taste, and, if obtainable, with celery salt. Where a hot beef tea is required the above preparation may be heated, care being taken not to remove the nutritious curdy flakes produced by boiling. Malted Milk Mix one or two tablespoonfuls of malted milk with a like quantity of warm, boiled water. Add more water to make up half a pint. Season with salt to taste. Boiling water can not be used to advantage in making up this preparation. Chocolate Grate one ounce of chocolate. Have ready one pint of boiling milk. Mix the grated chocolate with some hot milk into a paste, add to it the boiling milk and boil five or six minutes. Flavor with sugar, one teaspoonful to the pint. The chocolate issued in the hospital stores is partly sweetened. If unsweetened chocolate is used, a tablespoonful of sugar is required. If fresh milk is not available, make the chocolate with boiling water and add one teaspoonful of condensed milk to each half pint of chocolate. Arrowroot Blanc-Mange Two tablespoonfuls of arrowroot. Two-thirds pint of hot water. Two tablespoonfuls of sherry or brandy. Two teaspoonfuls of sugar. Mix the arrowroot into a smooth paste with three tablespoonfuls of cold •v\-ater. .Add this to the hot water. Bring to a boil, stirring constantly till veil blended and free from lumps. Let boil for ten minutes. Add the sugar and sherry or brandy. Beat up quickly and pour into a bowl or mold to cool. Arrowroot blanc-mange may be made with fresh hot milk or con- densed milk diluted. If boiling water is used it causes the starch of the arrowroot, when first poured in, to form into lumps. Hence it is best to lave the water not quite at boiling point. THE RATIONS Hard-Bread Toast Water Two tablespoonfuls of powdered hard bread. One pint of boiling water. One-half teaspoonful of salt. 282 MESS MANAGEMENT AND COOKJXG Add the powdered hard bread, after toasting or parcliiny in an oven, to the salted boiling water. Boil for ten minutes. Strain through gauze and serve hot or cold. The toast water may be flavored with sugar, condensed milk, or whisky. Hard-Bread Mush or Porridge One cup of powdered hard bread. Four cups of boiling water. One teaspoonful of salt Mix and boil for ten minutes. The resulting mush may be eaten with condensed milk or stewed dried fruit. Care should be taken to prevent scorching by frequent stirring, and the water should be boiling in all cases before adding the powdered bread. Hard Bread as Milk Toast Toast two or three pieces of hard bread to a good brown color by placing in an oven or over a clear fire on a toaster. When done, pour enough boil- ing water over them to soften thoroughly. Dilute two tablcspoonfuls of condensed milk in four times as much boiling water. Drain ofif the water from the toasted bread and pour on the milk. Serve hot. Hard Bread and Dried Apples (Brown Betty) Soak the dried apples for at least four hours. Grease a baking pan or dish and place in it first a layer of sliced apples, then a layer of hard-bread crumbs, or w-hole hard bread softened in boiling water for ten minutes, with small quantities of butter or fat pork and sugar, and a littK" ground cinna- mon sprinkled over each layer. Continue till the dish is full, havmg bread crumbs for the top layer. Moisten with a cup of water, or fresh or diluted condensed milk, and bake three-quarters of an hour in a moderately heated oven, When a fork easily pierces the apples the pudding is cooked. It can be eaten hot or cold w-ith butter and sugar worked up together and flavored with cinnamon or nutmeg; with a simple sirup of sugar and water, oj- with the f ollow-ing sauce : Sauce for Hard-Bread Pudding One pmt of l)oiling water. One tablcspoonful of flour. One-half cup of sugar. One lemon. To the water add the flour, mixed into a paste with three tablespoonfuls of cold water. P.oil for ten minutes. .\dd the sugar and lemon juice, strained ; or other flavoring to taste. Bacon, Broiled Wash in cold water. Cut into thin slices and broil over clear coals, either on a broiler *or with a fork. Serve immediately. THE RATIONS 283 Bacon, Frkd Cut into thin slices after washing, roll in hard-bread crumbs, and fry in a very hot pan which has been greased. Season with pepper and serve im- mediately. The bacon may be fried without the bread crumbs if preferred. Bacon, Boiled Wash the bacon in cold water. Scrape and trmi off any rusty or brownish spots, and, if very hard or dry, soak for a few hours in cold water. Put it on to cook in enough cold water to cover it well, let it come slowly to a boil, and then boil steadily until done. As the water evaporates or boils away, replenish it with more boiling water. When the bacon can be easily pierced with a fork in the thickest part, it is sufficiently cooked. Save the iat, it will be useful in frying; and if greens are to be cooked, leave enough in the water to season them. Canned Roast Beef Soup One pound (one-half can) of roast beef. One pint of cold water. Salt and pepper to taste. Cut the beef into small pieces and add it to the cold water. Let the whole come to a boil and then simmer gently for half an hour. Skim off the fat and stram, taking care to express all the meat juice and gelatin from the meat. Season with salt and pepper to taste. A little beef extract, when added to the above, improves the value and palatability of this soup. A tablespoonful of hard bread, powdered, may be added if rice and other grains are not available. Canned Roast Beef Stew Two pounds of canned roast beef. Six small potatoes. One onion. Salt and pepper to taste. Wash, peel, and slice the vegetables. Cover them with sufficient boiling salted water. Put them on to boil, and when nearly done add the roast beef, well cut up. Season to taste with pepper and salt, and let the whole simmer ten or fifteen minutes before serving. If potatoes are not to be had, hard bread, crumbled and softened in boiling water, may be used with the meat. Canned tomatoes, in varying proportions, make a good addition to the stew, as already described. Tn the absence of any other vegetables, they may be added to the meat in the proportion of pound for pound. Canned Roast Beef Hash Two poimds of canned roast beef. Six boiled potatoes, small. One onion. Pepper and salt to taste. 284 MESS MANAGEMENT AND COOKING Cliop up the meat and vegetables thoroughly. Mix well. Season with pepper and salt and brown in a hot dish or frying pan, previously greased with pork or bacon, in an oven or over the fire. When potatoes cannot be obtained, a very good hash may be made by the use of softened hard bread or boiled rice in their place. Canned Salt Beef Stew Cut up the contents of a two-pound can. Cover with cold water and bring to the boiling point. Then add vegetables as directed for roast-beef stew. Season with pepper, but add no salt. Stew for three-quarters of an hour. Canned Salt Beef Hash Two pounds (one can) of salt beef. One cup of hard-bread crumbs. One onion. Bacon fat or beef fat (about the size of an egg). Water, or soup stock. Pepper and salt. Chop up the beef. Add the bacon fat or beef fat, and add sufficient water or soup stock to moisten the whole. Season with pepper and a very little salt. Parboil the onion, chop it up, and add it to the mixture. Put into a frying pan or mess plate and brown on both sides. If desired, the onion may be fried before adding it to the hash. Rice Pudding Two tablespoonfuls of rice. One tablespoonful of sugar. One pint of fresh milk. Nutmeg or cinnamon as flavoring. Wash the rice and cover with the milk, previously sweetened and flavored. Set in a moderately hot oven. Stir every fifteen minutes during the first hour and then once at the expiration of the next half-hour. Bake two hours and until the brown top forms. This gives a creamy, slightly brown pudding. Baked Bean Soup Take cold baked beans, add twice as much water as beans, and let them simmer till soft. When done, add half as much canned tomatoes and strain. If too thick add more water. Season to taste with salt and pepper. Pea-Meal Soup One-half pound of salt pork or bacon. One and one-half pints of water. Two tablespoonfuls of pea-meal. Boil the bacon or pork in the water. When the meat is nearly cooked, add the pea-meal and let simmer until the meat is thoroughly done. Skim off the fat, season with pepper and serve. Canned salt meat can also be used to make pea soup, but does not require so long to prepare, as the meat is already cooked. Season with pepper and ver\' little salt. Serve hot. APPROXIMATE MEASURES 285 Fried Pea-Meal Mush One pint of water. One teaspoonful of salt. Four tablespoon fuls of pea meal. Add the pea-meal to the salted water. Boil for twenty minutes. Cool by pouring out into a plate or mess tin. Slice and fr>- quickly in hot bacon- fat (for convalescents). Tomato Soup To one can of tomatoes add an equal quantity of water and let simmer for half an hour. Mix one tablespoon ful of Hour with an equal quantity of beef dripping or bacon fat. Add it to the tomatoes. Season with pepper and salt. If very acid, a teaspoonful of sugar may be added to disguise the aciditj'. Boiled rice or hard-bread crumbs make a very good addition to tomato soup. Serve hot. Stewed Tomatoes with Hard Bread To each can of tomatoes add half an onion chopped fine, salt and pepper to taste, and if tomatoes are very acid, enough sugar to counteract the acidity. Cover, and stew for three-quarters of an hour. Hard-bread crumbs are added to thicken to the consistency desired. Baked Tomatoes with Hard Bread Mix enough hard-bread crumbs with the canned tomatoes to absorb the greater portion of the juice; season with salt, pepper, and thin slices of bacon laid on top, and bake from three-quarters of an hour to an hour. Onions, either raw or fried, may be chopped up and added to the seasoning. APPROXIMATK MEASURES Four teaspoonfuls of liquid are equal to one tablespoonful. Three teaspoonfuls of solid material, as sugar or arrowroot, are equal to one tablespoonful. One tablespoon contains one-half a fluid ounce. One coffee cup, quartermaster's, rontams ten fluid ounces. One coffee cup, usual size, contains eight fluid ounces. One glass tumbler, usual size, contains eight fluid ounces. Two coffee cups, or glass tumblers, usual size, are equal to one pint. One tin cup, soldier's field mess outfit, contains one and one-half pints. PART VI MATERIA MEDICA AND THERAPEUTICS, AND PHARMACE CHAPTER I MATERIA MEDICA AND THERAPEUTICS Materia medica treats of the materials or drugs used in medicine ; their origin, composition, physical and chemical properties, and their action. Therapeutics is the art of applying the articles of the materia medica to the cure of disease. Pharmacy is the art of preparing drugs and dispensing them. MATERIA MEDICA Drugs or medicines are derived from the animal, vegetable, and mineral kingdoms. The active principles of drugs are those constituents which are active in producing the effects of the drug; morphine, for example, is the active principle of opium. Among active principles are alkaloids and neutral principles. Alkaloids are usually very insoluble in water, but combine with acids to form soluble salts ; they have powerful medicinal effects ; their Latin names end in ina and their English names in ine ; mor- phine, atropine, and quinine are some of the alkaloids of the supply table. Neutral principles are neutral in character ; they are distinguished by having their Latin names ending in innm and English names end- ing in in. Among neutral principles of the supply table is santonin. Organic acids are found in organic substances. Examples : acetic acid, citric acid. Mineral acids are obtained from the mineral kingdom. Examples : (287) 288 AIATERIA AlEDICA, THERAPEUTICS, PHARMACY sulphuric acid, hydrochloric acid. They neutrahze alkalies and when concentrated act as caustics. Alkalies or aut-acids neutralize acids and in some forms act as caustics. , Examples : bicarbonate of soda, potassa. Fixed oils are non-volatile, and are decomposed by boiling with water and an alkali, the resulting products being soap and glycerin. Examples: olive, oil, castor oil. Volatile or essential oils exist in plants from which they are ex- tracted by distillation with water; they evaporate when exposed to the air and have penetrating aromatic odors. Examples : oil of cloves, oil of peppermint. Medicines are sometimes classified according to their most notice- able effects, thus : Anodynes are remedies which relieve pain. Examples : opium, acetphenetidin. Anesthetics are agents which temporarily destroy sensation; they are subdivided into General Anesthetics and Local Anesthetics. General anesthetics are volatile substances which, when inhaled, destroy consciousness and sensation. Examples : ether, chloroform. Local anesthetics act directly upon the nerves of the part with which they are brought in contact, destroying sensation temporarily. Examples : cocaine, phenol. Anthelmintics are agents used to expel worms from the intestines. Example : calomel. Antidotes are remedies against poisons; thus the alkaline sul- phates are antidotes for phenol. Antipyretics are agents which reduce fever. Examples : quinine, antipyrin. Antiseptics are substances which prevent or retard septic decom- position by destroying or arresting the development of the bacteria of sepsis. Astringents, of which alum is an example, are substances which cause a constriction of the tissues. Carminatives are agents which cause the expulsion of gas ; the essential oils are carminatives. Cathartics, purgatives, and laxatives are medicines which increase the action of the bowels ; rochelle salts is an example. Diaphoretics are agents which increase the secretion of sweat. Dover's powder is a diaphoretic. MATERIA MEDICA AXD THERAPEUTICS 289 Disinfectants are substances which destroy the specific germs which infect people with disease. Phenol and corrosive sublimate are disinfectants. Diuretics increase the flow of urine. Example : sweet spirits of niter. Emetics cause vomiting. Ipecac and apomorphine are emetics. Expectorants are agents which aid expectoration. Ammonium chloride is an expectorant. Hypnotics produce sleep. Veronal and chloral are hypnotics. Narcotics are agents which produce stupor. Example : opium. Styptics are substances which arrest bleeding. Alum is a styptic. Certain drugs affect the skin, urine, or feces in a way that should be known to those charged with their administration : Drugs wJiich may produce an eruption on the skin: Arsenic, acetanilid, antipyrin, belladonna, bromides, chloral, copaiba, iodides, opium, acetphenetidin, quinine, salicylic acid, turpentine. Drugs zvliich color the feces: Iron — black; bismuth — slate color or black; calomel — green. Drugs which color the urine: Carbolic acid — dark green ; rhu- barb — yellow ; santonin — saffron color if the urine is acid, purplish- red if alkaline. Drugs which have a tendency to become liquid on exposure to air, by the absorption of moisture, are said to be deliquescent or hygro- scopic, while those which lose their water of crystallization and become dry and powdery are called efflorescent. ADMIXISTRATIOX OF MEDICINES Medicines are given by the mouth and stomach, by the rectum, by the skin, blood-vessels, and subcutaneous cellular tissues. By the mouth and stomach is the method ordinarily employed. Medicines which are irritating to the stomach should be given well diluted and after meals. The rectum is sometimes employed for the adm.inistration of medicine when the stomach will not retain them. Remedies are injected into the veins direct only in case of great emergency. The administration of drugs by the subcutaneous cellular tissue is called the hypodermic method ; it is employed when prompt action is desired. Alkaloids like morphine and strychnine are especially suit- 19 290 MATERIA MEDICA, THERAPEUTICS, PIIARAIACV able for this method, and hirge quantities of normal salt solution are frequently so employed. Substances are also intr<'duced into the circulation Ijy simply rub- b.ing them into the imbroken skin. Fats and oils and remedies in- corporated, with them are often used in this way. Syphilis is fre- quently treated by inunctions of mercurial ointment. DOSAGl': Doses are only relative and cannot be represented in exact figures, since they are subject to so many influencing circumstances. The principal of these are age, size and weight, habit, idiosyncrasy, in- terval between doses, time of administration, condition of stomach or (if externally applied) of skin, disease, climate, method of administration, form of drug used, etc. Dosage in children: Doses ordinarily given are those for adults; to compute the suitable quantity for a child, either of the following rules may be made use of : (i ) Young's method : Divide the age by the age -)- 12 ; thus, sup- pose the child is 3 years old i-\i=^-h = l'- hence we give one-fifth of the adult dose. (2) Cowling's method : Divide the number of the following birth- day by 24 ; thus, child's age is 3, next birthday is A -I '. hence dose is one-sixth that of adult (this gives a slightly smaller dose than does Young's rule). Children bear opium badly, and hence the dose should be propor- tionately small. Comparatively large doses of belladonna, jaborandi, aconite, mercury, arsenic, quinine, and cathartics in general are borne by children. When given hypodermically, the dose of medicines is tzi'O-thirds of that used by mouth. When given by rectum, it is four-thirds of the dose by mouth. MEDICINES AND MEDICAL AGENTS OF THE ARMY AND N.WV SUPPLY TABLES Acacia (Gum Arabic). A gummy exudation from Acacia Senegal and other species of Acacia. A glassy-looking substance in frag- ments ; insipid taste, soluble in water, used as a vehicle. The pow- der is white. Mucilago Acaciae (acacia 340; lime water 330; water to 1,000). MATERIA MEDICA AND THERAPEUTICS 291 Acetanilidiim (Acetanilid). A derivative of aniline. A colorless crystalline powder, odorless, with a slightly burning taste, soluble in 179 parts water. Used in neuralgia. Dose : \ Gm. Acetphenetidinmn (/\cetphenetidin. Phenacetin). A phenol de- rivative. White scales or crystalline powder, odorless and tasteless. Soluble in 925 parts of water or 12 parts of alcohol. Antipyretic and antineuralgic. Dose : 4 Gm. Acidiim Acetictim (Acetic Acid). A clear, colorless liquid, hav- ing a strong vinegar-like odor and an acid taste. Acidum Aceticum Dilutum (acetic acid 100; water 500). Dose : 2 Cc. Acidum Boric urn (Boric Acid). Colorless scales or a light white powder; odorless and slightly bitter. Soluble in 18 parts of water. Used as a mild antiseptic. Dose : ^ Gm. Acidum Citricum (Citric Acid). Usually prepared from lime or lemon juice. Colorless, odorless, acid-tasting crystals ; efflorescent in dry air and deliquescent in moist air; soluble in 0.54 part water. Dose : | Gm. Acidum Gallicum (Gallic Acid). An organic acid usually pre- I>ared from tannic acid. Fawn-colored needles, astringent, slightly acid, permanent. Soluble in 83.7 parts water and 4.14 alcohol. Used as an astringent. Dose : 4 Gm. Acidum Hydrochloricnm (Hydrochloric Acid). A colorless, fuming liquid which should be kept in glass-stoppered bottles. Acidum Hydrochloricnm Dilutum (Hydrochloric acid 100, water 219). Dose: i Cc. Acidum Hydrocyaniciim Dilutum (Dilute Hydrocyanic Acid; Dilute Prussic Acid). A colorless liquid containing 2 per cent of absolute hydrocyanic acid, and having the odor of bitter almonds. As it is very poisonous, it should not be tasted except with great caution. Should be kept in dark amber-colored bottles in a cool place. Dose: o.i Cc. Acidum Nitricum (Nitric Acid). A colorless, fuming liquid; very caustic ; should be kept in glass stoppered bottles. Acidum Nitricum Dilutum (nitric acid 100. water 580). Dose : 2 Cc. Acidum O.valicum (Oxalic .Aid). Colorless crystals, very poi- sonous. Surgical use, externally only. Fatal results have followed 202 MATERIA AIEDICA. TllERArEUTICS,' PilARMACV mistaking this substance for sulphate of magnesia, which it resem- bles. The two may be distinguished by heating a few of the crystals to a red heat on the end of a spatula ; oxalic acid will be completely dissipated, while sulphate of magnesia will not. An- other distinction lies in the fact that oxalic acid decolorizes solution of permanganate of potash, while sulphate of magnesia does not. .-Icidnm Pliosplioricum Dilntiim (Dilute Phosphoric Acid). A colorless, odorless liquid, which should be kept in glass-stoppered bottles. (Phosphoric acid loo, water 750). Dose : 2 Cc. Acidum Salicyliciim (Salicylic Acid). An organic acid existing naturally in some plants, but generally prepared from phenol. Light, fine, white needles, or a crystalline powder, with a faint odor and sweetish taste. Soluble in 308 parts water. Used in rheumatic troubles. Dose : 4 Gm. Acidum Sidphuricum (Sulphuric Acid). A colorless, oily, very corrosive liquid. Should be kept in glass-stoppered bottles. Acidum Sidphuricum Aromaticiim (Aromatic Sulphuric Acid). Sulphuric acid in, tincture of ginger 50, oil of cinnamon i, alcohol to 1,000.) Dose: i Cc. Acidum Tannicum (Tannic Acid). An organic acid obtained from nutgalls. A light yellow powder with a faint odor, and strongly astringent taste. Soluble in about 0.34 part of water. Used as an astringent. Dose : | Gm. Acidum Tartaricum (Tartaric Acid). An organic acid occurring in colorless crystals or a white powder; odorless and with an acid taste; soluble in 0.71 part of water. Dose : ^ Gm. Aconiti Tinctura (Tincture of Aconite). 10 per cent strength. Used to quiet the heart. Dose : -|- Cc. Adcps Bcnzoiiiatus (Benzoinated Lard). (Benzoin 20, lard 1,000; in warm weather substitute 5 per cent of the lard by an equal quantity of white wax). Used as a basis for ointments. Adcps Lance Hydrosus (Wool-Fat. Lanolin). The purified fat of the wool of sheep, freed from water. A light-yellowish, tena- cious, unctuous mass; insoluble in, but miscible with large quantities of water. Used as a basis for ointments. Adrcnalini Chloridum (Adrenalin Chloride). An active principal obtained from the adrenal glands. MATERIA MEDICA AND THERAPEUTICS 293 Used locally to control bleeding from the nose and throat. ^ther (Ether). A transparent, colorless liquid, having a char- acteristic odor and a burning sweetish taste. Its vapor when mixed with air and ignited explodes violently. Used chiefly as an anesthetic, by inhalation. Dose internally i Cc. ^theris Spiritiis Compositus (Compound Spirits of Ether. Hoff- man's Anodyne). (Ether 325, alcohol 650, ethereal oil 25.) Used as a stimulant and carminative. Dose : 4 Cc. Aitheris Spiritus Nitrosi (Spirits of Nitrous Ether. Sweet Spirits of Niter). A clear, volatile liquid of a pale yellowish tint, fragrant odor and burning taste. Used as a diuretic and carmina- tive. Dose : 2 Cc. JEthylis Chloridiim (Ethyl Chloride). An extremely volatile liquid kept in hermetically sealed glass tubes. Used chiefly in the form of a spray as a local anesthetic by virtue of its freezing properties. Also sometimes used as a general anes- thetic by inhalation. Alcohol (Alcohol). A colorless volatile liquid containing about 95 per cent by volume of absolute alcohol. It is obtained by the distillation of grain. Alcohol, Methyl (Wood Alcohol). A colorless, poisonous liquid of a disagreeable odor obtained in the destructive distillation of wood. It is used as an adulterant in cheap liquors and toilet prep- arations and as fuel, and when taken internally has caused many deaths. Aloe (Aloes). The inspissated juice of the leaves of Aloe vera and other species of Aloe. Aloe Pulfis (Powdered Aloes). A brownish-yellow powder of bitter taste, used as a laxative. Dose: ^ Gm. Aloiiii Piliihv Couipositcc (Compound Aloin Pills). Contain 8 mgm. each of aloin, podophyllum resin, and extract of belladonna, 0.8 mgm. of strychnine, and i.y mgm. of oleoresin of capsicum. Dose : 1-2 pills. Ahimen (Alum). The powder is white, with a sweet, astringent taste ; soluble in 9 parts water. Used as an emetic and as an astringent. Dose : ^ Gm. 2'n MATERIA AIEDICA. Tl UlRAPLLUTICS, PllARAlACY Ammonia' Aqua (Ammonia Water). A lo per cent aqueous solution of ammonia gas. A colorless, volatile liquid, which deteri- orates on keeping ; should be kept in glass-stoppered bottles in a cool place. A powerful stimulant. Dose : i Cc. well diluted. Ammonia' Spiritiis Aroniaticiis ( .Xromatic Spirits of Ammonia). (Ammonium carbonate 34, ammcnia water 90, alcohol 700. aromat- ics q. s., water to 1,000.) A yellowish liquid used as a stimulant. Dose : 2 Cc. well diluted. .Immonii Bromidum (Ammonium Bromide). Colorless crystals or a white crystalline i)owder, odorless and of saliu'c taste; soluble in 1.2 parts of water; irritating to the stomach; should l)e adminis- tered in plenty of water. Used as a sedative. Dose : i Gm. .lm)no)iii Carbonas (Ammonium Carl^onate). White, translucent or opaque masses, having a strong odor of ammonia. Only the translucent portions should be dispensed. Used as a stimulant. Dose : ^ Gm. Ammonii Cliloridum (Ammonium Chloride). A white, odorless powder, with a cooling taste. Used as an expectorant. Dose : 4 Gm. Ammonii Chloridi TrocJiisci (Ammonium Chloride Troches). Each contains 130 mgms. ammonium chloride and 4 gm. extract of licorice. Dose : i lozenge. Amxlis Nitris (Amyl Nitrite). A clear, yellow liquid of a pecu- liar, penetrating odor. A powerful stimulant, used by inhalation only. Dose : 0.2 Cc. Anfimonii ct Potassii Tartras (Tartar Emetic). Colorless crys- tals or a white granular powder; odorless and with a sweetish taste. Soluble in 15.5 parts of water. Dose : as an expectorant, 5 milligrammes ; as an emetic, 30 milligrammes. A)itipyri)tum (Antipyrin). A ct'lorless, almost odorless, crystal- line powder obtained from coal tar, having a bitter taste ; soluble in less than i part of water. Dose : | Gm. Apomorphinci' Hydrochloridnm (Apomoq:)hine Hydrochloride). The salt of an alkaloid derived from opium. White crystals acquir- MATERIA :\IEDICA AXD TIIERAPELTTICS 295 ing a greenish tint after exposure to light. Used hypodermically as an emetic. Dose : 5 milHgrammes. Aqua Hydrogcnii Dio.xidi (Sokition of Hydrogen Dioxide. Peroxide). (10 per cent by volume.) A colorless, odorless liquid rapidly deteriorating upon exposure. Used chiefly externally to cleanse suppurating wounds. Argcnti Nitras (Silver Nitrate). Colorless crystals, soluble in 0.54 part of water, and decomposed by light. Used externally principally. Dose: 10 milligrammes. Argenti Nitras Fiisus (Lunar Caustic). White or gray pencils. External use. Argyrol. A proteid silver salt, occurring in black hygroscopic scales, containing 30 per cent metallic silver. Soluble in all propor- tions in water. Used chiefly locally in inflammation of mucous membranes, and in 20-50 per cent solution. Dose : 4 Gm. Arseni et Hydrargyri lodidi Liquor (Solution of Arsenous and Mercuric Iodides). (Donovan's Solution.) Used in skin diseases and syphilis. Dose: i-ioCc. Arseni Trioxidum (^^^^ite Arsenic. The Acidum Arsenosum of 1890). An opaque, white, poisonous powder; odorless and taste- less. Soluble in about 100 parts of water. Dose : 2 milligrammes. Asafefida (Asafetida). A gum-resin from the root of Ferula fcBtida and other species of Ferula. Yellowish-white masses. Dose : j Gm. Aspidii Oleoresinw (Oleoresin Aspidium). A thick, dark-green liquid, depositing a granular substance on standing; this granular part should be well mixed with the liquid portion before dispensing. Used especially against tape-worms. Dose : 2 Gms. Aspirin. A salicylic acid compound. Colorless crystals not very soluble in water; readily soluble in alcohol. Used as a substitute for salicylic acid. Dose: -J to i Gm. Atropincc Sulphas (Sulphate of Atropine). The sulphate of an alkaloid obtained from Atropa Belladonna and other plants of the same family. A white, odorless, bitter powder; very poisonous. Used especially to dilate the pupil. Dose: 0.4 milligramme. 296 :\IATERIA .Ml- DRW. 'I'l 1 |-.R.\lM:i"rie"S. ['ilARMACY Balsiniitiiii Pcniz'iaiiuiii ( nalsaiii of Peru). A viscid, dark- brown licjuid, of agreeable odor. Used as a wtmnd dressing. Balsainuiii Tolntanum (Balsam of Tolu). BcUadomur liinplastnim (Belladonna Plaster). Belladonna Foliorum Extractuni (Extract of Belladcjnna Leaves). Used chiefly externally. Dose: lo milligrammes. Benzoin! Tinctiira Composiia (Compound Tincture of Benzoin). Used chiefly by inhalation with the vapor of hot water. Dose : 4 Cc. Bisniuthi Siibijallas (Bismuth Subgallate. Dermatol). An amor- phous, yellow powder, insoluble in water, odorless and tasteless ; colors the stools black. Used in diarrheal diseases. Dose : ^ Cm. Bismuthi Stibnitras (Bismuth Subnitrate). A white powder, odorless, tasteless, and insoluble in water. Used in diarrheal dis- eases. Colors the stools black. Dose : ^ Gm. Biichu Fluidcxtractum (Fluidextract of Buchu). A greenish- black liquid. Used as a diuretic. Dose : 2 Cc. Caffeina Citrata (Citrated Caffeine). A white, odorless, bitter powder. Used as a diuretic and heart stimulant. Dose : ^ Gm. Calcii Phosphas Pnecipitatus (Precipitated Phosphate of Cal- cium). An amorphous, white powder, insoluble, odorless, tasteless, and permanent. Used chiefly in tuberculosis. Dose : i Gm. Calx (Lime). Hard white or grayish-wdiite masses. Soluble in 760 parts of water. Slakes in the air. Used to prepare lime water. Calx Chlorinata (Chlorinated Lime). A white powder with the odor of chlorine, and decomposing on exposure to air. Used as a disinfectant. Dose : \ Gm. Camphora (Camphor). White masses, sparingly soluble in water, but readily soluble in alcohol and in oils. Used principally externally. Dose: ^ Gm. Camphorw et Opii Pilulcp (Camphor and Opium Pills). Each pill contains 65 mgms. opium and 130 mgms. camphor. Dose : i pill. MATERIA AIEDICA AXD THERAPEUTICS 297 Cantharidis Emplastriim (Canthariclis Plaster. Blistering Plaster). Cantharidis Tinctiira (Tincture of Cantharides). An alcoholic extract of powdered Spanish J-'lics. Used chiefly externally. Dose : /j Cc. well diluted. Capsici Pnh'is (Powdered Capsicum. Red Pepper). A red powder. Dose : 65 milligrammes. Capsici Tinctiira (Tincture of Capsicum). Used chiefly exter- nally. Dose : -J Cc. well diluted. Capsici Fluidextractum (Fluidextract of Capsicum). Used in the same manner as the tincture. Dose : 0.05 Cc. Cardamomi Tinctiira Coniposita (Compound Tincture of Car- damomum). Used chiefly as a bitter tonic. Dose : 4 Cc. Cera Flava (Yellow Wax). Ceratum Resince (Rosin Cerate. Basilicon Ointment). (Rosin 350, yellow wax 150, lard 500). External use. Chloralum Hydratiim (Ilydrated Chloral. Chloral.) Colorless, transparent crystals, with an aromatic odor and bitterish taste. Freely soluble in water and alcohol. Used as a hypnotic. Dose: i Cm. dissolved in water or whisky. Chloroformum (Chloroform). A clear, colorless liquid of char- acteristic odor and sweetish, burning taste. Should be kept in amber- colored, glass-stoppered bottles in a cool, dark place. Used chiefly as an anesthetic by inhalation. Dose : ^ Cc. Chromii Trioxidum (Chromium Trioxide. Chromic Acid). Should be kept in glass-stoppered bottles and great care taken not to bring it in contact with organic substances such as cork, sugar, alco- hol, etc., as an explosion may result. Needle-shaped crystals of purplish-red color; corrosive, deliquescent, very soluble in water. Used solely as a caustic in crystals or solution. Chrysarohinnm (Chrysarobin). A neutral principle extracted from goa pozcdcr. An orange-yellow, crystalline powder, odorless, tasteless, and very insoluble. Used externally. Dose : 30 milligrammes. Cinchona Tinctiira Composita (Compound Tincture of Cinchona). Used as a tonic and in malarial diseases. Dose : 4 Cc. Cocaince H\drochloridum (Cocaine Hydrochloride). A salt of 298 MATERIA MEDICA, THERAPEUTICS, PHARMACY an alkaloid obtained from several species of coca. A colorless, odor- less, crystalline powder ; soluble in 0.4 part water. Used chiefly as a local anesthetic. Dose : 2~ milligrammes. Codciiuc Siilplias (Codeine Sulphate). A salt of an alkaloid from opium. A crys>talline powder, odorless, with a faintly bitter taste. Used as a sedative. Dose : 30 milligrammes. Colchici Scminis Fluidcxtractnm (Fluidextract of Colchicum Seed). Used chiefly in gout. Dose : i Cc. well diluted. Collodium (Collodion). A colorless, syrupy liquid, with the odor of ether. Used externally only. Collodium CantJiaridatum (Cantharidal Collodion). Cantharides 60, flexible collodion 85, chloroform to 100. Used externally to blister. Collodium Flexile (Flexible Collodion). Collodion 930, Canada turpentine 50, castor oil 30. Capaiba (Copaiba). An oleoresin of a yellowish color, more or less transparent, viscid, having a peculiar aromatic odor. Used chiefly in gonorrhea. Dose : i Cc. Copaih<2 Pilulcc Composite (Compound Copaiba Pills). Each contains 100 mgms. copaiba with guaiac, iron, and cubebs. Dose : i pill. Creosotal (Creosote Carbonate). Contains 90 per cent creosote. A thick, oily, amber-colored liquid, with but little taste or odor. In- soluble in water ; soluble in 95 per cent alcohol and in oils. Use and dose the same as creosote. Creosotum (Creosote). A mixture of phenols and phenol deriva- tives obtained by the distillation of wood tar, preferably from the beech. A yellowish, oily liquid having a penetrating, smoky odor and a burning taste. Used principally in phthisis. Dose : ^ Cc. Cresol (Cresol. Tricresol). A mixture of three cresols obtained from coal tar. A straw-colored liquid, having a phenol-like odor. Soluble in Tk) parts of water. Used externally as a disinfectant. Dose : 0.05 Cc. ]\1ATERIA MEDICA AXD THERAPEUTICS 299 CrcsoUs Liquor Composittis (Compound Solution of Cre?ol). A 50 per cent solution of cresol with 35 per cent linseed oil and 8 per cent caustic potash in water. Used externally as a disinfectant. Crcfa Prccparata (Prepared Chalk). A white powder; odorless, tasteless, insoluble, permanent. Used in diarrheal troubles. Dose : i Gm. Cubebce Oleoresina (Oleoresin of Cubeb). Used in gonorrhea. Dose : h Gm. Cupri Arsenis (Arsenite of Copper). Dose : 0.65 milligramme. Cupri Sulphas (Sulphate of Copper). Deep-blue crystals, odor- less, efflorescent, soluble in 2.2 parts of water. Used as an astringent. Dose: 10 milligrammes. Digitalinum (Digitalin). A glucoside, and active principle of digitalis. Dose : i milligramme. Digitalis Tinctura (Tincture of Digitalis). Used as a heart tonic. Dose : i Cc. Eriicstiiii Hydrochloridum ( Ernstine Hydrochloride). An alka- loidal salt obtained from ipecac. Dose : 30-60 milligrammes. Ergotce Fluidextractum (Fluidextract of Ergot). Used chiefly to control bleeding. Dose : 2 Cc. Ergotinum (Ergotin). An unofiicial extract of ergot. Dose: 130 milligrammes. Eucaine Hydrochloridum-B . A synthetic preparation closely re- sembling cocaine, for which it is often used as a substitute in the production of local anesthesia. Dose : 30 milligrammes. Eucalyptol (Eucalyptol). An oxide from the oil of eucalyptus. A colorless liquid of aromatic odor and pungent taste. Dose : i Cc. Ferri Chloridi Tinctura (Tincture of Ferric Chloride). A bright, brownish liquid, having an astringent, styptic taste. Injures the teeth ; should be taken through a glass tube and well diluted. Used as a tonic. Dose : ^ Cc. Ferri ct Ouinina: Citras Solubilis (Soluble Iron and Quinine 300 MATERIA MEDICA, THERAPEUTICS, PHARMACY Citrate). Thin, greenish, odorless, dehquescent scales; completely soluble in water, partly soluble in alcohol. Used as a tonic. Dose : ^ Gm. Fcrri lodidl Syrup us (Syrup of Ferrous Iodide). A syrupy, pale- green liquid, having a sweet taste. Used as a tonic. Dose: i Cc. Ferri Piluhc Compositcc (Compound Iron Pills). Each contains 65 mgms. pyrophosphate of iron, 32 mgms. sulphate of quinine, and I nigm. sulphate of strychnine. Dose : 1-2 pills. Fcrri Fhosplias Solubilis (Soluljle Ferric Phosphate). Thin, apple-green, odorless scales ; decomposed by light ; soluble in water, insoluble in alcohol. Used as a tonic. Dose : ^ Gm. Ferri Sulphas Exsiccatiis (Dried Ferrous Sulphate). A grayish- white powder, slowly but completely soluble in water. Dose : 125 milligrammes. Fcrrum Reductum (Reduced Iron). A fine, grayish-black pow- der; odorless, tasteless, insoluble. Dose : 65 milligrammes. Foot Powder. Contains 3 parts salicylic acid, 10 of starch, and 87 of talcum. Gentiancr Tiuctura Composita (Compound Tincture of Gentian). Used as a tonic. Dose : 4 Cc. Glycerilis Nitralis Tahellce (Nitroglycerin Tablets). Heart stim- ulant. Dose : One tablet containing 0.65 milligramme. Glycerbuim (Glycerin). A liquid obtained by the decomposition of fats or fixed oils ; clear, colorless, odorless, sweet. Used exter- nally. Dose : 4 Cc. Glycyrrhiccc Extractum Piirtim (Puh-is) (Pure Extract of Lico- rice). A brown powder used for flavoring. Glycyrrhhcc Mistura Composita (Compound Licorice Mixture. Brown Mixture). Contains paregoric, wine of antimony, sweet spirits of niter, licorice, gum arabic, syrup and water. Eight Cc. contains about i Cc. of paregoric and ^ Cc. of sweet spirits of niter. Used as cough mixture. Dose: 8 Cc. Glycyrrhi"cc Pulz'is Compositus (Compound Licorice Powder). MATERIA MEDICA AXD TIIERAPEL'TICS 301 Contains senna, sulphur, licorice, oil of fennel, and sugar; about f Gm. of senna and /j Gm. of sulphur in each 4 Gms. Used as a laxa- tive. Dose : 4 Gms. Guaiaci Tinctura Ammoniata (Ammoniated Tincture of Guaiac). Used especially in tonsillitis. Dose : 2 Cc. Guaiacolis Carbonas (Guaiacol Carbonate). One of the chief constituents of creosote. A white powder, almost tasteless and odor- less ; insoluble in water. Used in tuberculosis. Dose : i Gm. Ilamamelidis Folioriim Fluidextractuni (Fluidextract of Ham- emelis Leaves. (Witch Hazel). Used chiefly externally. Dose : 2 Cc. Ilcroini Hydrocliloridum (Heroin Hydrochloride). A morphine derivative. Used chiefly to control cough. A white powder, soluble in water. Dose : 5 milligrammes. Hcxamethyloiamina (Hexamethylenamine. Urotropin). Color- less, odorless crystals; soluble in 1.5 parts of water and 10 parts alcohol. Used as a urinary disinfectant. Dose : ^ Gm. Homatrophina Hydrohromidiim (Homatropine Hydrobromide). An artificial alkaloid derived from atropine. Used to dilate the pupil. Soluble in 10 parts of water. Hydrargyri Chloridum Corrosivum (Corrosive Chloride of Mer- cury. Corrosive Sublimate). Colorless, odorless, permanent crys- tals, soluble in 13 parts of water, 3 parts of alcohol. Used as an antiseptic and in syphilis. Dose: 3 milligrammes, dissolved in abundance of water. Hydrargyri Chloridum Mite (Mild Mercurous Chloride. Calo- mel). A white powder, insoluble, odorless, 'tasteless, permanent. Used as a laxative and in syphilis. Dose: 65-215 milligrammes. Hydrargyri lodidiim Flavian (Yellow Mercurous Iodide). A bright yellow powder, odorless, tasteless, insoluble; decomposed by exposure to air. Used in syphilis. Dose : 10 milligrammes. 302 jMATERIA AIEDICA, THERAPEUTICS, PHARMACY Ilydravijyri Massa (Mass of Mercury. Blue Mass). A blue mass. Used as a laxative and in syphilis. Dose : j Gm. Hvdrargyri Nitratis Unguentum (Ointment of Mercuric Nitrate. Citrine Ointment). A bright yellow ointment. Used externally. Hxdrargyri Olcatum (Oleate of Mercury). A thick, yellowish liquid. Used externally. IJxdrargyri Oxidiim Flavian (Yellow Mercurous Oxide). A light orange-yellow powder; insoluble in water or alcohol. Used externally. Hydrargyri Salicylas (Salicylate of Mercury). Hydrargyri Unguentum (Mercurial Ointment. Blue Ointment). A blue ointment. Used externally in syphilis. Hydrastis Fluidextractum (Eluidextract of Hydrastis). Used in coughs. Dose : 2 Cc. Hyoscincc Hydrohromidum (Hyoscine Hydrobromide). The salt of an alkaloid obtained from hyoscyamus or henbane. Colorless, odorless crystals; soluble in 1.5 parts of water. Used as a sedative. Dose : ^ milligramme. Hyoscyami Extractum (Extract of Hyoscyamus). Used as a sedative. Dose : 65 milligrammes. Hyoscyami Pilulcc Compositcr (Compound Pills of Hyoscyamus). Each contains 65 mgms. each of extract of hyoscyamus and of cam- phor, and 3 mgms. each of acetate of morphine and of oleoresin of capsicum. Dose : i pill. Ichthyolum (Ichthyol). A black, tarry substance, obtained from bituminous oil and containing about 15 per cent of sulphur. Used externally in skin diseases. Insect Powder {Pyrethrum. Dalmatian Poivder). The powdered flower heads of a species of chrysanthemum similar to our daisy. lodoformum (Iodoform). A yellow powder with a peculiar, penetrating odor. Very insoluble in water. Used externally as a mild antiseptic. lodum (Iodine). Bluish-black crystals. Very insoluble in water ; soluble in 10 parts alcohol. Used to make the tincture. Ipecacuanluc Pnlvis (Powdered Ipecac). A yellowish powder. Used as an emetic. Dose as an emetic : i Gm. Ipecacuanhcr ct Opii Puhis (Powder of Ipecac and Opium. MATERIA MEDICA AXD THERAPEUTICS 303 Dover's Powder). (Powdered ipecac lo. i)owdered opium lo. sugar of milk 80.) A yellowish-white powder. Used as a dia- phoretic. Dose : ^ Gm. Ipecacuanha: Fluidextractum (Fluidextract of Ipecac). Dose : 0.05 Cc. Liquor CresoUs Compositus (Compound Cresol Solution). A linseed-oil-soap solution of cresol of 50 per cent strength. Used as a disinfectant in mixtures of i to 2 per cent. Liquor Formaldchydi (Solution of Formaldehyde. Formalin). A solution containing ^/^ per cent of formaldehyde. A clear, color- less liquid having a very pungent odor. Used as a disinfectant by vaporization. Lifliii Carhonas (Lithium Carbonate). A white, odorless pow- der; permanent; soluble in 75 parts of water. Used in gouty troubles. Dose : ^ Gm. Litliii Citras Effervescens (Lithium Citrate. Effervescing). Tab- lets, odorless and having a cooling, alkaline taste, soluble in about 2 parts of water; insoluble in alcohol. Uses and doses same as carbonate. Lycopodiitm (Lycopodium). A very light, pale-yellow powder, Used as a drying powder in pill boxes. Maynesii Carbonas (Magnesium Carbonate). A white, insoluble, permanent powder. Used in acidity of -the stomach. Dose : 3 Gm. Magnesii Oxidum (Magnesium Oxide. Magnesia). A white, bulky powder, odorless, and having an earthy taste. Almost insolu- ble in water. Used chiefly as an antidote to arsenic. Dose : 2 Gm. Magnesii Sulphas (Magnesium Sulphate. E])som Salt). Small, colorless needles, odorless, efflorescent ; soluble in 0.85 part of water. Used as a laxative. Dose: 15 Gm. Menthol (Menthol). An alcohol obtained from oil of pepper- mint. Colorless crystals having an odor of peppermint. Only slightly soluble in water ; freely souble in alcohol. Used externally. Methylis Salicylas (Methyl Salicylates. Oil of Wintergreen, Synthetic). A colorless liquid having a wintergreen odor. Dose : i Cc. Morphincc Sulphas (Sulphate of Morphine). The salt of an alka- loid obtained from opium. White, feathery crystals ; odorless, per- 304 MATERIA MEDICA, TlIERArEUTlCS, PHARMACY manent, and bitter. Soluble in 15.3 parts of water. Sometimes mis- taken, foi quinine, wbich it closely resembles, with fatal results. May be distinguished l)y the action of nitric acid, which with morphine gives an orange-red color fading to yellow, and with quinine does not give the color reaction. Used to relieve pain. Dose : 15 milligrammes. MyrrJuc Tinctura (Tincture of Myrrh). Used chiefly in mouth washes. Dose : i Cc. Kapiithalciium (Naphthalene). A coal-tar derivative. Color- less, shining, transparent laminse. ■ Dose: 125 milligrammes. Neosalvarsan. Resembles salvarsan, except tliat its solution in water is neutral. Dose : 3CX)-900 milligranimes. Normal Saline Solution Tablets. Each contains 2 grams sodii chlcridum and 300 mgms. sodii carbonas monohydratus. A^ucis Vomica: Tinctura (Tinctura of Nux Vomica). Used as a tonic. Dose : ^ Cc. Nucis Vomiccc Extractum (Extract of Nux Vomica). Used as a tonic. Dose: 15 milligrammes. Oleum Aurantii Corticis (Oil of Orange Peel). A pale yellow liquid used as a flavoring agent. Should be kept in amber-colored bottles in a ccol place. Oleum Caryophyli (Oil of Cloves). A pale-yellow, volatile oil, distilled from cloves. Dose : 0.2 Cc. Oleum Gaulthericr (Oil of Wintergreen). A volatile oil distilled from wintergreen leaves. Used in rheumatism. Dose : i Cc. Oleum Gossypii Seminis (Cottonseed Oil). A fixed oil expressed from cottonseed. Oleum Menthce Piperita (Oil of Peppermint). A volatile oil dis- tilled from the leaves and flowers of peppermint. Used chiefly for flavoring. Dose : 0.2 Cc. Oleum MorrhucT (Cod-liver Oil). A fixed oil expressed from fresh livers of codfish. Used chiefly in tuberculosis. Dose : 15 Cc. Oleum Ricini (Castor Oil). A fixed oil expressed from castor beans. Used as a laxative; acts in 4 to 6 hours. Dose : 15 Cc. MATERIA MEDICA AND THERAPEUTICS 305 Oleum Santali (Oil of Santal). A volatile oil distilled from san- dal wood. Used in gonorrhea. Dose : i Cc. Oleum Theobromotis (Oil of Theobroma. Cacao Butter). A fixed oil expressed from the roasted cacao seeds. A yellowish- white solid. Used chiefly as a basis for suppositories. Oleum Tiglii (Croton Oil). A fixed oil expressed from the seeds of Croton Tiglium. A pale-yellow, viscid liquid, having an acrid, burning taste. Used as a powerful cathartic ; acts in i to 2 hours. Dose : 0.05 Cc. Oleum TerebinthincT Recti ficatnin (Rectified Oil of Turpentine). A thin, colorless liquid used as a stimulant and diuretic. Dose : i Cc. Opii Tinctura (Tincture of Opium. Laudanum). Used to re- lieve pain and control diarrhea. Dose : | Cc. Opii Tinctura Camphorata (Camphorated Tincture of Opium. Paregoric). Contains opium, benzoic acid, camphor, and oil of anise, each 4, glycerin 40, alcohol 950. Dose : 8 Cc. Opii Pulvis (Powdered Opium). A brownish powder. Dose : 65 milligrammes. Pancreatinum { Pancreatin). A mixture of the digestive fer- ments of the pancreas. A cream-colored power used to aid diges- tion. Dose : ^ Cm. Pcpsinum (Pepsin). A digestive fermen obtained from the hog's stomach. Yellowish scales or a white powder. Dose : ^ Gm. Peptonizing Tablets. Contain pancreatin and bicarbonate of soda. One tablet is sufficient for 250 Cc. of milk. Petrolatum (\^aseline). A petroleum product. Used externally as a basis for ointments. Petrolatum Liquiduni (Liquid Petrolatum. Liquid \''aseline). A yellowish, oily liquid, used externally, chiefly in sprays for the nose and throat. Phenol (Carbolic Acid). Obtained by distillation from coal tar or prepared synthetically. A white crystalline mass sometimes ac- quiring a reddish tint. Soluble in 19.6 parts of water and liquefying in the presence of 13.6 per cent of water. In poisonous doses colors the urine dark green. Used chiefly as an antiseptic. Dose : 65 milligrammes. 20 306 MATERIA IMEDICA. THERAPEUTICS, PHARMACY Phcnolphthalcin (Tablets). A coal tar derivative. White or grayish-white powder, soluble in 600 parts water. Used as a mild laxative. Dose: 100-300 milligrammes. Phenylis Salicylas (Phenyl Salicylate. Salol). A white powder having a faint aromatic odor and a slight taste. Soluble in 2,^23 parts of water. Used as an intcstmal antiseptic. Dose : ^ Cm. Pliysosfigmince SuIpJias (Sulphate of Physostigmine). A salt of an alkaloid obtained from physostigma or calabar bean. A yel- low powder, deliquescent, odorless. Used in the eye. Dose : i milligramme. Pilocarpiiicc Hydrochloriditm (Pilocarpine Hydrochloride). A salt of an alkaloid obtained from pilocarpus or jaborandi. Used as a diaphoretic. Dose: 10 milligrammes. Pilulcc CafJwrticcc Compositcu (Compound Cathartic Pills). Con- tain calomel, colocynth, jalap, and gamboge. Each pill contains 60 milligrammes of calomel. Piliilcr Carminative (Carminative Pills). Each contains 0.8 mgm. morphine sulphate with carminatives. Pliimbi Acetas (Lead Acetate. Sugar of Lead). Colorless crys- tals ; efflorescent, soluble in 2 parts of water ; having a sweetish taste. Used as an astringent. Dose : 65 milligrammes. Podopliylii Rcsina (Resin of Podophyllum). A grayish-white powder of peculiar odor and bitter taste. Used as a laxative; acts slowly in 6 to 12 hours. Dose: 5 to 15 milligrammes. Potassii Acetas (Potassium Acetate). A white, very deliques- cent powder, soluble in 0.4 part of water. Used as a diuretic. Dose : 2 Gm. Potassii Arscnitis Liquor (Solution of Potassium Arsenite. Powler's Solution). Used in malarial and skin diseases. Dose : 0.2 Cc. well diluted. Potassii Biscarbonas (Potassium Bicarbonate). A colorless, granular, permanent powder. Used in rheumatism. Dose: 2 Gm. Potassii Bromidiim (Potassium Bromide). Colorless crystals, odorless, permanent; soluble in 1.5 parts of water; should be admin- istered dissolved in plenty of water. Dose : i Gm. AlATEklA MEDICA AX I) Tl lERArEL'TICS 307 Potassii Chloras ( Potassium Chlorate). Colorless plates or a white granular powder; odorless, permanent, soluble in 16 parts of water. Handle with care, as dangerous explosions are liable to fol- low trituration with organic substances like sugar, or oxidizable sub- stances such as suli)hur. Dose : | Gm. Potassii ct Sodii Tartras (Potassium and Sodium Tartrate. Ro- chelle Salt). A white, odorless powder, soluble in about 1.2 parts of water. Used as a laxative. Dose : 8 Gm. Potassii Hydroxidum (Postassium Hydroxide. Potassa). Fused, white masses; odorless, acrid tasting, deliquescent, caustic. Not used internally. Potassii lodidum (Potassium Iodide). A white, granular pow- der; deliquescent; soluble in 0.7 part of water; irritant to the stom- ach and should be given dissolved in plenty of water. Used espe- cially in syphilis. Dose: ^ Gm. Potassii Permanganas (Potassium Permanganate). Slender dark-purple prisms, permanent, soluble in about 15 parts of water. Used chiefly externally as a skin disinfectant. Dose : 65 milligrammes. Protargol. A protein silver compound containing 8.3 per cent of silver, and non-irritating in character. A yellow powder soluble in water. Used externally in inflammation of mucous membranes, i to 5 per cent solutions. Pruni Virginiancc Fuidextractum (Fluidextract of Prunus \'ir- ginianse or Wild Cherry). Used in cough mixtures. Dose : 2 Cc. Oninincc Hydroclilorosiilphas (Quinine Hydrochlorosulphate). A solt of an alkaloid from cinchona bark. Colorless crystals ; soluble in I part of water. Used in malaria, especially for hypodermic })urposes. Dose : I- Gm. Ouiniiuc Sulphas (Quinine Sulphate). Has the same qualities as the bisulphate, but less soluble in water, i :y20. Used in malaria. Dose : i-io to i Gm. Rhamni PursJiiaiicr Fluidcxtractnni (Fluidextract of Cascara Sagrada). Used as a laxative; acts as such in 8 to 10 hours. Dose : i Cc. Rhamni Purshiancc Extractum (tabellcc) (Cascara Tablets). Each contains 130 milligrammes of extract of cascara. Dose : I to 2 tablets. 308 MATERIA AIEDICA, TJlERAi'EUTICS, PHARMACY Rhci Puh'is (Powdered Rhubarb Root). An orange-yellow powder. Used as a laxative. Dose : i Gm. Sacchanim Lactis (Sugar of Milk). A white powder from the whey of cow's milk. Salophen (Salophen). A white powder containing about 50.9 parts salicylic acid. Almost insoluble in water. Used in rheuma- tism. Dose: ^ Gm. Salvarsan. A yellow crystalline powder ccMitaining 31.5 per cent of arsenic metal; being readily oxidizalilc it must be kept in vacuum tubes. Readily soluble in water with acid reaction. Dose : 300-600 milligrammes. Santouinum (Santonin). Obtained from Santonica flowers. Colorless crystals, turning yellow on exposure to light, odorless, nearly tasteless, insoluble, permanent ; colors the urine a greenish yellow or reddish purple. Sapo Mollis (Soft Soap). A soft, unctuous, yellowish-brown mass. Used externally. Scillcc Syrupus (Syrup of Squill). Used in c(nigh mixtures. Serum Antidiphthericum (Diphtheria Antitoxin). A fluid sepa- rated from the blood of a horse immunized through the inoculation of diphtheria toxin. Should be kept in sealed glass containers in a dark, cool place. A yellowish, transparent or slightly turbid liquid. It gradually loses its power. Dose, hypodermically : 3,000 units. Immunizing dose: 500 units. Serum Antitetanicum (Tetanus Antitoxin). Scrum Antimeningitidis. Sinapis Emplastrum (Mustard Plaster). Sinapis Nigra Pidvis (Powdered Black Mustard). Sodii Bicarbonas (Sodium Bicarbona,te). A white, odorless pow- der, having an alkaline taste ; soluble in 12 parts of water. Dose : i Gm. Sodii Bicarhonat. et Menthcc Pipcrltcc Tabellcc (Soda mint tab- lets). Dose: 1-2 tablets. Sodii Boras Pulvis (Powdered Borax). A white, odorless efflorescent powder, having a sweetish taste, soluble in 20.4 parts of water. Used as an astringent. Dose : -J Gm. Sodii Bromidum (Sodium Bromide). A white, granular powder, odorless; soluble in 1.7 parts of water. Used as a sedative. Dose : i Gm. well diluted with water. MATERIA MEDICA AND THERAPEUTICS 309 Sodii Carhonas Monohydratus (Dried Sodium Carbonate). A white, odorless powder having a strongly alkaline taste and absorbs moisture readily ; soluble in 2.9 parts of water. Dose : | Gm. Sodii Fluoridi (Sodium Fluoride). A powder used to poison cockroaches. Antiseptic. Poisonous. External use only. Sodii Phosphns Exsiccatus (Dried Phosphate of Sodium). A white, hygroscopic powder. Used as a laxative. Dose : i Gm. Sodii Salicylas (Sodium Salicylate). White scales, or a color- less powder with a faint pink tinge ; odorless and having a sweetish taste; soluble in about 0.8 part of water. Irritating to the stomach and should be dissolved in an abundance of water. Used in rheu- matism. Dose : i Gm. Sodii Thiosidphas (Sodium Thiosulphate. Hyposulphite). Color- less crystals, odorless and having a cooling taste ; soluble in 0.35 part of water. Used chiefly externally in parasitic diseases of the skin. Spiritus Frumcnti (Whiskey). Spiritiis Glycerilis Nitratis (Spirit of Nitroglycerin). A clear colorless liquid containing i per cent of Nitroglycerin. Dose: i minim (0.05 Cc). Spiritus Vini Gallici (Brandy). Strophantlii Tinctura (Tincture of Strophanthus). Used as a heart tonic. Dose : | Cc. StrychnifKS Sulphas (Strychnine Sulphate). The salt of an alka- loid obtained from Xux Vomica. Colorless, efflorescent crystals, or a white powder, odorless, intensely bitter. Soluble in 31 parts of water. Dose : i milligramme. SulphonethylmctJionum (Trional). Colorless, odorless scales, with a bitter taste; soluble in 195 parts of cold water, more readily in hot water. Used as a hypnotic. Dose : i Gm. Sulphonmethanum (Sulphonal). Colorless, inodorous and nearly tasteless crystals; soluble in 360 parts of cold or 15 parts of boiling water. Used as a hypnotic. Dose : i Gm. Sulphur Lotiim (Washed Sulphur). A fine yellow powder, odorless, tasteless, and insoluble. Used as a laxative. Dose : 4 Gm. 310 MATERIA MEDICA, THERAPEUTICS, PHARMACY Syrupit^ Hypophosphitum Compositus (Compound Syrup of Hypophosphites). Contains the hypophosphites of calcium, potas- sium, sodium, iron, magnesium ; also quinine, strychnine, citrate of soda, and dilute hypophosphorous acid. Used as a tonic. Dose: 8 Cc. Talcum (Talc). A white or grayish-white powder. External use. Terebenmn (Terebene). Obtained by the action of sulphuric acid on oil of turpentine. A thin, colorless liquid with an agreeable odor; becomes resinified on exposure to air and light. Used as an expectorant. Dose : 4 Cc. Thymol (Thymol). A phenol occurring in the oil of thyme. Colorless crystals having an aromatic odor and taste. Soluble in i.ioo parts of water, freely soluble in alcohol and in oils. Dose: 125 milligrammes. Thymolis lodidum (Aristol). A bright chocolate-colored or red- dish-yellow powder, insoluble in water. Used externally. Tolntanum Balsamum (Balsam of Tolu). A yellowish-brown solid, readily soluble in alcohol, nearly insoluble in water. Dose : i Gm. Trinitrophcnol (Picric Acid). Light yellow scales. Used chiefly externally for burns. The solution employed is 5 parts picric acid and 75 parts alcohol in 1,000 parts of water. Valenancc Fluidextractum ( Fluidextract of Valerian). Used as a sedative. Dose : 2 Cc. Veronal. Colorless crystals, slightly bitter in taste; soluble in 145 parts of water. Hypnotic. Dose : ^^ gram to i gram. Viniim Xcricum (Sherry Wine). Zinci Oxidum (Zinc Oxide). A fine, white powder, insoluble, odorless, and tasteless. Used externally in ointments. Dose : \ Gm. Zinci Phcnolsulphonas (Zinc Phenolsulphate. Sulpho-carbolate of Zinc). Colorless, odorless, efflorescent crystals; readily soluble in water or alcohol. Used chiefly as a local application. Dose : 125 milligrammes. Zinci Sulphas (Zinc Sulphate). Colorless, efflorescent crystals; odorless and having an astringent, metallic taste; soluble in 0.53 part of water. Used externally and as an emetic. Dose as an emetic : i Gm. Zingiberis Fluidextractum (Fluidextract of Ginger). Dose : i Cc. CHAPTER II PHARMACY Pharmacy is the art of preparing medicines for administration. Official Pharmacy deals w iih the processes and preparation of the Pharmacopceia. Extemporaneous Pharmacy describes the methods of preparing and dispensing physicians' prescriptions. A Pharmacopceia is an official list of drugs and their preparation recognized by the medical profession of a certain country ; such drugs and methods are known as official. A Dispensatory is a private treatise on official and other drugs. The National Formulary is a book containing numerous useful formulas not found in the Pharmacopoeia, and which have been officially recognized by Congress. PHARMACEUTICAL OPERATIONS USE OF HEAT For all operations requiring a temperature below that of boiling water, an ordinary copper water-bath is used ; as the vapor can escape freely, the temperature can not rise above that of boiling water. MECHANICAL SUP.DIVTSION OF DRUGS It is usually necessary to reduce drugs to fine particles before employing them in the various operations of pharmacy. One of the most common of th:se procedures is called trituration, which is the process of reducing a drug to a fine powder by rubbing it up in a mortar; the pestle is given a rotary motion with downward jiressure, describing a series of concentric circles from within outward, and then from without inward ; should the powder begin to cake, it is separated from the surface of the mortar by a spatula. (311) 312 MATERIA MEDICA, THERAPEUTICS, PHARMACY SOLUTIUX \Mien a solid substance is dissolved in a liquid, both the process and tUe liquid are termed solution. The li(|uid used to produce the solution with a solid, is called a iiiciistniuiit or solvent. Sometimes two solids may ])e rul)l)ed together, so as to make a clear liquid, as for instance, camphor and chloral hydrate. Some hygroscopic solids are apt to run together and form cakes, if powdered before solution; such are the scale salts of iron, which will dissolve more readily in scale form. The term " solubility," when applied to a drug, and no solvent is mentioned, always refers to water at ordinary temperature. Saturated solutions are solutions which can not take up any more of the substance at ordinary temperature. Pejxcntagc Solutions. — These are solutions which contain a cer- tain definite percentage of a given substance. Percentage solutions of solids should always be prepared by weight, while for liquid substances, weight or volume may be employed. The quantity of each ingredient necessary to make a specified amount of any particular percentage solution, may be found as fol- lows : Multiply the amount of solution desired in grammes by the percentage, divide by lOO, and the result zi'ill show the quantity of solid drug necessary; subtracting this amount from the quantity of solution desired, the ronainder indicates the necessary amount of menstruum. Some of the most useful solvents of drugs are alcohol, chloroform, ether, glycerin, water, acids, alkaline solutions, and oils. The resulting solutions are given various names, such as tinctures, infusions, etc. Water is the most useful of all solvents; nearly all salts of the alkalies, earths, and metals are dissolved by it, and many vegetable acids and salts of the alkaloids. Alcohol is next in importance to water as a solvent. Its great advantage over water is that it makes the preparations in which it is employed keep indefinitely, while the watery solutions soon de- compose. Resins, volatile oils, alkaloids, and glycosides dissolve in alcohol, while gum, albumen and starch are insoluble. Glycerin is used on account of its antiseptic qualities, when alcohol can not be employed for any reason. It dissolves pepsin, tannins. PHARMACY 313 some mineral salts and vegetable acids, and forms the basis of the (jlycerites. Ether is escepially valuable as a solvent for oils, fats, resins, and some alkaloids and neutral principles. Chloroform resembles ether in its solvent properties, and also dissolves phosphorus. It is noni-inflammable and has a higher boiling-point. Acids are used with water or alcohol, to extract the active princi- ples of such drugs as cinchona. They are also used in the prepara- tion of vinegars. Alkalies dissolve resinous bodies, and the oils are used as a basis for liniments. Infusions are made by pouring boiling water on vegetable sub- stances, and letting them stand for various lengths of time. DecoctioJis are made by boiling the drug in water, and are used when there are no volatile principles to be driven ofif. Maceration is a process of dissolving out active principles at ordinary tempera- tures. The mixture must be frequently shaken. Percolation or displacement is one of the most important and generally useful processes of pharmacy. By means of it, a powder contained in a suitable vessel, has its solid constituents dissolved out, by the descent of solvent through it. The apparatus in which the process is carried on is known as a percolator, the resulting solution as the percolate, and the residue as the marc. The directions of the United States Pharmacopoeia are as follows : " Percolation, as directed in this Pharmacopceia, consists in sub- jecting a substance or a mixture of substances, in powder, contained in a vessel called a percolator, to the solvent action of successive portions of a certain menstruum in such a manner that the liquid, as it traverses the powder in its descent to the receiver, shall be charged with the soluble portion of it, and pass from the percolator free from insoluble matter. " When the process is successfully conducted, the first portion of the liquid, or percolate, pa'^sing through the percolator, will be nearly saturated with the soluble constituents of the substance treated ; and if the quantity of menstruum be sufficient for its exhaustion, the last portion of the percolate will be nearly free from color, odor, and taste, other than those of the menstruum itself. "Percolators. — The percolator most suitable for the quantities 314 MATERIA MEDICA, THERAPEUTICS, PHARMACY contemplated by this Pharmacopeia should be nearly cylindrical, or slightly conical, with a funnel shaped termination at the smaller end. f(See Fig-. 218.) The neck of this funnel end should be rather short, and should gradually and regularly become narrower toward the orifice, so that a perforated cork, bearing a short glass tube, may be tightly wedged into it from within until the end of the cork is flush with the outer edge of the orifice. The glass tube, which must not project above the inner surface of the cork, should extend from 3 to 4 Cm. beyond the outer '^"''^ surface of the cork, and should be provided with LJ- a closely fitting rubber tube, at least one-fourth Fic.is-Percoiator. j^^^^^j. ^^^^^ ^j^^ percolator itself, and ending in another short glass tube, whereby the rubber tube may be so sus- pended that its orifice shall be above the surface of the menstruum in the percolator, a rubber band holding the tube in position. " The shape of a percolator should be adapted to the nature of the drug to be operated upon. For drugs which are apt to swell, particularly when a feebly alcoholic or an aqueous menstruum is employed, a conical percolator is preferable. A cylindrical or only slightly tapering percolator may be used for drugs which are not liable to swell, and when the menstruum is strongly alcoholic, or when ether or some other volatile liquid is used for extraction. The size of the percolator selected should be in proportion to the quantity of drug extracted. \\'hen properly packed in the perco- lator, the drug should not occupy more than two-thirds of its height. The percolator is best constructed of glass, but, unless otherwise directed, may be made of any suitable material not afifected by the drug or menstruum. " The percolator is prepared for percolation by gently pressing a small tuft of cotton into the neck above the cork, and this may then be moistened by pouring a few drops of the menstruum upon the cotton, to facilitate the passage of the first portion of percolate, which is often very dense. " The Process. — The powdered substance to be percolated (which must be uniformly of the fineness directed in the formula, and slnould be perfectly air dry before it is weighed) is put into a basin, PHARMACY 315 the specified quantity of menstruum is poured on, and the powder thoroughly stirred with a spatula, or other suitable instrument, until it appears uniformly moistened. The moist powder is then passed through a coarse sieve — No. 40 powders, and those which are finer, requiring a No. 20 sieve, while No. 30 powders require a No. 15 sieve for this purpose. Powders of a less degree of fine- ness usually do not require this additional treatment after the mois- tening. The moist powder is now transferred to a sheet of thick paper and the whole quantity poured from this into the percolator. It is then shaken down lightly and allowed to remain in that con- dition for a period varying from fifteen minutes to several hours, unless otherwise directed ; after which the powder is pressed, by the aid of a plunger of suitable dimensions, more or less firmly, in proportion to the character of the powdered substance and the alco- holic strength of the menstruum, strongly alcoholic menstrua, as a rule, permitting firmer packing of the powder than the weaker. The percolator is now placed in position for percolation, and, the rubber tube having been fastened at a suitable height, the surface of the powder is covered by an accurately fitting disk of filtering paper, or other suitable material, and a sufficient quantity of the menstruum poured on through a funnel reaching nearly to the sur- face of the paper. If these conditions be accurately observed, the menstruum will penetrate the powder equally until it has passed into the rubber tube and has reached, in this, a height correspond- ing to its level in the percolator, which is now closely covered to prevent evaporation. The apparatus is then allowed to stand at rest for the time specified in the formula. " To begin percolation, the rubber tube is lowered and its glass end introduced into the neck of a bottle previously marked for the quantity of liquid to be percolated, if the percolate is to be measured, or of a tared bottle, if the percolate is to be weighed ; and by raising or lowering this receiver the rapidity of percolation may be in- creased or decreased as may be desirable. A layer of men- struum must constantly be maintained above the powder, so as to prevent the access of air to its interstices, until all has been added, or the requisite quantity of percolate has been obtained. This is conveniently accomplished, if the space above the powder will admit it, by inverting a bottle containing the entire quantity of menstruum over the percolator in such a manner that its mouth may 316 MATERIA MEDICA, THERAPEUTICS, PHARMACY dip beneath the surface of the liquid, the bottle being of such shape that its shoulder will serve as a cover for the percolator. " When the dregs of a tincture, or of a similar preparation, are to be subjected to percolation, after maceration with all or with the greater portion of the menstruum, the lic|uid portion should be drained off as completely as possible, the solid portion packed in a percolator, as before described, and the liquid poured on, until all has passed from the surface, when immediately a sufficient quantity of the original menstruum should be poured on to displace the absorbed liquid, until the prescribed quaintity has been obtained." SEPARATIOX OF SOLIDS FROM LIQUIDS Filtration is the process of separating solids from liquids so as to render the latter more transparent. Colation or straining is dififer- ent from filtration only in that it is less thorough. For straining, filter-bags, conical in form, and made of felt or flannel, are usually employed. For filtration, two kinds of paper filters are used, plain and plaited. Plain filters are usually employed when it is desired to collect the solid matter, called the precipitate. It is made by doubling a circu- lar sheet of filter paper upon itself, then refolding this in the middle ; the filter is then opened in such a manner that there is one thickness on one side and three thicknesses of paper on the other side of the cone, which exactly fits an ordinary funnel. A plaited filter exposes a much larger filter surface, that does not come in contact with the funnel, thus effecting a much more rapid filtration. The method of preparing a plaited filter is shown in all works on pharmacy. In plaiting a filter, do not extend the creases entirely to the apex, for the point of the filter may be so much weakened that the weight of the liquid would tear it. The upper edge of the filter should not reach the top of the funnel; this is in order to allow the funnel to be covered to keep out dust. The filter should be moistened with water after placing in the funnel, and before adding the liquid to be filtered ; the latter should be poured quietly on the side of the filter, so as not to rupture the point. In filtering into a bottle, place a piece of twine between the funnel and bottle, to allow the escape of air. The process of separating a liquid from the solid, by pouring off the liquid, after the solid settles, is called decantation; it may be greatly assisted and the spilling of the liquid avoided, by using a glass rod as a director PHARMACY 317 When the soHd sul)stance or precipitate is Hght and easily mixed with the hquid, it is better to use a siphon. This usually consists of an ordinary glass tube, bent at a rather acute angle, and with the two arms of ditYerent length. The siphon is first entirely filled with the liquid to be drawn otT, and the shorter arm is then inserted in the liquid, taking care to keep the end of the longer arm below the surface le\el. The empty siphon may be inserted into the liquid and the flow started by suction on the long arm, ])rovided the liquid is not corrosive or prisonous. A rubber tube may be used as a siphon, in place of a glass tube, and in the same way. SEPARATIOX OF VOLATILE MATTER Volatile substances are separated from those which are less vola- tile, by the action of heat, and the process is known as vaporisation. The process of separating a volatile liquid from a less volatile one, by heat, is called evaporation. When the purpose sought is to obtain the volatile liquid, it is called distillation. \\\\tn the purpose is to obtain the solid, it is called desiccation. When it is wished to separate a volatile solid from another solid body, it is called sublimation. OFFICIAL PREPARATIONS ^ Liquids. Solids. Made witliout perco- Made by percolation Made by percolation Made without perco- lation or macera- or maceration. or maceration. lation or macera- tion. tion.= Aqueous Solutions. Aqueous Liquids. Extracts. Powders. Waters. Infusions. Resins. Triturations. .Solutions. Decoctions. Masses. Aqueous Solutions Alcoholic Liquids. Confections. Containing Sweet Timtures. Pills. or Viscid Sub- Wines. Troches. stances. T'hiidextracts Cerates. Syrups. Oleoresinous Liquids. Ointments. Hcincys. Oleoresins, Plasters. Mucilages. Acetous Liquids. Palmers. Emulsions. Vinegars. Suppositories. Mixtures. Glycerites. Alcoholic Solutions. Spirits. Eli.xirs. Ethereal Solutions. Coilcdioiis. Oleaginous Solutions. Liiiiiiiciits. Olcatcs. ] ' Those u^cd internally are in Roman type; those used externally, in italics. ■ Tlie preparations in this class are mostly extemporaneous. 318 MATERIA :\IEDICA, THERAPEl'TICS, PHARMACY .Iqucc, waters, are solutions of volatile substances in water. They do not keep well and s^iould be freshly prepared. Ccrata, cerates, are ointments made stiff with wax. Chartce, papers, are medicated papers such as mustard paper. CoUodia, collodions, have as their basis a solution of gun-cotton in alcohol and ether. Decocta, decoctions, are made by boiling- vegetable substances in water; little used. Elixiria, elixirs, are sweetened, aromatic, alcoholic preparations serving as a pleasant vehicle for medicines. Emplastra, plasters, are solid compounds, usually spread on muslin, and for external use. Example : Belladonna plaster. Eniulsa, emulsions, are suspensions of insoluble oily or resinous substances in water by means of some other substance, such as gum arabic or the yolk of egg known as the cxcipient. Extracta, extracts, are semisolid preparations obtained by evapo- rating watery or alcoholic solutions of the active principles of drugs. Fluidextracta, flnidextracts, are permanent, concentrated solutions (usually alcoholic) of vegetable drugs of such strength that i Cc. of the fluidextract represents i Gm. of the drug. Glycerita, glycerites, are mixtures of medicinal substances with glycerin. Infusa, infusions, are prepared by treating vegetable substances with hot or cold, but not boiling water. Linimenta, liuitnents. are solutions or mixtures of various sub- stances in alcoholic or oily liquids, and intended for external use, with rubbing. Liquores, soluthns, are solutions of non-volatile substances in water. Misturcr, mixtures, are suspensions of insoluble substances in water by the aid of some viscid body. Oleoresincc, oleoresins. are liquid preparations consisting princi- pally of natural oils and resins extracted by ether. Pihdcr, pills, are spherical masses to be swallowed whole. They consist of the active ingredients and the excipient, the latter being the substance used to make the mass adhesive and plastic. Glycerin and acacia are excipients. Spiritus, spirits, are alcoholic solutions of volatile substances. Suppositoria, suppositories, are solid bodies containing drugs PHARMACY 319 usually incorporated with cacao butter and intended for use in the vagina, rectum, or urethra. Sxnipi, sxnips, are concentrated sokitions of sugar in water with or without medicinal substances. TabcUcc, tablets, consist of powdered drugs compressed into disc shape by machinery. They are extensively used in the field supply table because they are convenient for tran>portation and for accurate dosage without weights or measures. Their disadvantages are that they are so firmly compressed that if swallowed whole many of them pass through the gastro-intestinal tract unchanged, and that there- fore they must be first reduced to a powder before being taken. Others are very irritating to the stomach and should be dissolved freely in water before being administered. Tincturcc, tinctures, are solutions of non-volatile substances in alcohol. Tincture of iodine is an exception, iodine being a volatile substance. Potent tinctures are of lo per cent strength and other tinctures usually 20 per cent. Trocliisci, troches or lecciiges, are small cakes of medicines incor- porated with a mass which usually has sugar for a basis. They are used by allowing them to dissolve slowly in the mouth. Unguenta, ointments, are soft, fatty mixtures of medicinal agents usually with a basis of lard and wax or petrolatum. NON-OFFICIAL FORMS OF MEDICINES Bou'gia, bougie, a urethral suppository. Ca'psula, capsule, a small, hollow, gelatin receptacle for medicines, intended to be swallowed, and thus concealing the taste of its con- tents. Catapla'sma, poultice. Cha'rtula, small paper, the subdivision of powders into separate doses inclosed by small pieces of paper, folded. C oily' ri urn, eye-zcater. Di'scus. disk, a small, flat piece of medicated gelatin, used when the dose is small, especially with alkaloids, for application to the eye, or for use in hypodermatic syringe. E'nema, enema, a rectal injection. Esse'ntia, spirits, essence, solution of volatile oil in alcohol. Gargari'sma, gargle. 320 MATERIA MKDIGA, THERAPEUTICS, PllAK.MACV Gra'iiiilimi, a small pill, a granule. Hon'stus, draught, when a considerable amount of fluid is to be swallowed at one dose. InJiala'tio, inhalation, a vapor. * Injc'ctio, injection. Lo'tio, lotion, a wash. Po'tns, drink, a draught. Sn'ccns, juice. Tablet triturates. Triturations compressed into small masses, for exact dosage and convenience of administration. Tablets, hypodermic. Small, masses containing exact doses of sub- stances used for hypodermatic administration ; some innocent but soluble substance is used as the basis. Among the preparations which are most often made in the dis- pensary are emulsions, pills, ointments, powders, and suppositories; it is, therefore, necessary to consider these operations a little more in detail. Emulsions. IMilk and yolk of egg are natural emulsions, the fat in each case being divided into minute globules which are surrounded with a film of albumen or casein by which they are suspended in water; the artificial emulsions are imitations of those existing in nature. The most commonly used excipients are acacia and yolk of eggs (vitellus), but emulsions made with the latter must be used within a few days, as they do not keep well. The method of preparing an emulsion which experience has shown to be the best is as follows : Add the oil. resin, etc., to a proper quantity of the excipient and mix both thoroughly in a mortar ( Fig. 219). Then add enough water to Fig. 219. — Wedgewood Mortar and Pestle, equal OnC-half the weight of the previous mixture, and triturate the whole rapidly and unceasingly until the emulsion is homogeneous and of a whitish color. Next add the remainder of the water slowly, with continual stirring, finally incorporating the other ingredients, if any. PHARMACY 321 Pills. Pills should not exceed five grains in weight unless com- posed of a heavy substance such as calomel. The ingredients should be weighed out separately, commencing with that of which the smallest quantity is ordered, and thoroughly rubbed up in a mortar ; t'he excipient is then added and the rubbing continued until the mass is of the proper consist- ence and does not show any particles of any one ingredient. If the mass Fig. 220.— Spatula. sticks to tlie pestle it is removed with a spatula (Fig. 220) and may be kneaded a few minutes in the fingers. It should then be placed upon the pill tile, which has been previously dusted with a little lycopodium, and rolled into a long cylinder by the aid of a broad spatula until the mass is of a length corresponding to the division on the tile scale which represents the number of pills to be made. The mass should then be placed along the scale and a cut made tJirough it with the spatula at each division, the pieces being at once rounded separately into pills by the thujiib and the two fingers of each hand. A pill machine may be used for the division of the portions (Fig. 221). The pills are then left to dry while the label is being written, after which they are placed in a pill box with a little lycopodium to pre- vent their sticking together. The excipient to be used is usually left to the discretion of the Fig. 221. — Pill Machine. compounder. Som« substances such as the softer extracts and gum resins need no excipient, but may be made at once into pills. Among the more generally used excipicnts are: 21 322 MATERIA MEDICA, THERAPEUTICS, niARMACV Glxccrin: \'aluable on account of its property of atlraclini^ mois- ture and thus preventing the pills p^ettinj;' too hard. Syrup: Should not be used for metallic salts, es[)ecially calomel, which it reduces in a short time. Mucilage of Acacia: Eor vegetable powders not adhesive. Water: For vegetable powders containing mucilage. Alcohol: For resinous substances. Soap: Best for resinous and fatty substances and essential oils. Ointmeuts: Ointments are usually prepared by rubbing the ingre- dients together in a mortar, or thoroughly incorporating them on a pill-tile with the aid of a firm spatula. When resins or waxes are to be incorporated with fats, or medicines are used which are soluble in warm fats, melting is used. When extracts, powders, or gritty substances are ordered, the ingredients should first be finely powdered, then rubbed with a small quantity of the basis into a smooth, impalpable paste, the remainder of the basis being added gradually until the whole is thoroughly incorporated. Soluble salts should be triturated with a little water before adding the basis. Camphor needs a little alcohol to enable it to be pul- verized. Volatile substances should be added last to allow of as little evaporation as possible. Poivders: Substances which are insoluble and too bulky to be pre- scribed in pills are often ordered in the form of powder. The in- gredients are to be thoroughly mixed and accurately divided. The mixing is usually done in a mortar unless it is explosive, but may be effected on a pill-tile with the aid of a spatula. Substances such as alkaloids are very active and when employed in small doses require some inert substance to give them bulk sufficient for division and handling; sugar of milk is usually employed for the purpose. The active ingredient is placed in the mortar first and thoroughly mixed with a small quantity of the diluent, the addition being gradually continued. Powders are dispensed in bulk when the dose is large, or in papers, chartulas, when the dose is small. Hvgroscopic and effervescent powders should be dispensed in waxed paper, others in ordinary white paper. The paper should be cut to fit the powder and folded to fit the box. It should be the rule to weigh out separately each dose of the active ingredients. Suppositories: Rectal and vaginal suppositories usually have PHARMACY 323 cacao butter as a basis, while glycerinated gelatin is commonly em- ployed for the urethra. Rectal suppositories are cone-shaped and weigh from one to two grammes. Urethral suppositories are pencil- shaped, and either seven centimeters in length, weighing two grammes, or fourteen centimeters injength, weighing four grammes. / 'aginai suppositories should be globular or egg-shaped and weigh about four grammes. Cacao butter suppositories are prepared by reducing the medicine to a powder or softening it, and then rubbing it up in a mortar with an equal quantity of the finely grated excipient until a smooth paste is formed, after which the remainder of the excipient is slowly added. A little castor-oil or glycerin may be added to make the mass more plastic. Next roll the mass on a graduated tile until a cylinder of the proper length is formed, divide this into the required number of equal parts, and with a spatula form them into the desired shape. Cacao Initter suppositories may also l)e prepared by melting the ingredients together and molding them. Gelatin Urethral suppositories are prepared by dissolving or thor- oughly mixing the medicine with a little water and sufficient glycerin to make the weight of the mixture one-half that of the finished product. Then carefully incorporate it with an equal weight of melted glycerinated gelatin, and pour it at once into suitable molds which have been greased with a small quantity of petrolatum. Cool the molds before removing the suppositories. WEIGHTS AND MF„\SURES. Three different systems of weights and measures are used in this country, avoirdupois zceight, apothecaries' zceight, and metric zceighf. Avoirdupois weight is used in the purchase and sale of drugs. The divisions of avoirdupois weight are the pound, ounce, drachm, and grain, which are represented by the following characters : lb., oz., drm.. gr. ; each pound contains i6 ounces and each ounce i6 drachms or 4373^ grains. The term drachm is rarely employed, quantities less than an ounce being usually designated by common fractions, such as 1/16 oz., ^ oz., ^4 oz., or in grains. Apothecaries' weight is frequently employed in the writing and compounding of physicians' prescriptions, and is divided into grains, scruples, drachms, and ounces, of which 20 grains are equal to i scruple, 3 scruples are equal to i drachm, and 8 drachms are equal to I ounce. 324 MATERIA AJI-.DICA. I'l I l-.K A ria'TJcS. rilAK.MALA' TABLE OF AIMJTIIICCARIES' WEIGHT. Grain. (Gra'num.) Symbol: gr. Scruple. (Scru'pulus.) Rarely em- ployed now. Drachm. (Dra'chma.) Ounce. (U'ncia.) Pound. (Li'bra.) lb. 20. 60. 480. 5,760. 1 . 3- 24. 288. I. 8. 96. I . 12. I. TABLE OF APOTHECARIES' MEASURE. Minim. (Mi'niinum.) Symbol : Fluidrachin. (Fluidra'clima.) Fluidounce. (Fluidu'iicia.) Pint. (Octa'rius.) 0. Gallon. (Co'ngius.) C. 60. 480. 7,680. 61,440. I . 8. ij8. 1,024. I. 16. 128. 8. I. The metric or decimal system is prescril^ed for use in the medical department of the army. The name metric is derived from one of the units of the system, the meter or unit of length, which is the forty-millionth part of the earth's circumference around the poles. The unit of capacity is the liter, which is equal to 1,000 cubic centi- meters. The unit of w^eight is the gramme, w^hich is the weight of one cubic centimeter of water at its maximum density. The prefixes which indicate multiplication are Deka (10), Hecto (100), and Kilo (1,000), while division is indicated by Deci (l-io), Centi (i-ioo), and A'lilli (i-ooo). Tlie system resembles the United States money system, which is also decimal, in the latter the dollar is the unit, and there are mills (l-iooo), cents (i-ioo), dimes (i-io), and eagles (10); like the money system too, only a few of the terms are used in pharmacy; thus we use cubic centimeters (Cc), kilogrammes (Kilo), gramme (Gm.), and milligraniime (Mgm.) ; also the term j^ gramme and J4 gramme may he employed. Fractional parts of a dollar may be written in several ways, thus: $0.50, 50 cents, and 500 mills, all mean the same thing, and so do grammes 0.50, 50 centigrammes, and 500 milligrammes ; but while we use cents as applied to fractional parts of a dollar, we usually employ mills as applied to fractional parts of a gramme. Concerning the relative z'ahies of these two systems of weights and measures, there can be no question of the great advantage of the Metric over the Apothecaries' system. The fomier is founded upon a decimal basis, and thus everything is in tens; thus it is easier to compute amounts and divide doses : it is expressed more easily : then. PHARMACY 325 again, there is an exact correspondence between the metric system of weights and the measures — one cubic centimeter of water at 4° C. weighing exactly one gramme. In the Apothecaries' system, such an exact correlation does not exist, the minim not weighing exactly one grain, and one fluidounce of water (480 minims) weighing only 455 grains ; the difference is, however, only trifling, and in the case of liquids having a specific gravity differing but little from that of water, need not be considered ; and thus we can, as a rule, take one minim as one grain. The quantities are expressed much more simply in the Metric than in the Apothecaries' system ; instead of being required to place the sign before each figure, we place on the top of the column the words " grammes," or " cubic centimeters " and then below this the figures, separating the whole numbers from decimals either by a line or period ; or " grammes " or " cubic centimeters " may be abbreviated to " Gm." or " Cc."' Translation from one system into the other can be done very easily, as will be seen from the following tables. The appro.ximate equivalents are the ones ordinarily to be employed, the exact ones being added for reference only : TABLES OF EQUIVALENTS Length Meters. Inches. I 39-37 0.1 : 3-93 o.oi 39 Capacity Liters Fluidounces Minims I 33-81 0.01 (Cc.) 15 Weight Grammes Grains I 15-43 ( 15^ approximately). 0.1 1.54 ( I ^ approximately). 0.01 15 ( /; approximately "). o.ooi 015 ( approximately). 326 MATERIA MEDICA, THERAPEUTICS, PHARMACY Table of Equivalents — Continued. Domestic Measures I teaspoon fill =r approximately 5 Co. I dessertspoonful = approximately 10 Co. I tablespoon ful = approximately 15 Cc. To convert metric weights and measures into those in ordinary use, and vice versa, multiply by the corresponding equivalents. To convert : Meters into inches, multiply by 39.370. Example: 39 -370 5 5 meters 19O.850 inches. Liters into fluidounces. multiply l)y 33.815. Example: 33 -^i 5 5 5 liters 169.073 fluidounces. Grammes into grains, multiply by 15432. Example: 15-432 5 Grammes 77 . i^o grains. Inches into centimeters, multiply by 2.539. Example: 2.539 5 5 inches 12.^1)5 centimeters. Fluidounces into cubic centimeters, multiply by 29.572. Example: 29.572 5 5 fluidounces I47.8(')0 cubic centimeters. PHARMACY 2>n Table of Equivalents — Continued. Grains into grammes, multiply by 0.064. Example: 0.064 5 5 grains o. 320 gramme. Pharmacists can not be too careful in the use of metric weights and measures in the writing and reading of prescriptions. In Europe, where the metric system has been in use for many years, no signs are used in prescriptions, because all ingredients, whether solid or liquid, are weighed, and it is understood that weight is always intended; whenever, for any reason, measures are wanted, the signs " L." (liter) and " Ccm." (Cubic centimeter) are em- ployed. But in this country, where it is still customary to weigh solids and to measure fluids in the dispensing of medicines, the official abbreviations given in the U. S. Pharmacopceia should be used invariably, so as to avoid all possible confusion. With water, and the average diluted alcohol tinctures, it would probably not make much difference whether grammes or cubic centimeters were dispensed, but in the case of all liquids having a higher or lower specific gravity than water a marked variation will be observed; thus 20 Cm. of glycerin measure 16 Cc, and 20 Cc. of glycerin weigh 25 Cm. ; 60 Gm. of simple syrup measure 45.5 Cc, and 60 Cc. of syrup weigh 79.02 Gm. ; 30 Gm. of chloroform measure 20.13 -|- Cc, and 30 Cc. of chloroform weigh 44.7 Gm. ; 4 Gm. of bromoform measure only 1.4 Cc, and 4 Cc. of bromoform weigh 11.32 Gm. ; 10 Gm. of ether measure 13.77 + Cc. and 10 Cc. of ether weigh only 7.26 Gm. ; 50 Gm. of alcohol measure 60.97 + Cc, and 50 Cc. of alcohol weigh 41 Gm. SCALES AND WEIGHTS The most useful instrument in pharmacy is the balance or scales. The form usually employed is a single beam with equal arms. The beam or lever is divided at the center into two equal arms by a knife edge upon which it rests. There are also, at each end of the beam, knife edges upon which the scale pans are suspended, these knife edges being hard and indestructible, and usually of agate. 328 MATERIA MEDICA. TIIERAIM'.UTICS, PHARMACY The scale [)ans are generally of nickel or silver, but for weighing corrosive substances, glass scale pans are employed. The balance should be enclosed in a glass case and carefully pro- tected from moisture, corrosive vapors, dust, and from jarring and shaking. They should be kept very clean by polishing with leather and dusting with a camel's hair brush. Weights are usually of brass or aluminum, and platinum is also used for small weights, on account of its hardness and resistance to corrosion. The term tare denotes the weight of the empty vessel or container in which the substance is to be weighed ; gross weight includes both the substance and the container, while net weight is the weight of the substance alone. Measures in pharmacy are used for liquids only; they are ordi- narily glass, and are known as graduates. Approximate measurements. The number of drops contained in a certain volume of liquids varies according to its density and the size and shape of the vessel from which it is dropped ; they are not identical with the minim. The following table gives certain domestic measures and their equivalents : One teaspoonful = i fluidrachm One dessertspoonful = 2 fluidrachms One tablespoonful = ^ fluidounce One wineglassful = 2 fluidounces One teacupful = 4 fluidounces One tumblerful == 6 to 8 fluidounces According to the U. S. Pharmacopceia, the following are the metric equivalents : One teaspoonful = 4 Cc. One dessertspoonful = 8 Cc. One tablespoonful = 16 Cc. FILLING PRESCRIPTIOX.S (Extemporaneous Pharmacy) This includes a variety of operations, and requires a knowledge of the meaning of the Latni words and abbreviations ordinarilv PHARMACY 329 used in prescription writing, as well as great care and accuracy in the various steps required. A prescription is an order to the druggist to deliver to the patient certain medicines. Such orders are written in Latin, this language presenting decided advantages. It is customary to have so-called " prescription blanks " on hand, and a convenient size for these is three and one-half inches by five inches. ICach prescription may be considered to be ccomposed of five parts : (i) The preliminaries. (2) The name of the drug or preparation ordered, or two or more of such names. (3) The quantity of such ingredients. (4) Directions to the druggist as to what he is to do with these ingredients. (5) Directions to the patient as to how the medicine is to be taken. (l) THE PRELIM IXARIES Besides the portion relating to the compounding and dispensing of the medicine ordered ,each prescription should have added the name and address of the prescriber, the name of the patient and the date. The address may be written or printed at the top of the paper, and is to be followed by the date, just as in writing a letter. The name of the patient is also to be placed above, and is preceded by " For.'' The prescriber's name is signed below. Should any special directions to the druggist, not intended to be put upon the label attached to the medicine, be added, such as " Not to be repeated." " To be repeated once only." etc., they are to be written either aljove or below the main subject matter of the prescription. (2) THE N.^ME OF THE DRUG OR PREP.\RATI0N, OR TWO OR MORE OF SUCH N.XMES Regarding pharmacopoeial nomenclature, the following may be noted : (a) The title of a vegetable drug is, with few exceptions, its botanical gcnns-namc ; it is represented by a single term, unless more than one part of the plant is official, in which case the part of the plant desired is specified in addition. Thus we say: "Aconitum," 330 MATERIA MEDICA, THERAPEUTICS, PHARM.vCY because only tlie root is official ; but " Colchici Radix" and " Colcliici Semen;' because both parts are official. (b) Pharmacopocial salts are usually designated by the Latin of their chemical names, with the basic name first in the genitive, fol- lowed by the acid name in the nominative. Thus : " Magnesic Sulphate" is "Magiiesii Sulphas," i. e., "of Magnesium, the Sulphate." In a few instances, the common names are employed instead of the chemical ones, as "Alumen" for " Potassio-aluminum sulphate." When tivo classes of the same salt are employed, one is distinguished from the other by a difference in nomenclature (i) chemically, such as " Sodii Carbonas " and " Sodii 5/carbonas," " Liquor Ferri ^wfosulphatis " and " Liquor Ferri T^rsulphatis ; or (2) by some reference to their physical or physiological qualities, such as " Hydrargyri Chloridum Corrosivnm " and " Hydrargyri Chloridum Mite," Hydrargyri Oxidum Flavum and Hydrargyri Oxidum Rubrum. (c) Adjectives follow the nouns which they qualify; thus: " Cinchona Flava," " Yellow Cinchona." When two nouns occur together in drugs and chemicals (not in preparations), the genitive following "of" is placed first; thus: " Belladonnse Radix," "Of belladonna, the root." He******** Each ingredient of a prescription is to be in the genitive case, since it follows "Recipe." We say: "Take of so and so certain quantity." The only exceptions to this rule are the following : (a) When we order a definite number or size of any pharma- copceial preparation, the latter is to be in the accusative case, since it is now the direct object of "Recipe." Thus we say: "Take twelve Compound Cathartic Pills," " Recipe Pilulas Cartharticas Compositas, numero xij." Again: "Take a Belladonna Plaster six inches by four inches " is " Recipe Emplastrum Belladonnc-e six inches by four inches." But if we directed the druggist to " take a certain quantity of Belladonna Plaster, and then to spread this upon adhesive plaster," we would write : " Recipe Emplastri Belladonnae, 3 ij-; extende supra emplastrum resinae, six inches by four inches." {h) When we have ordered one or more ingredients, and wish to add enough water or other liquid, so as to give a desired bulk, with- out stopping to compute the exact amount necessary, we may order PHARMACY 331 the final ingredient in the following manner : " Take Water up to a certain quantity." Here " water "' would be the direct object of " Recipe," and thus be in the accusative case, thus : " Recipe, Aquam, ad fl. 5 iv." The latter phrase can also be rendered: "Take of Water a sufficient quantity up to four fluidounces." " Recipe, Aqucc, quantum sufficiat ad fi. 5 iv." THE QUANTITY OF THE INGREDIENTS These are placed in the accusative case, being the direct object of " Recipe ; " but it is not only customary, but is advisable to express quantities in symbols and not to wrie them out. The cardinal numerals are usually represented by the Roman symbols: i., ii., iii., iv.. etc. It is customary to draw a line over the symbol and to dot the L This is an additional safeguard against mistakes, since the number of dots should correspond to the number of I's ; when the symbol I is final, it is usually modified, and the fact of its being the final number indicated by changing it into a "j" — thus"j." DIRECTIONS TO THE DRUGGIST as to what he is to do with the ingredients which have been ordered : These begin with the IJ, the abbreviation of "recipe," at the commencement of every prescription. The ingredients and quanti- ties also apply to him, for he is directed to take these different substances in specified quantities. Where a certain number or certain quantity of an oflficial prepara- tion is ordered, there may be no further directions for the druggist except " Signa," " Label," and then the directions to the patient. But where two or more ingredients are combined, after enumerat- ing these, we direct the druggist to mix — " Misce." In the case of all preparations excepting pills, powders, suppositories, and troches, this would be all that would be necessary. But it is a little more elegant to add " Fiat ," mentioning the form of medi- cine which we have prescribed, the name of the medicine being in the nominative singular, after the passive imperative " Fiat; " thus: " Fiat mistura," " Fiat linimentum," " Fiat unguentum," " Fiat collyrium," etc. In the case of pills, suppositories, and troches, we direct the Z2>2 MATERIA MEDICA, THERAPEUTICS, PIIARATACY druggist to " make a mass and to divide it into a certain numl)cr of pills, suppositories, or troches. This we may express in cither oi the following ways : (1) Eiat massa, et divide in pilulas (suppositoria, trcchiscos) numero . (2) Fiat massa, in pilulas (suppositoria, trochiscos), numero dividenda. " Pilulas," " suppositoria," and " trochiscos " being in each case in the accusative plural after the preposition "in." "Dividenda" always agrees with " massa." In the case of a pozvder which is to be divided into a certain number of papers, we direct the druggist to " make a pozcder and to divide this into a certain number of papers," and again we have two methods of expressing this : (i) Fiat pulvis, et divide in chartulas numero . (2) Fiat pulvis, in chartulas numero dividendus. Here we say " dividend/u," to agree with " pulvis." It is quite common in Europe to order a single dose of a powder, pill, troche, or suppository, and then to direct the druggist to " make of such doses a certain number." This method is occasionally em- ployed in this country, and, then, supposing we wished twenty papers of Dover's powder each weighing five grains, we would write for : Recipe: Pulveris Ipecacuanhae et Opii gr. v. Fiat chartulae tales doses numero xx., or we may also say: Fac chartulas tales doses numero xx. ; in this case, " chartulas " is in the accusative plural after " fac." In ordering pills, it is not necessary for us to specify the sub- stances which are to be used in making a pilular mass ; this belongs to the pharmacist. Very often, however, the substances ordered in pills, such as extracts, are themselves all that are necessary for making a suitable pill mass. Next, we direct the druggist to " label " — " Signa." Other Latin words and phrases used in pre.scriptions are the following : A'dde, add. Ad li'bitum, at pleasure. Ad satura'ndwn, to saturation. Be'ne, well. PHARMACY 233 Ana, da, of each. Bis, twice. Bis ill di'cs, twice daily. Bu'Uiat, let (it) boil. Ci'biis, food. Cochlea- re ma'giiiim, a tablespoon. Cochlea're parvnm, a teaspoon. Co'la, strain. Colliito'riiim, a mouth-wash. De'in, thereupon. Dimi'dius, half. Di'vide, divide. Do'sis, a dose. Et, and. Este'nde, spread. Exte'nde su'pra, spread upon. Fac, make. Fi'at (sing.), Fi'ant (plur.), let (it, them) be made (into). Fi'ltra, filter. Grada'tiiu, gradually. Gu'fta, a drop. Gutta'tiui, drop by drop. Ho'ra, an hour. In di'es, daily. Lage'na, a bottle. Libra, a pound. Li'nfeiim, lint. Ma'cera, macerate. Ma'iie, in the morning. Ma'iie pri'mo, early in the morning. Mi'ca pa'nis, a crumb of bread. Mi'sce, mix. Non, not. No'cie, at night. No'cte mane'qne, at night and in the morning. Nu'merus, a number. Nu'mcro, in number. Octa'rius, a pint. Pa'rtcs crqua'lcs, equal parts. 334 MATERIA MEDICA, THERAPEUTICS, PHARMACY I'i'o re na'id, as required. Qiia'ntnm sufficiat, as much as is necessary. Qua'qua Jw'ra, every hour. Recipe, lake. Sattira'tus, saturated. Sca'tnla, a box. Se'mcl, once. Semissis, a half. Scmidra'chma, a half drachm. Si'gna, mark. Si'miil, together. Si'ne, without. So'lve, dissolve. Sta'tim, immediately. Sujfi'ciat, may suffice. Tales, such. Ta'les do'ses, such doses. Te're, rub. Te're si'mul, rub together. Ter in di'e, three times a day. Tri'tura, triturate. 5. DIRECTIONS TO THE PATIENT These are to be written in English, and are to be definite. The words " as directed," having absolutely no value, are never to be employed. No greater proof of the uselessness of these words can be given than to state that when a prescription is sent out without directions, druggists are in the habit of labelling: " Use as directed." Compounding means the preparation of the various drugs ordered, while dispensing includes putting them up and issuing them. To fill a prescription, first read it over carefully until it is thor- oughly understood, then number it, and write the label ; next meas- ure out the ingredients, checking each one off to prevent duplication, compound them as directed, and dispense. Poisonous prescriptions should be plainly labeled Poison. The prescription should then be filed in the prescription book. Prescriptions should not be refilled without an order from a med- ical officer in each case ; the date refilled should 'be noted on the prescription and on the label. PHARMACY 3yD IXCOMPxVTIBILITY Incompatibilitv of drugs means unfitness for combination in the same prcscri]nion. Incompatibility may be chemical, pharmaceuti- cal, or therapeutical. In chemical incompatibility a chemical reaction takes place result- ing in the formation of precipitates, explosives, or poisonous com- pounds. Combination of cinchona preparations with salts of iron forms an inky mixture; of nitric acid with glycerin an explosive substance; of dilute hydrocyanic acid with calomel a virulent poison. In pharmaceutical incompatibility no chemical action takes place, but precipitation and an unsightly mixture often results ; the addition of aqueous solutions to resinous tinctures illustrates this principle. Therapeutical incompatibility arises when two agents which oppose each other in their action on the system are prescribed together. such, for example, as morphine and atropine. It is always to be borne in mind, however, that chemically or therapeutically incom- patible drugs are often prescribed together intentionally to serve a definite purpose. It will be well to mention certain underlying principles which should be considered when w-e order mixtures of two or more remedial agents. 1. Jl'ater is the solvent usually employed for soluble salts, for acids, sugars, gums, vegetable extractive matters, and for albuminous and gelatinous compounds. 2. Alcohol is usually employed for dissolving volatile oils, oleo- resins, resins, gum-resins, camphor, balsams, and vegetable sub- stances containing oily and resinous principles. 3. When more than a small amount of such aqueous solutions are added to alcoholic solutio)is. or rice versa, a precipitation of previ- ously dissolved principles often ensues, and an unsightly or other- wise undesirable mixture results. This is, however, not always the case, for the substance, which is dissolved in the alcohol, may also be soluble in water, or may be soluble in a mixture of alcohol and water, and thus no change will occur. 4. Free acids unite icitJi bases forming salts. 5. Strong acids and bases (such as inorganic acids, lead, mercury) displace iceaker acids and bases (such as organic acids, potassium, lithium). 336 MATERIA MEDICA, THERAPEUTICS, PHARMACY 6. Salts in solution exchange acids or bases, if, by so doing, a precipitate can be formed. 7. The occurrence of an apparent incompatibility, such as a pre- cipitate in a solution, may be desirable, as in the cases of black and yellozv li'aslies (made by adding calomel and corrosive sublimate respectively to lime water) ; here this fact should be made known by adding to the directions on the bottle that the mixture is to be shaken before using. 8. Agents rich in Oxygen (oxidising) when mixed in concentrated form ivith readily oxidizable substances may cause explosions. Hence Potassic Chlorate and Permanganate, strong Nitric, Nitro- hydrochloric, and Chromic Acids (all powerful oxidizing agents) should not be mixed with dry vegetable powders. Tannic Acid, Sugars, Glycerin, Alcohol, tinctures. Ether, Sulphur, and Phos- phorus. 9. A drug should never be prescribed with any of its tests or antidotes. TABLE OF MOST IMPORTANT MUTUALLY PRECIPITANT SOLUTIONS. P. = precipitate tj ao .i — ; •5 5 .BH -B -B •■« -2 £-5 -~-u: < t/5 Solutions of Alkalies P. P. P. P. P. P. _ _^ P. Tannic Acid and \'egetale Astringents P. P. Solutions of Carbonates P. P. Solutions of Sulphates and Sulphuric Acid Solutions of Phosphates and Phosphoric Acid.. P. P. Solutions of Borax and Boric Acid P. P. Solutions of Chlorides and Hydrochloric Acid.. Solutions of Bromides and Hydrobromia Acid. Solutions of Iodides, of Iodine, and Syrupus Acid Hydriodici P. Solutions of Sulphides and Sulphurous Acid... P. P. Arsenical Solutions P. P- Albuminous Solutions P. P. P. P. P P. P. P. P. P. P. P P. P. P. P. P. P. P P. P. P. P. P. P. P. P. P. P. P. P. P P. P. P. P P. P. PART VII HYGIENE. POST AND CAMP SANITATION CHAPTER I WATER TJie amount of i^'atcr needed by the average man daily for drink- ing purposes varies according to the amount of exercise he takes and tlie temperature of the atmosphere ; a fair average is three or four pints in addition to that which he takes in food. On the march the amount is hmited by the capacity of the canteen to about one quart, and this quantity should be very carefully husbanded. The total daily allowance in the field is usually calculated at about two gallons per man; four and one-half quarts for drinking and cooking, two and one-half for washing, and one quart for wastage. Waters are usually divided into two classes : surface zvaters and ground zvaters. The former include rain, river, lake, and pond waters, and the latter well and deep spring waters. A water is said to be potable when it is fit to drink. A potable water is an uncontaminated water ; no matter how clear, bright, and sparkling a water may be, it is not potable if it is so situated that it can be fouled by fecal matter, urine, or the drainage from manured lands. There is a very common error that all spring water is pure ; many springs, especially those which are not constantly flowing, draw their water from surface sources. Water from deep wells is usually safe ; from shallozv icells suspi- cious. \\'hether a well is to be considered a deep or shallow well depends upon whether or not it passes through an impervious layer of rock or clay so that surface drainage cannot get into it; if it passes through such a layer it is a deep well ; if it does not it is a shallow well. Though rain zcater is originally pure, cistern zvater may be very 22 {ZZ7) 338 HYGIENE. POST AND CAMP SANITATION impure ; the impurities come from the washings of the roof from which it is collected, from dust blown into it, and if it is an under- ground cistern, there may be a crack through which surface drainage may enter. Hard ivatcr is water that will not lather well with soap ; the hard- ness is due to lime salts and may be partially removed by boiling; well water, especially deep well water, is usually hard. Ice has the same impurities as the water from which it is made ; therefore natural ice is often impure. Ice made from distilled water is usually very pure. JJ'atcr may be purified in three ways: by chemical treatment, by boiling or distillation, and by filtration. The first two methods are usually applied to limited supplies, while the last is applicable on a large scale. Chemical treatmoit : The simplest form of chemical treatment is the use of alum, about a third of a gramme to the gallon, thoroughly stirred in the water, which is then allowed to settle. The alum causes a bulky precipitate, which in falling carries down with it most of the suspended matter, including the bacteria. Permanganate of potash is useful in quantities of one or two grains to the gallon, or just enough to give the water a faint tinge. Iodine may be used, three-quarters of a grain to a gallon, or tinc- ture of iodine added to the water until it acquires a faint yellow tinge. The taste and color of the iodinized water may be destroyed by the addition of three-quarters of a grain each of hyposulphite of soda and citric acid or tartaric acid. Both iodine and permanganate act on the same principle as chlorine. Chlorinated lime is a very valuable water sterilizer ; it is used both for general water supplies and individually in the form of tablets for soldiers on the march. Its destructive effect on bacteria is due to the action of the oxygen set free when the chlorine com- bines with the hydrogen of the water. A very useful appliance for utilizing the bactericidal effect of chlorine and water has recently l^een devised by Major \\m. J. Lyster, Medical Corps, for use in the field. It consists of a canvas bag of s])ecially woven flax, of sufficient capacity to supply a com- pany of infantry at war strength with a canteen-full of water for each officer and man. This bag at the opening is sewn over a gal- WATER 339 vanized iron ring, hinged at one diameter, which permits the bag to be folded. It is su[)ported when in use by two pieces of hemp rope, 3 feet 2 inches in length, spliced to the ring at points equi- distant. The bag is fitted with five self-closing faucets just above the bottom seam, spaced at equal intervals. This gives a container that weighs about seven and one-half to eight pounds, that can be folded up into a convenient and readily portable package not too large or heavy to be carried over the infantry pack. Sufficient chemical can be carried in sixty glass tubes to supply an infantry company at war strength with five canteens of water a day per capita for twelve days. Such a package of these tubes weighs ten ounces and measures 6^x3.'( x2^ inches. Under ordinary circumstances this bag, when filled with water, will have its contents rendered safe in about five minutes. After the bag has been filled with water, the calcium hypochlorite con- tained in one tube, which is easily broken in the hands at the point marked by a file, may be shaken directly onto the surface of tlie water, or it may be added to a small amount of water in any ordi- narily clean container and poured directly into the water in the bag; no stirring is necessary. As the oxidation of organic matter in water through the agency of hypochlorite proceeds best in clear water, it is desirable to remove fine clay and other comparatively coarse matters before introducing the hypochlorite. It is probable that in the field many surface waters will carry suspended matter to an extent that may interfere slightly with the hypochlorite process. To reduce this matter in amount, a piece of Scotch outing flannel is used. This cloth, weigh- ing one ounce, is fastened by tapes sewn to it to the ropes by which the bag is suspended, so it almost covers the opening of the bag. Through this cloth the water is poured in filling the bag. In the hands of a medical officer or instructed non-commissioned officer of the hospital corps, the starch iodine reaction gives exact information as to whether sufficient hypochlorite is being used. As iodine and starch are at hand in the field, we have a practical method of control. Boiling and filtration are also applicable in the field. One min- ute's active boiling is sufficient to destroy all the bacteria of water- borne diseases; it does not, however, clear water nor remove dis- solved organic matter. As it removes the erases of water it becomes flat to the taste, and 340 HYGIENE. POST AND CAMP SANITATION must be aerated before use, but this is easily accomi^lished by shak- ing it up, or pouring from one vessel to another. To make the water palatable it must also be cooled. Distillation, is an efficient process of sterilizing water, but if the water is taken from a very polluted source offensive gases may pass liij. 222. — I'arnali Filter, set up ready for use. over in sufficient quantity to cause a disagreeable taste and perhaps diarrhea. Filtration is a process requiring constant care and supervision. Individual or barrack filters, while they clear the water, are liable to increase rather than diminish the numljer of bacteria. Unless such filters are in perfect condition and frequently sterilized the bacteria WATER 341 grow into the substance of the filter, which finally becomes a culture medium. The Darnall Siphon filter, from which very satisfactory results have been reported, combines precipitation xcith filtration, and pro- vides for maintaining the bacterial efficiency of the filtering mate- rials. The precipitant used is a combination of alum and soda known as hydroxide pozvder. The apparatus arranged ready for use is shown in Fig. 222. Improvised filters intended only to clear muddy water are readily prepared. The simplest form is that so common in tropical coun- tries, a small hole being dug in the sand near the edge of a stream, the water filtering through the intermediate sand or being caught on its way to the stream. Another simple method is to take two barrels of dififerent sizes, bore holes in the bottom of the larger and near the top of the COARSE GRAVei. CHARCOAL SAND M0S3 Fig. 223, — Improvised Filter. Jil W /^ // ^U ^Zb=^ ^;i==S^^:^ri\ ?^£?= IS ^Sii Fig. & fe^^.^. ■COARSE GRAVEL -CHARCOAL y^ '., - ;/■ -SANO 224 — Improvised 1 filter. smaller, place the smaller barrel inside the larger, fill in the inter- vening space with sand and sink both in the water (Fig. 223). Or the larger barrel may be left intact, holes being bored in the bottom of the smaller, and the water being poured in on the sand between the barrels (Fig. 224). Sand used for such purposes should always be washed and if possible sterilized before use, and this process should be frequently repeated during use. Impure water may cause disease in several ways. Hard water or water containing mineral salts often causes diarrhea, constipation, or indigestion in those unaccustomed to its use. Decomposing vegeta- ble or animal matter in water or the presence of living alg?e may also cause diarrhea and indigestion, but the great danger in the use of 342 HYGIENE. POST AND CAMP SANITATION polluted water is the liability to swallow the germs of certain special diseases, notably typhoid fever, cholera, and dysentery. Great epidemics have been traced directly to the use of water fouled by the discharges from patients afflicted with those diseases. A great many intestinal parasites, round worms, pin worms, etc., are also carried by impure water. Hospital corps men should know how to take samples of ivater for analysis. For chemical analysis not less than three liters are neces- sary; for bacteriological test about 200 cubic centimeters are re- quired. Samples should be collected in perfectly clean glass bottles stoppered with glass or clean new cork; if for bacteriological pur- poses, the bottle must be sterilized. If taken from a tap, water enough must be allowed to waste to empty the branch pipes ; if from a pump, the barrel must be emptied; if from a pond, the sample must be taken from below the surface and at some distance from shore. CHAPTER II AIR AND VEXTILATION As we have already seen, air is a mixture of oxygen, nitrogen, carbonic acid, and watery vapor. Oxygen is the element that sup- ports all animal life; it is being constantly withdrawn from the air in the processes of respiration and combustion, and returned to it, combined with carbon, as carbonic acid. Vegetable life takes up the carbonic acid and decomposes it, retaining the carbon and returning the free oxygen to the air, so that the equilibrium is maintained. Watery vapor is a normal constituent of air, and the higher the temperature of the air the more it is capable of holding; when it will hold no more the air is said to be saturated. If air so saturated meets with a cooler stratum the excess of moisture is precipitated as ;■(//// or dc-.c. Humidity refers to the amount of watery vapor in air; relatiir humidity is the degree of approach to saturation at any given temperature, while absolute humidity is the actual weight of the moisture in a given quantity of air. The imf^iiritics of air with which we have to deal in dwellings are dust and bacteria, organic matter, and undue proportion of carbonic acid. The organic matters are particles of epithelium and the vola- tile products from the lungs and skin, from unclean mouths, noses. and the intestinal tract ; in hospitals there are also pus cells from suppurating wounds, and the bacteria of infectious diseases. The effects of overcrowding and vitiated air are well known; immedi- ately they are headache, dizziness, and loss of appetite; when long continued, there is loss of bodily vigor and diminished resistance to disease. Besides these indirect effects of vitiated air many diseases are directly caused by the inhalation of bacteria from the air ; among the most important air-borne diseases are tuberculosis, pneumonia, ery- sipelas, and possibly the eruptive fevers. The pollution of air in diccllings is caused not only by the exhala- tions from the human body, but also by the products of combustion in (343) 344 HYGIENE. POST AND CAMP SANITATION healing and lighting. It is estimated tliat an ordinary live-foot gas burner when in use adds to the air of the ajjartnient fully as much carbonic acid, besides other impurities, as one man. The process by which the vitiated air of dwellings is removed and replaced or diluted by fresh air is known as ventilatioti. For the maintenance of the human body in a fair degree of health and vigor it has been found that about three thousand cubic feet of fresh air per hour must be supplied each person. The size of the air space which must be provided for each person depends upon the possibility of supplying this amount of air without causing draughts ; if the entering air is warm, draughts of course are not felt so much as if it is cold. As a matter of experience it has been found that even when warmed the air of a room under the most favorable circumstances can not be changed more than three or four times an hour without causing a sensation of draught ; so that the mini mum cubic air space per man should be at least one thousand feet, which with three changes per hour will give the necessary three thousand cubic feet of fresh air; in the tropics the minimum cubic air space should be two thousand feet, with a floor space of not less than one hundred square feet. In computing the cubic air space in a room we multiply the length by the breadth and then by the height of the room, or by twelve if the height is greater than twelve feet. The reason we d" not ordinarily count height above twelve feet is because above that height there is very little movement of the air in the room unless there are special arrangements for its change. The floor space, therefore, should be not less than one-twelfth of the cubic space. /// hospitals, owing to the additional inqnirities from the sick, four thousand cubic feet of fresh air per man per hour should be allowed , the floor space should not be less than one hundred square feet and the cubic space not less than twelve hundred feet in temperate climates, and 50 per cent more in the tropics. The agencies concerned in ventilation are diffusion, and gravity or weight. Diffusion is net of much value and can not be relied upon alone; the important agent is gravity. Equal volumes of air of the same temperature and under the same pressure have equal weights ; now if one of the volumes is heated it expands and becomes lighter, and being surrounded by heavier air, rises, or rather is forced up, AIR AND VENTILATION 345 by the sinking of the heavier air, and thus currents are produced. When the air in a room is heated by fire, hghts, or even the human body, it becomes Hghter, and the heavier outside air forces itself in through all the openings and crevices, at the same time forcing the lighter air out, thus effecting a certain amount of ventilation. Unequal temperatures in masses of air outside dwellings give rise to winds, and winds aid ventilation in two ways : First, by perflation, or blowing through a room when the windows are open, and second, by aspiration when it blows across chimneys or flues. Ventilation of a dwelling is said to be either natural or mechanical ; natural when we trust to the forces of nature, merely providing the ■Flo. 225. — Heating and Wntilation by Jacketed Stove. necessary entrance and exit openings, together with heat if required : mechanical when the air is forced in or drawn out by fans or other mechanical means. In any system it is neces.sary to remember that it requires two openings to secure ventilation; if only one opening is provided, the incoming and outgoing currents interfere with each other and venti- lation fails. This is well illustrated by the familiar experiment of burning a candle inside of an unstoppered bottle; if the opening into the bottle is divided into two parts by a partition, the candle will burn, because the air currents pass up one side of the partition 346 HYGIENE. POST AxND CAMP SANITATION and down the other without interference; if the partition is removed the hght goes out. Ventilation in summer. or in hot chmates is largely a matter of the action of winds, because the temperature of inside and outside air is practically the same, so that we merely leave doors and windows open, and provide special openings in the ridge or under the eaves for the escape of the heated air in the upper parts of the building. (Jr fans are provided to keep the air in motion; and such de\ices as the punkah or electric fans. In winter the subject of ventilation is so intimately connected with that of heating that it is well to consider the latter befure going into details of the arrangements for ventilation. In the military service the methods for heating are practically con- fined to stoves and furnaces in the older buildings, hot water in the new hospitals, and steam in the new barracks. Stoz'cs are of very little value in assisting ventilation unless special arrangements are made with that end in view. This may be done by partially surrounding the stove from the floor to the level of the top of the stove by a sheet-iron jacket, and admitting fresh air under the stove from an air- shaft; if in addition to this the stove pipe is made to heat an ex- tracting shaft, opening preferably at the floor level, ventilation may be very materially assisted (Fig. 225). Heating stoves in use should always have a pan of water on them to maintain the proper moisture of the air. Furnaces are very valuable ventilators ; fresh air is brought to the dome of the furnace bv an air shaft, heated, and delivered, where required, through tin tubes. hi hot-water Jieatiiig there are two systems, loic pressure and Jiif/Ji pressure. In the low- pressure system, which is that used in the army hospitals, a small, open tank Fig. -'?6. — Heating by Hot Water. Low pressure. AIR AND VENTILATION 347 is provided at the highest point of the system to allow for expansion and the escape of gases. The circulation of the water is due to the difference in weight of the columns of hot and cold water. The water is heated in a boiler in the basement; from the top of the boiler rises a main, with branches to all parts of the building; these branches terminate in radiators, and from the bottom of each radi- ator a branch return comes off, the branch returns uniting to form a main return, which empties into the lower part of the boiler. As the water in the boiler becomes heated it grows lighter, and the Fig. 22-. — Heating by Steam. Low pressure. heavier water in the returns falls and forces up the hot water, thus effecting a circulation {\'\g. 226). In the high-pressure system the pipes are completely closed; hence there is some danger of explosion, but the water can be made hotter and circulation is more rapid. Steam heating is the same in principle as the low-pressure hot- water heating, only steam is used instead of water, and the pipes constitute a closed system (Fig. 227 )• Radiators heated by either steam or hot water may be placed in the room to be heated without any connection with the outside air; this is known as the direct system ; or they may be placed in the basement or some other room, enclosed in a sheet-iron box connected with a fresh-air shaft, the warm air being then conducted to the room, the indirect system; or the radiator may be placed in the room to be heated and the fresh air brought directly in under it and allowed to pass up between the pipes so as to be warmed, the direct-indirect system; the last is that commonly used in hospitals and barracks (Fig. 228). 348 HYGIENE. POST AND CAMP SANITATION When no special arrangements have heen made for ventilation a useful and simple device is to place a strip of l)oard under the lower sash, so that air can enter between the sashes and be directed upward Fig. 228. — Heating by Direct-Indirect Method. (Fig. 80) ; or to pull down the upper sash and place a board sloping down over the opening left above (Fig. 81) ; air will enter between the sashes and escape above. The best simple test of the efficiency of ventilation is to notice the odor on coming into the room from the outside air; if it is stufify and close, ventilation is imperfect. CHAPTER III THE DISPOSAL OF WASTES The organic, dangerous wastes which it is necessary to dispose of in such a manner as not to invite disease are night-soil (urine and feces), slops, and garbage; the first is by far the most dangerous, containing, as it often does, the bacteria of disease. The arrange- ments for the reception of the night-soil may be pits, pans, or water- closets. Pits are the most objectionable because they pollute the soil, may infect the water supply, and permit the access of flies, which may carry disease germs on their feet and bodies from the pits to the kitchens and barracks and there infect the food and drink. Pans, usually used in connection with dry earth to cover and deo- dorize the feces, are little better than pits. They are open to the same objections, except that soil pollution from accidental spilling is not so marked ; in addition they have to be emptied, thus affording another opportunity for scattering infection and creating a nuisance. Jl'ater-closets are best. They may discharge into cess-pools, or into sewers. Cess-pools are excavations in the ground which may or may not have a waterproof lining; if they do not have such a lining they are known as leaching cess-pools. Cess-pools are objec- tionable for the same reason as pits and pans. Sezi-'ers are the pipes or channels which carry off the liquid wastes ; the wastes themselves are known as sezvage. Water-closets and all plumbing fixtures in dwellings empty through short branches into a vertical iron pipe known as the soil pipe, and this in the basement empties into a more or less horizontal iron pipe called the house drain, and finally the house drain beyond the walls of the house terminates in the sezver. The arrangement of the house drainage system is well shown in Fig. 229. Traps are used on all fixtures, and these traps are usually vented to prevent siphonage. The purpose of the trap is to supply a water seal to prevent sewer gas from getting into the dwelling; the three- quarter S-trap is the type ( Fig. J30 ) . The flask trap used by the Quartermaster's Department for lavatories and sinks is practically the same as an S-trap in its interior arrangement. In yards and (349) 350 HYGIExNE. POST AND CAMP SANITATION ■basements where the flow of water is intermittent a particular type of trap known as the bell trap is generally employed (Fig. 231 ) ; the objection to this trap is that in order to be efficient both the cover and the water seal must be in place, while as a matter of fact the one is often misplaced and the other soon lost by evaporation. A much better type of trap is shown in Fig. 232. Fig. 229. — House Drainage. A, B, C, Plumbing fixtures; D, disconnecting trap; E, branch sewer; F, ventilation opening; G, house drain; K, H, vent pipes connected by dotted lines with each trap. Sewage is disposed of by discharging into cess-pools, into run- ning streams, upon sewage farms, and by the bacterial purification methods. The purpose of the bacterial purification systems, which are now- being used in the army to a considerable extent, is to liquefy and purify the sewage so that it may not unduly pollute the streams into which it is discharged. They consist essentially of two parts, a closed tank in which the bacteria which work in the absence of air liquefy the organic solid matters, and a series of filter beds in which the nitrifying or air-using bacteria continue the purification until the sewage should emerge as a clear, colorless liquid like water. Garbage is best disposed of by burning in a crematory which is usually in operation in all the larger posts. In the field the disposal of wastes, especially excreta, becomes a matter of greatest importance and considerable difficulty. Abundant experience has proven that whenever large bodies of soldiers are collected together typhoid fever is sure to be introduced THE DISPOSAL OF WASTES 351 Fig. -'31.— Bell Trap. by some one, and that, unless the command is vaccinated and proper disposal made of excreta, the disease will spread through the agency of infected water, food, bedding, clothing, soil, dust, or flies. A c B D ^^ 1^ K^ 1^ Fig. 230. — Different Forms of Traps. A, Running trap; B, .S-trai>; C, 3 S-trap; D, J S-trap. 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 cannot 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 pos- sible to provide latrine boxes, as for permanent camps, deeper trenches should be dug. These may be used as straddle trenches or a seat improvised. 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 pro- vided 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 scrubbing and in- side by applying when necessary a coat of oil or whitewash. The pit is burned out daily with approximately one gal- lon oil and fifteen pounds straw. When filled to within two feet of the surface, such latrines are discarded, filled with earth, and their position marked. All latrines and kitchen pits are filled in before the march is re- sumed. In permanent camps and can- tonments, urine tul)s may he placed in the company streets at night and emptied after reveille. Fig. 232. — Improved Yard Trap. 352 HYGIENE. POST AND CAMP SANITATION The proper disposal of garbge and stable refuse in camps is also a matter of importance, otherwise they pollute the soil and become a breeding place for swarms of flies ; everything which is combustible must be burned ; what can not be burned must be buried. The burning may be done in the kitchen fire, or the solid garbage may be mixed with more combustible matter such as straw or manure, saturated with petroleum and burned. Manure should be burned in the same way as far as practicable. In more permanent camps crematories should be provided. The following crematory has proved very effective in practice. Fig. 233. — Crematory — Vertical Section. A A, Ground level. At some convenient spot at the rear of the camp, a circular pit is dug three feet deep and fifteen feet in diameter. The bottom is covered with loose stones to the depth of fourteen to sixteen inches. On this is built a circumferential wall to the height of one foot above the original ground level, and the excavated earth is packed against it, clear to the top so as to provide a sloping approach and thereby prevent surface water gaining access to the pit. A pyra- mid of large stones, four or five feet high, occupies the center. This feature is essential to provide central draft and steady fire. The bottom stones receive the liquid portions of the garbage without afifecting the fire, and the heated stones soon evaporate and dissipate it. The solid portions are soon desiccated and become fuel. Care should be exercised to empty the garbage into and not around the crematory. The following rules for the sanitation of camps sums up the whole subject: (a) When practicable, camps should be established on high and well-drained ground not previously occupied. (&) Men should not lie on damp 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 ground may THE DISPOSAL OF WASTES 353 be warmed by fires, the men making their beds after raking away the ashes. (c) Tent walls are raised and the bedding and clothing aired daily, weather permitting (d) In camps of permanence excreta should be disposed of by sewers or incinerators. (c) All kitchen refuse should be promptly burned or buried, and perfect sanitary police maintained. (/) The water supply is carefully guarded. When several com- mands are encamped along the same stream this matter is regulated by the senior officer. If the stream is small, the water supply may be increased by building dams. Small springs may be dug out and lined with 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 twenty minutes, then cooled and aerated. (g) The discharges of patients with typhoid fever, camp diar- rhea, or cholera should always be disinfected at once with a solution of phenol (5 per cent) or of chloride of lime (six ounces to the gallon of water), or with milk of lime, made from fresh quick-lime. {h) The diseases just mentioned are frequently communicated to soldiers in camp through the agency of flies, which swarm about fecal matter and filth of all kinds, and directly convey infectious material, attached to their feet or contained in their excreta, to the food which is exposed Avhile being prepared at the company kitchen or while being served in the mess tent. The water supply may be contaminated in the same way, or by surface drainage. Infection is also often carried on the hands and shoes. It is for these rea- sons soldiers are required to wash their hands before meals and after visiting the latrines, and that all kitchens and mess shelters should be screened to exclude flies. (i) If it can be avoided, marches should not be made in the hottest part of the day. (/) AMien called upon for duty at night or early in the morning a cup of hot coffee should be taken. (k) It is unsafe to eat heartily or drink freely when greatly fatigued or overheated. If alcoholic drinks are used at all, such use 23 354 HYGIENE. POST AND CAMP SANITATION should be postponed until after the day's march and preferable in conjunction with the evening meal. (/) Ripe fruit may be eaten in moderation, but green or over-ri|)e fruit will give rise to bowel complaints. Food should be thoroughly cooked and free from fermentation or putrefactive changes. (m) In decidedly malarious localities from three to five grains of quinine should be taken three times a day as a prophylactic, but the taking of quinine as a routine practice should only be recommended under exceptional circumstances. The best safeguard against malaria is, however, the protection of the body against the bites of infected mosquitoes. To this end mos- quito nets should be used whenever available in malarial localities or seasons, and if not available the skin should be as far as possible covered during sleep. (n) Light woolen underclothing should be worn, and when a soldier's clothing or bedding becomes damp from exposure to rain or heavy dews the first opportunity should be taken to dry it in the sun or by fires. CHAPTER IV DISEASE PREVENTION In chapter XIII of the section on " Nursing" the infectious dis- eases have already been discussed as far as the prevention of their spread in posts is concerned. While there are no diseases entirely peculiar to camp life, there are certain diseases which are specially apt to become epidemic under the more crowded conditions which necessarily prevail in camps. Among the more notable of these diseases are typhoid fever and malarial fevers, diarrhea and dysentery, the eruptive fevers, bronchial troubles and rheumatism, and in certain climates yellow fever and cholera. Typhoid fever. To prevent typhoid fever in the field all soldiers should be vaccinated with the typhoid prophylactic ; in addition all urine and feces must be disinfected ; soil pollution must be prevented ; flies must be destroyed ; drinking water must be boiled ; men must not be allowed to bathe in polluted water lest they get it into their mouths; in permanent camps the kitchens and messes must be screened against flies and all food protected from bith flies and dust. Flies breed in decayed organic matter, especially in stable manure, which should, therefore, never be allowed to accumulate in camp or garrison. In their reproduction flies pass through the s-tages of o\um or tgg, larva or maggot, pupa, and adult. They carry not only typhoid fever but also cholera, tuberculosis, and probably other diseases. Besides the common fly which carries these diseases on its feet and body there is a biting fly, known as tsetse, which transmits sleeping sickness and other trypanosome diseases, by biting, in the same manner as a mosquito transmits malaria. Malarial fevers. W't have seen that malaria is spread in one way only, that is by the bites of the anoplielincv mosquitoes which have previously bitten a human being who has malaria. As protection against malaria involves mosquito destruction, it is necessary to learn something about the life history of mosquitoes. (355) 356 HYGIENE. POST AND CAMP SANITATION Though all mosquitoes are annoying, only three kinds, as far as we know, carry disease; these are the anophclincc, which carry malaria; culex fatigans, which carries dengue and in certain localities in the tropics a blood worm (filaria) which causes elephantiasis; and cedes calopus, which carries yellow fever. It is the female mosquito only that bites, and therefore the female only which conveys disease. Aides calopus (the yellow-fever mosquito) is especially a day biter, and where mosquitoes are found biting in the daytime they are apt to be of that variety. Then again (cdes calopus is the blackest mosquito, and is beautifully marked with silver bands on the legs and body ; a lyre-shaped silver mark on the back is characteristic and identifies (cdes calopus at once. This mosquito is of medium size (Figs. 234, 235 ). The anophclincc (the ma- larial mosquito), Fig. 236. differ from culex and ste- gomyia in having palpi as long as the proboscis in the female : this mosquito differs also from the other two in that the body and proboscis of the anop- hclincc form one straight line, while the other mosquitoes are humpbacked. The resting position of the anophclincc is nearly vertical to the surface, while that of cedes calopus and culc.r approaches the hori- zontal ( Fig. -'37 ) . The males of all mosquitoes are distinguished from the females by the fact that the former have feathered antenUc-e (woolly heads), while the latter have not (Fig. 247). The y ell ozv-f ever mosquito is essentially a domestic or house mosquito ; that is to say, she breeds in small collections of water such as are found about a house, and does not stray far from home. The malarial moscjuito is a rural or country insect; breeds in large Fig. J31 --iides calopus, male. DISEASE PRE\'EXTION 357 pools, the still edges of running streams, irrigating ditches, etc., and is found far from human habitations. When one of these mos- quitoes bites a person afflicted with the disease which she is capable of carrying, she sucks a little blood and with it the germs of the disease. After a week or two these germs re- produce themselves in the mosquito, migrate to her sali- vary glands, and she then be- comes capable of infecting other persons. If she now bites such a person, she in- jects into his blood with her saliva some of the germs, and after a variable period, known Fig. 235. — .5;des caiopus, female. as the period of incubation, that person is usually taken down with the disease. The measures to be taken to prevent such diseases are destruction of mosquitoes, protecting the mosquitoes against infection by screening infected persons — and in the case of malaria destroying the germs in their blood by the use of quinine ; protecting well persons from infection by the use of screens and nets, and in the case of malaria, by the use of quinine to render the blood insusceptible to infection. ^ , , . r^Iosquitoes breed onlv in Fig. 336. — Anopheles raacuiipennis (quad- _ " _ rimacuiatus), female. Water, but Very little water is required for the purpose. The female deposits her eggs to the num- ber of 40-400 upon the surface of the water, and after a period of 358 HYGIENE. POST AND CAMP SANITATION twenty-four hours to two or three days they hatcli. becoming larvce or wiggle-tails ; the larval stage lasts one or two weeks until the pupce Fig. 237. — Resting posture of mosquitoes: i and 2, Anopheles; 3, Culex Pipiens, form ; after two to five days more imagos or adult insects emerge (Figs Fig. J3S. — t'ulc.x pungcns, male. we prevent mosquito breeding". This is accomplished by drain- ing and filling, and by remov- ing all small articles capable of holding water. Collections of water that can not be re- moved should be closely cov- ered and screened, or else oiled with petroleum, about an ounce to each fifteen square feet of surface, the petrolia- ing being repeated about once a week. the i)upal shells split and the 240 to 241^) ) . The entire transition from egg to adult insect requires from ten days to two or three weeks. Any collection of water, provided it is moderately still, answers the mosquito for breeding purposes. They breed in marches, ponds, ditches, rain barrels, cisterns, gutters, watering troughs, hoof-prints, old tin cans, in fact anything capable of hold- ing water. By allowing no unprotected water collections Fill. -3ij,- — C'ule.x pungeiis, l\ir.a,'_-. DISEASE lMands gradually and relax the legs. To Mount (with saddle) 344. The horses equipped with saddles and curb bridles are habitually formed in line. The troopers standing to the horse, the instructor causes them to count fours, and commands : i. Prepare to Mount. 2. Mount. At the first command the odd numbers lead out. All the troopers drop the right rein, take two back steps, stepping off with the left foot, at the same time sliding the right hand along the left rein; half face to the right; this should place the trooper about opposite RIUiXG 3S3 the girth; with the aid of the left hand take both reins in the right, fore- finger between th« reins, and place the right hand on the pommel, the reins coming into the hand on the side of the forefinger, and held so as to ieel lightly on the horse's mouth, the bight falling on the off side. (TWO.) Place a third of the left foot in the stirrup, with rhe assistance of the left hand if necessary, and support it against the forearm of the horse; r^st upon the ball of the right foot, grasp a lock of the mane with the left hand, tlie lock coming out between the thumb and forefinger. At the command mount, spring from the right foot, holding firmly to the mane and keeping the right hand on the pommel ; pass the right leg, knee bent, over the croup of the horse without touching him ; sit down in the saddle; let go the mane, insert the right foot in the stirrup, pass the reins into the left hand and adjust them. At the command: 3. Form, 4. R.wk, the even numbers move up in their intervals. Position of the Trooper (with saddle) 345. Same as previously explained (par. 294), with the following excep- tions : Buttocks bearing equally and as flat as possible upon the middle of the saddle; reins coming into the left hand on the side of the little finger, and leaving it between thumb and forefinger; little finger between the reins, right rein above it ; the other fingers closed, thumb pointing to the right front in prolongation of the forearm and pressing the reins firmly on second joint of forefinger; the end of the reins falling to the front and outside of the right rein; left forearm horizontal and close to the body without pressure ; the back of the hand nearly vertical ; right hand behind the thigh, arm hanging naturally; feet inserted in the stirrups so that the ball of the foot rests on the tread of the stirrup, heel slightly lower than the tread. Stirrups 346. The stirrups should support the feet and the weight of the legs only, and be (jf such length that when the legs are in proper position, the feet out of the stirrups, the treads will be on a level with the lower part of the inner ankle bone. The length depends somewhat on the formation of the man; a man with a thick heavy thigh requires a shorter stirrup than a man with a thin, flat one. P"or long distances at the gallop and trot, a shorter stirrup is required than at the walk. When riding, the stirrups take up, in a measure, the weight of the body in its descent to the saddle, by a yielding of the ankles to prevent shock. This action is an easy, quick stiffening of the muscfes which distributes the downward motion between the feet, thighs, and seat. If, after the trooper has been exercised a short time at the slow trot, he has a close seat, his leg in proper position, with his heel down, but does not easily keep his stirrup, then the stirrup requires shortening. 384 RIDING, PACKING, AND DRIVING stable Duty 995. A noncommissioned officer, designated stable sergeant, or corporal, is detailed in each detachment to take immediate general charge of the forage and stable. He is held responsible for the proper policing and sanitary condition of the stable, picket line, and groimd pertaining to them. One or more men, called stable police, are detailed for the purpose of policing, removing manure, feeding, etc., under the direction of the stable sergeant. Usually horses are groomed twice daily, at morning and at evening stables, imder the supervision of the stable sergeant and a commissioned officer. Under special circumstances, it may be advisable to groom only once a day. The stable police, after grooming their own horses at morning stables, clean out the stalls and pohce the stable, under the direction of the stable sergeant. The bedding is taken up, that which is much soiled being separated for the manure heap, and the remainder put on the litter racks or spread upon the ground to dry. At or before evening stables, the stable is policed; the bedding is laid down and fresh straw spread on top of it ; the bed must be soft and even, with the thickest part toward the manger; where horses eat their bedding, the old litter should be placed on top of the new straw. Grooming' The grooming is always done at the picket line, except in stormy weather. Stable call is the first call or warning call for stables, and precedes assembly by such intervals as may be prescribed. The roll having been called, the detachment is marched to the horses or stable, and upon arrival there the first sergeant commands, Commence grooming; Fall Out. The horses are then tied on the picket line, if not already there, and are groomed under the direction of the platoon leader. Each man habitually grooms his ow'n horse, except that the horses of the sergeants, first class, may, at the discre- tion of the company commander, be groomed by the men of the platoon to which these horses are attached. Drivers and wagoners groom the animals assigned to them. For the purpose of proper super\nsion in grooming, feeding, etc., the horses of the men not assigned to platoons and other supernumerary horses, will be attached to platoons. At stables, each man examines his horse's feet. Horses requiring shoeing are reported to the noncommissioned officer in charge of the section, who notifies the stable sergeant. Each horse should be groomed not less than 20 minutes, and as much longer as may be necessary. When the horses of any platoon are sufficiently groomed, the platoon leader reports that fact to the first sergeant. The platoon at the discretion of the detachment commander, may then lead in, and the horses Avill be led to their stalls and properly secured under the supervision of the platoon leader. Should the officer wish to inspect the horses of any platoon or of the whole detachment before they are led in, RIDING 385 he will notify the platoon leader or the first sergeant, who will then com- mand: Cease grooming; Stand To Heel; each man stands one yard in rear of and facing his horse. When all the horses have been groomed and led in, and the grooming kits put away, the sergeant will form the detach- ment, march it to the company parade, and dismiss it. If, when the horses are inspected, the officer finds anj' of them not properly groomed, he will direct that these horses be left at the picket line and groomed under the supervision of a noncommissioned officer detailed for that purpose. To Groom 997. Take the currycomb in the right hand, fingers over back of comb ; begin on the near side at the upper part of the neck, thence proceed to the chest, arms, shoulders, back, belly, flank, loins, and croup in the order named. Then go to the off side, taking the comb in the left hand, and proceed as before. The currycomb is applied gently and is used only to loosen the scurf and matted hair; it is not used on the legs from the knees or hocks downward, except to carefully loosen dried mud. Next, take the brush in the left hand and change the currycomb to the right ; begin at the head and then the neck on the near side, and proceed ill the same order as in currying, brushing also the parts not touched by the comb; on the off side, take the brush in the right hand, the currycomb in the left. The principal working of the brush should follow the direction of the hair, but in places difficult to clean, it may be necessary to brusli against it, finishing b}^ leaving the hair smooth. After every few strokes clean the brush from dust with the currycomb. Having finished with the brush, rub or dust off the horse with the groom- ing cloth, wipe out the eyes, ears, and nostrils, and clean the dock. The skin under the flank and between the hind quarters must be soft, clean, and free from dust. Currycombs, cards, or common combs must never be applied to the mane or tail; the brush, fingers, and cloth are freely used on both. The wisp is used when the horse comes in wet from exercise, rubbing against the hair until dry, from his hind quarters up to his head. If very wet, very hot, or very cold, blanket the horse, groom and hand-rub the legs ; then remove the blanket and groom the body. Feeding' 998. Guiding principles in feeding are: (i) Feed in small quantities and often: (2) Do not work the animal hard immediately after a full meal. In garrison and on the march, animals should be fed at reveille, at mid-day. and at night, ordinarily one-third of the grain ration being given each time. In garrison, the stable sergeant, assisted by members of the stable guard or police, may feed at first call for reveille. In the evening, grain should he fed after hay has been distributed, the stable swept out and the dust thoroughly settled. 25 386 RIDIXG, I'ACKIXG, AND DRI\1XG The men are marched to the forage wagons or other grain depository where the noncommissioned officer in charge, with an allowance measure, issues to each in turn. The platoon leaders then march their platoons back to the horses and command : Feed. Ordinarily one man of each platoon will remain near the horses unlil they have linished eating, to adjust feed bags. Each man may be required to feed and groom as soon as he has received his grain. Very little hay, if any, is fed in the morning when hard work follows, but about one-third of the ration should be fed at noon, and the remainder at night. The dust must be well shaken out of* the hay when it is put in the mangers. In camp hay is fed at the picket line morning, noon, and evening; on tlie march, when the horses are grazed during the day, in the evening only. The use of bran once or twice a week is important for stable horses. In spring or early summer they should be grazed. Two and a half ounces of salt should be given each week, preferabl}- lumps of rock salt, secured in or near the manger. Grazing should be encouraged at every spare moment, both in camp and at halts on the march. The daily allowance of oats, barley, or corn is I2 pounds to each horse and 9 pounds to each mule; that of hay, 14 pounds to each animal; the allowance of straw for bedding is 100 pounds a month to each animal. Watering 1000. Horses must be watered quietly and without confusion; the manner in which this duty is performed is often a good test of the discipline of a mounted command. Horses are to be led or ridden to and from water at a walk. At the drinking place, no horse should be hurried or have his head jerked up from the water. In the field or on the march, the watering is from the most convenient running water ; in garrison, it is usually from troughs, which should bo cleaned each day. In warm weather, water drawn from a cold well or spring should stand long enough for the chill to pass off. The horses are watered under the immediate direction of the sergeant, but, if they are liable to meet those of other commands at the watering place, a commissioned officer should supervise this duty. Horses should be watered before feeding or not until two hours after feeding. Ordinarih-, they should be watered twice a day : in hot weather, three times a day. In very cold weather, once a day, about noon, is sufficient. A horse will rarely drink freely very early in the morning. If a mounted command have to march a long distance without water, so that it will be necessary to encamp en route, the animals are fed, but denied water until just before starting, when they arc permitted to drink freelv. The command marches in the afternoon, and does not encamp RIDING 387 until it has accomplished at least half of the distance, and moves early the next morning to reach water. Watering the horses on the march depends in a great measure upon tlie facilities to be had. If nothing is known as to the country over which the day's march is to be made, water call should be sounded shortly before leaving camp and every horse given an opportunity to drink. As many animals, however, will not drink at an early hour or until after exercising the horses should be watered again at the first opportunity. On severe marches, frequent watering is of great benefit. The daily allowance of water for a horse at rest is about six gallons ; when at work, from eight to twelve gallons ; for a man, one gallon for all purposes. One gallon of fresh water weighs 8>^ pounds, approximately one pint to one pound. General Rules for Stable Management I118. The following general rules are recommended: The stable sergeant has immediate charge of the police and sanitary condition of the stable, picket line, etc., and is the custodian of the forage and stable property generally. The stal)le is to be kept thoroughly policed, free from smells, and, except portions of stalls that horses can reach, should be well limcwashed. There must be no accumulation of manure or foul litter inside, nor near the doors or windows without. The feed boxes are washed from time to time, and kept clean. The ground about the picket line is swept dail}', and all dung, etc., carried to the manure heap. Except at night, when the horses are bedded down, no manure or urine is to remain in the stalls ; the stable police remove it as it accumulates. If practicable, all woodwork within reach of the horses, and not protected with sheet iron or other metal, should be painted with thin coal tar to pre- vent it being gnawed. The same precaution may be followed with regard to troughs, picket posts, and picket line. It should be thoroughly dried before putting horses near it. Smoking in stables, or in their immediate vicinity, is prohibited. One or more lamps will be hung in each stable to burn during the night. The horses are stalled according to their positions in the squads ; their places at the picket line will be in accordance with the same rule. Over each horse's stall is placed the name of the horse, under that of his rider. Clay is the best for earthen floors. Gravel, or sandy earth, is not suitable. The sloping of the floor of stalls from the manger to the heel post is injurious and uncomfortable for the animal, making him stand in an im- natural position, with the forelegs higher than the hind ones. When the earthen floors are level, the horse will paw a hollow for his forefeet unless he can elevate his hind quarters by backing out of the stall. Whenever horses go out of the stable, the windows of their stalls are to be kept open, unless necessary to exclude rain or snow, or when cold drafts affect the animals in contiguous or opposite stalls. 388 RIDING, PACKING, AND DRIVING Stable doors are never closed in the daytime, except to keep out wet, or to exclude cold winds that blow on the horses. If the doors be in a single piece, bars are put across the doorway; if divided into upper and lower halves, it will usually be sufficient to open the upper part. At night, the entrance to the stables should be secured in such manner as will prevent the escape of animals. When circumstances permit, horses should be turned loose in the paddock during the daytime, or herded under charge of a guard. When neither is practicable, they should, except in very cold, windy weather, or in very hot weather where there is no shade, stand most of the day at the picket line, as they have better air and are less confined, while the stables become drier and more healthful. In ordinary climates, cavalry stables must be kept as cool as possible. If the horses do not stand directly in the draft, the colder the stable the less will they sufifer if called suddenly to take the field. For the same reason, horses should never be blanketed in the stable, except during vei-y cold weather. Treatment and Care of Horses 1 1 19. Horses reqtiire gentle treatment. Docile but bold horses are apt to retaliate upon those who abuse them, while persistent kindness often reclaims vicious animals. A horse must never be kicked or struck upon or near the head with the hand, reins, or any instrument whatever. At least two hours' exercise daily is necessary to the health and good con- dition of horses; they should be marched a few miles when cold weather, muddy ground, etc., prevent drill. Horses' legs will be hand-rubbed often, particularly after severe exercise, as this removes enlargements and relieves or prevents stilYness. In mild weather the sheath will be washed occasionally with warm water and castile soap, and then greased ; in cold weather, when necessan.-, the sheath should be greased. Horsese used freelj^ in snow and slush must not be placed in a warm stable with littered stalls. CHAPTER II PACK SADDLE AND PACKING THE MEDICAL DEPARTMENT PACK OUTFIT Each. No. I. Pack frame, of metal number. . i No. 2. Stretches of spreaders for saddle pads, of corrugated metal number . . 2 No. 3. Saddle pads do. ... 2 Fig. 250. — The Pack Saddle Proper. No. 4. Quarter straps do. . . . No. 5 and 6. Quarter strap ring sets, complete, consisting of 2 rings with leather union f^") and 2 cincha straps {6} sets... No. 7. Cincha. horsehair, double do. . . . No. 8. Accessory leather straps number. . ■(389) 390 RIDING. PACKING, AND DR1\ ING No. 9. Breast collar straps number. No. 10. Breast collar body piece d(3. . . No. 1 1. Breast collar neck piece do. . . No. 12. Brea>t ctjllar choke strap do. . . No. 13. I'ork straps for turnback do. . . No. 14. Turnback and crupper, comi)lete do. . . No. 16. Breed. ing hip strap do. . . No. 16. Breeching- straps do. . . No. 17. Breeching body piece do. . . No. 18. Thongs, rawhide do. . . Each. 2 I I I 2 I I 2 I 6 No. 19. No. 20. No. 21. No. 22. No. 23- No. 24. No. 25. No. 26. ACCESSORY ARTICLES Cargo slings, webbing, complete, with 4 straps number. . Load cincha (belly piece) short, complete, with 2 cincha straps number. . Cupi:)ed blind, complete, with 2 thongs do. . . . Load cincha (top piece) long, complete do. . . . Cargo cover, canvas, 3 by 6 feet, with 14 rawhide thongs number . . ]\Iantas, canvas, 6 by 6 feet, with 20 rawhide thongs, number. . Bags, canvas, complete do ... . Saddle blanket do ... . METHOD OF USING THE PACK OUTFIT As the ])ack outfits are issued from the supply depot, the pack saddle proper is asseml)led as shown in Fig. 250. The accessory articles are loosely packed in the shipping box. To use the pack outfit, the pack saddle proper is placed on the animal with a saddle blanket imder it. The breast collar and breeching are adjusted to the animal as required. The saddle is then firmly cinched in position. To prevent undesirable moving about on the part of the pack animal while the saddle and load are being placed in position, it is advisable to blindfold the animal by means of the cupped blind. To load the animal, the webbing slings are placed on the ground with the link piece down. On them are placed such articles as PACK SADDLE AND PACKING 391 may be desired. Chests, bedding^ rolls boxes, etc., are conveniently carried in the slings ; dressings, or a number of small pieces that are likely to be lost, can be put into the canvas bags and then placed in the slings. If desired, all articles may be previously wrapped in the canvas mantas to protect them from the elements. The sling is then securely fastened about the load by means of the leather straps secured to its metal rings. The load is divided in such a manner that each sling will carry approximately the same weight. The next step is to place the load on the animal. To do this, the loaded slings are raised from the ground and supported on the Fig. 251. — .\ccessory Articles. metal posts of the pack frame by means of the iron links on the slings. If possible, both sides should be loaded at the same time to prevent the saddle from turning on the animal's back. The load is now protected by means of the canvas cargo cover, which is thrown over it and fastened by a number of its thongs. Over this is thrown the long canvas load cincha. By means of the 392 RIDING, PACKING, AND DRIVING short-load cincha and its straps (which pass under the belly of the animal) the load can be securely fastened so that it will not shift. Any additional load, such as sacks of grain, etc., for which there is not room in the slings, as well as such necessary articles as mantas, canvas bags, etc., not in use, are carried on the animal's back between the two sling loads, the long-load cincha holding them in position when tightened. CIIAITER III DRIVING The wagons which the hospital corps man may have to drive and care for are the four-mule escort wagon, the six-mule army wagon, and the four-mule ambulance wagon. The standard wagon is the four-mule escort wagon. The load should not exceed 3,000 pounds on goods roads ; for average condi- tions, 2,500 pounds is considered a fair load. For the six-mule army wagon the load should not exceed 4.000 pounds on good roads ; for average conditions, 3,500 pounds. Wagons should always be supplied with a spare pole, an axe, a bucket for watering the animals, a hammer, a monkey wrench, spare bolts, a candle lantern, and a box of axle grease. The ambulance is a four-wheeled vehicle, ordinarily drawn by two animals in garrison and four in the field. It provides transportation for eight men sitting or four recumbent on litters, or four sitting and two recumbent. It is fitted with four removable seats, which, when not used as such, are hung, two against each side. The arrange- ments for supporting the upper tier of litters (upper berths) con- sist of two litter-supporting posts and four straps. The litter- supporting posts are two upriglits, placed 73 inches apart. The one in front it stationary, being secured to the roof and floor ; the one at the rear is hinged at the top. and when the upper berths are not to be used it is strapped to the roof. A\'hen the upper berths are to be used, it is unstrap])ed and swung into a vertical position, when its lower end is secured to the floor by a slot and bolt. Fastened to each of the litter-supporting posts, 27^ inches from the floor, is a socket for the inside handles of the litter, and opposite each socket, attached to the side of the ambulance, is a strap to hold the outside handles. The floor is 7-J- feet long and 4 feet wide. The art of harnessing and driving can only be taught practically. Familiarity with the parts of the harness fFig. 252) and the methods of harnessing and unharnessing should be imparted to the whole class, and one man should be detailed at a time as assistant (393) 394 RIDING. PACKING, AND DRIVING to the ambulance driver and stable man in order that he may learn practically how to care for the animals and harness and how to drive. The following course of instruction is taken from the " Service Manual for Sanitary Troops." Fig. 252. — Harness, i, Crown; 2, check piece; 3, front; 4, 4, blinds; 5, nose band; 6, bit; 7, curb; 8, check; 9, throatlatch; lo, rein; 11, collar; 12, hame; 13, hame link; 14, kame strap; 15, pole strap; 16, martingale; 17, trace-tug; 18, trace; 19, saddle; 20, terret; 21, belly-band; 22, turn-back; 23, crupper; 24, breeching; 25, hip-strap; 26, trace bearer THE AMBULANCE DETACHMENT THE DRIVER 380. To each driver are assigned four mules, a wheel pair, and a lead pair. The mule on the left side is called the near mule and the other the off mule. 381. At the discretion of the company commander, the ambulance orderly may be placed in charge of one pair of mules in harnessing and unharnessing and in hitching and unhitching at drill, and in the field when his services are not required by the sick. DISPOSITION OF HARNESS 382. In garrison: The harness is arranged on two or four pegs in the harness room. If two pegs only are avaiable, the wheel set is placed on one peg and the lead set on the other. When four pegs are avaiable, the near harness of eadh set is kept on the left side of the off harness. In the field: The lead bars are placed under the end of the pole, and the harness is hung over the pole. Care should be taken to keep the harness off the ground. In bad weather it is advisable to put the harness inside the ambulance. DRIVING 395 TO HARNESS 383. A pair of quiet mules, in a double stall, is assigned to each recruit, who should be supervised at first by a competent man. The instructor causes a pair to be harnessed, points out the names of the dilTerent parts of the harness and explains their uses; he then causes tlie harness to be taken off and replaced on its pegs. The harness being on the pegs, the instructor causes the recruits to stand to heel, and commands : I. BY DETAIL, 2. HARNESS Collar on: At this command each driver puts on and buckles the collar of his off mule, then that of his near mule. Traces and breeching: Each driver takes the hames, traces, and breeching from the peg, carries them on the right arm and, approach- ing the proper mule from the near side, gently places the harness upon the mule's back. The hames are put on the collar and the lower hame strap buckled. Then the saddle is buckled on the near .«ide, and the straps which are attached to either side of the breech- ing are attached to the ring in the martingale by means of snaps. Bridle: The oil mule is bridled first, then the near mule. Unless instructions to the contrary are given, the halters are removed be- fore bridling. The check rein is taken in the right hand, the crown in the left ; the mule is approached from the near side. The check rein is slipped over his head and allowed to rest on his neck. The crownpiece is then taken with the right hand and the bit in the left; the crown piece is then brought in front and slightly below its proper position. The left thumb is inserted in the side of the mouth, above the tusk, the jaw pressed open and the bit inserted by raising the crown piece. The ears are then gently drawn under the crown piece, beginning with the left ear. The throatlatch is then secured. Couple: Each driver backs his pair out of the stall, places them side by side facing the stable exit, and attaches the reins properly. To harness without detail: I. HARNESS The mules arc harnessed in the manner described above, but each successive step is taken without command as rapidly as possible. 396 RIDING, PACKING, AND DRIVING TO UNHARNESS 384. The command is given : I, BY DETAIL, 2. UNHARNESS Uncouple: Each driver stands in front of his mules, uncouples the reins, and fastens them hy looping them on the near hame of the near harness and the oil hame of the oil harness, and tying them with a half hitch, and then leads the mules into the stall. Unbridle: He then unbridles the near mule, hanging the bridle on the near hame, puts on the halter, and fastens the chain to the manger ; the same is done with the off mule, hanging the bridle on the off hame of the off' harness. Traces and breeching off : The various parts of the harness men- tioned in traces and breeching are unfastened in reverse order. The left hand is used to place the breeching, saddle, and hames on the right arm in removing the harness from the mule. The harness is placed on its proper peg. Collar off: He removes the collar of the near mule, then that of the off' mule, and hangs them up in the same order, first near collar, then off' collar. Harnessing and unharnessing in the held is executed as in garri- son with such modifications as the disposition of the harness re- quires. The mules are ordinarily tied by the halters to the wheels of the ambulance while harnessing and unharnessing. FITTING HARNESS 385. When the recruit has become familiar with the methods of harnessing and unharnessing he will be instructed in fitting harness, and the importance thereof will be thoroughly impressed on him. The bridle is so adjusted that the bit touches, but does not draw up the corners of the mouth. The collar when adjusted should freely admit the hand between the lower part and the throat of the animal, and the fingers between the sides and the neck. A short collar chokes an animal by pressing upon the windpipe ; a narrow one pinches and rubs its neck, and a broad collar works about and galls the shoulders. The breech strap should be adjusted so that it will bear quickly when the animal is required to check the momentum of the ambu- lance, but will not impede his mcn^ements while in draft. This DR1\"L\G 397 ■adjustment is most important. It can best be made by observing tlie animal in draft, and tightening the straps as much as can be done without impeding the free movements of the animal while in draft. The hip straps should be of such length that the breech strap will bear just below the point of the buttocks. The lower the breech strap is adjusted, the less does it assist the animal in checking the momentum of the ambulance. The loin strap should be so adjusted that the traces, when in draft, Vv'ill be straight and without downward pull on the loops that support them. The length of the wheel and lead traces must depend in a great measure upon the size of the animal and his stride. The rule for lead pairs is to allow but i yard from the heads of wheel pair to points of buttocks of leaders when in draft. The wheel traces should be so adjusted as to allow' at least 14 inches between hind quarters and singletree when in draft. The traces should be adjusted so that the line of traction will be straight from the singletree to the collar. This rule will regulate, in a measure, the length of the loin straps, and the matching of animals. TO LEAD OUT 386. To form pairs after harnessing the instructor indicates the place of formation, and w^hether the formation is to be in line or in column of pairs, and commands : LE.\D OUT BY PAIRS 387. The pairs are led out by the driver, and formed at the designated place. TO POST THE TEAMS WITH THEIR AMBULANCES 388. The teams are marched to the park in columns of teams, and so directed as to approach the flank and rear of the ambulance. As the head of the column approaches the ambulances the instructor commands : TEAMS, TO YOUR POSTS Each team, as it comes opposite its ambulance, wheels from the column and proceeds to its ambulance ; having passed the end of the pole the driver causes the wheel pair to back so that the pole is 3'icS RIDIXG, PACKJXG, AXIJ URlXJXii between tlie ninles. The lead ])air takes its position immediately in front of tlie wheel pair. THE PARK 389. Ambulances are ordinarily arranged in park in order in line, the ambulances being arranged from rigiht to left in order of their numbers. The interval between vehicles may be either the normal of 12.5 yards, or such interval as the commander may direct. The three escort wagons are parked on the left in the same formation as the ambulances, or in a second park, as may be prescribed. The lead bars are used to support the pole by means of one single- tree. In garrison ambulances are kept in a shed. 390. The column of drivers is halted in front of the building, the sergeant, first class, gives the necessary directions for the formation of the park, and commands : FORM PARK The drivers fall out and run the ambulances out by hand and form them in park. The ambulances having been formed in park, the drivers fall in and are marched to the stable or picket line, commanded by the sergeant, first class. TO HITCH AND UNHITCH 391. The brake is firmly set before teams are hitched to an ambulance or wagon, and hitching is so conducted that the mules are kept under control ; until teams are well broken, this may necessitate the assignment of the orderly, or of other drivers, to assist the driver of the team. 392. Well-broken teams are hitched as follows: After lead and wheel teams have been harnessed, the lead teams tied near their respective ambulances, and the wheel teams placed in position in front of the ambulances, the pole between the mules and each driver at the heads of his wheel team, the command is given : I. DRIVERS, 2. HITCH The pole straps are passed through the rings on the chains at the end of the pole and fastened to the rings on the hames ; the driver passes behind the near mule and attaches the near trace of the off DRR'IXG 399 mule and the traces of the near mule. Going in front o^ the team, he passes to the rear of the off mule and attaches the fourth trace, lie then brings the lead team iuto position, hooks the lead bar to the end of the pole, attaches traces as described alxDve, takes the reins, first of the lead team and then of the wheel te-am, aud mounts to the right side of the seat. The orderly mounts the seat from the left side. 393. At the command : I. DRIVERS, 2. UXHITCH Each driver reverses the several steps used in hitching. DRIVING 394. Xever pole too tightly, especially when the pole is a heavy one, because if the pole chains are tight the weight of the pole will continually rest on the neck. On the other hand, if the poling up is too loose the constant swaying will l^e a source of irritation and danger to the team. COUPLING REINS 395. The correct adjustment of the two short inside reins, called coupling reins, requires great care. They should be so fitted that an even pressure is brought to bear on both sides of the animals' niouths, and in such a way also that both animals shall go straight and pull evenly on the traces. For instance, if the near horse carries his head to the near side, the coupling rein on the off side should be taken up, when his head will be straightened. Supposing we have two animals apparently well matched, but th.at the near one carries his head rather out to the front, and has a light mouth, while the oft' animal has a hard mouth and carries his head close to his chest. Now, to get this pair to pull equally on the traces we must have the near animal's rein considerably longer than those of the oft* animal. In this case we should begin by letting out the oft" side coupling rein and taking up the near side rein the same number of holes. The reins will now be adjusted so as to permit the near horse to hold his head well in front of the other, while the collars are brought level. The most general fault is coiiy')ling up both reins too tightly, which makes the animals carry their heads in toward the pole, instead of going straight, as they should do. To prevent animals acquiring 400 RIDLNG, PACKING, AND 1)K1\ IXG this habit, it is a good plan to change their positions occasionally, instead of always driving them on the same side of the pole. It is a convenient plan to have more than one hole in the billets for buckling the reins on the bits, so that an animal can be pulled back or let out a hole or two on either side without altering the coupling rein. HOLDING THE REINS 396. Place both reins in the left hand, the near rein over the forefinger and the off rein under the middle finger. Thus you have two fingers between the reins. The reason for this is that it gives much more scope for play of the wrist on the mouths than if you have only one finger between the reins. The thumb should point straight to the right and the forefinger be held well out, pointing to the right rear. This will keep the rein close up to the knuckle, and the pair may be easily moved across the road by turning the back or hand up or down ; up for left turn, down for right turn. 397. Sit firmly but comfortably in your seat, body erect, without stiffness, and elbows close to side. Do not lean forward. Now take the whip in the right hand, at the place where it balances com- fortably, and you are ready to start. 398. Bring the pair to attention by feeling their mouths gently, and speak to them. If they do not respond, touch them gently with the whip. The moment they start drop the hand slightly; "jibbing'' is often caused by neglect of this precaution. 399. The elbows should be held close to the sides, with the points almost touching the hips. The wrist should be well bent, as by this means the driver '"s enabled to keep a perfectly steady bearing on the mouths without any jerking. The forearms should be horizontal, and the fingers from 3 to 5 inches from the center of the body, with the knuckles to the front The thumb should not be pressed down on the rein. The fingers that should grip the reins are the three lower ones. 400. Never hit an animal while the right hand is holding a rein, because if you try to cut him when you have the off rein in the right hand you must slack that rein off, and the pair is apt to dash to the left. 401. Do not get into the habit of " jabbing " the pair with the DRIVIXG 401 bits, and do not flap the reins on their backs to start them or make them increase their pace. Drive at a steady, even pace, as nothing tires a team so much as to constantly change the rate of speed. When it is necessary to pull up in a hurry, the proper course to pursue is to catch hold of the reins with the finger and thumb of the right hand, just behind the left, and shorten them as much as neces- sary by pulling them through. This is safer and more business-like than elevating the hands, which disturbs the seat. 402. The driving gloves should be large and very comfortable. They should never be of a size to cramp the hand in the slighest. 403. The right hand is known as the whip hand. It is generally used only for holding the whip, for assisting the left hand, and for shortening the reins by pulling them through from behind the rein hand. DRIVING FOUR-IN-HAND 404. The driving of four animals as they should be driven is an art that can only be learned by constant practice and study. 405. When driving, the body should be kept upright and square to the front, but all stiffness should be avoided. The driving seat should be about three or four inches higher at the back than in front, so that the driver can sit well back in a really comfortable position. The ankles and knees should be just touching each other, and the arms close to the sides. The forearm should be about horizontal, and the left hand, as in driving a pair, from four to five inches from the center of the body, the back of the hand being turned toward the front, but inclined a little toward the team. The wrist should be bent slightly toward the body, and on no account allowed to 1)end the other way. This is far the best position for feeling the mouths, as the wrist then acts like a spring, and an even pressure can be maintained. The driver should on no account be helf standing, or merely lean- ing against the seat, with unbent knees, as, in the event of a wheeler falling or shying to the side, he will probably be jerked off the wagon. THE REINS 406. The best way of holding the reins is to have the near lead over the left forefinger, the off lead between the forefinger and the middle finger, the near wheel between the same and under the oft' 26 402 RIDING, PACKING, AND DRUING lead. The reins must be gripped firmly by the three lower fingers of the left hand. The thumb should point to the right, and the forefinger be held well out. The near lead rein should pass over or close to the knuckle of tli« forefinger and not over the first or second joint. ADJUSTING THE REINS 407. All four reins can be shortened, if much is required, by l)ulling them through from behind, but it is generally quicker and neater to hold the reins with right hand two or three inches in front of left (the little and third fingers over the off-side reins and the middle finger between the near-side reins), and then slide the left hand up to the right. This movement is generally required when going down hill. WHEEL REINS 408. It is better to shorten these by pulling them through from behind. This is necessary when going down hill, especially when the wheelers are loosely poled up, so as to prevent the singletrees from hitting the leaders' hind legs. LEAD REINS 409. In order to shorten these, take out both the leaders with the right hand (the third and little fingers over off, and first or middle finger over near side rein) ; they then can be passed back to the left hand the required length by letting them slip through the right hand the necessary amount. To lengthen them, simply pull them through from the front. NEAR LEAD REIN Either push through from the front, with the full of the right hand over the rein, or take it right out of left hand and replace it the I)roper length. OFF LEAD REIN Push it through from the front. NEAR WHEEL REIN This is the most difficult rein to keep in its right place and to shorten. It is constantly slipping when the wheelers pull. It appears to be the best plan to pull it through from behind. DRIXIXG 403 OFF WHEEL REIN Push it through from tlie front with the right hand. CROSSING THE ROAD 410. To the left: Turn the left hand, knuckles upward, and pass it across the body from left to right; the team will incline to the left, the reins on that side being shorter. To the right: Pass the left hand down toward the left hip, back of the hand to the front, with the knuckles of the forefinger downward, and that of the little finger uppermost. This shortens the right hand reins and causes the team to incline in that direction. The whip can be applied to the oflf wheeler in the first instance, or to the near one in the second, if they do not cross rapidly enough. TURNING TO THE LEFT 411. With the right hand seize the near lead and wheel reins under the lower fingers ; then either pull those reins up toward the center of the body, which will shorten them, or allow the left hand to go slightly to the front, which will slack ofif the right reins, or, better still, combine these motions. TURNING TO THE RIGHT 412. Take hold of the ofif lead and wheel reins with the lower fingers of the right hand and treat them in the same way as in using the left reins. TO STEADY THE TEAM 413. In order to steady the animals or to ease the left hand, the right may be placed in front of the other over all the four reins, the third and little fingers being over the off reins and the upper fingers over only one of the near reins. THE WHIP 414. The handle should rest in the palm of the right hand and be kept firmly in its place by the action of the thumb pressing against the base of the forefinger; the lower fingers will then be left free to catch hold of the reins. If, however, it is necessary to pull the reins through from behind, the lower fingers must be tightened on the handle, so as to allow the thumb and forefinger to be used. 404 RIDING, PACKING, AND DRRING Hold the whip at an angle of about 30° to the left and about 40° upward. The thong ought to have three or four turns round the handle. The point of tlie thong should be just under the inside of the thumb; this will keep it from slipping. Hold the whip where it will balance comfortably, the end of handle under the forearm, the wrist well bent, and the elbow dose to the side. 415. \\'hen the right hand is on the reins or using the whip, it should be kept close to the left, the forearm being nearly horizontal. It can then rest on the thigh and yet be ready for any emergency. 416. The wheelers should be hit in front of the saddles, to avoid ■making them kick. It is no use hitting the wheelers if the leaders' reins are too long. In this case you must first shorten up the wheelers' reins, and then use the whip on the leaders ; otherwise, as soon as the wheelers have jumped into their collars, the leaders will again press forward and allow the wlieelers to hang back as before. 417. The proper hitting of the leaders with the whip can only be acquired by constant practice when off the wagon. A good whip can hit his leaders wherever he desires and without the dangerous, flail-like swipes that some teamsters appear to consider necessary. TO START 418. Feel all the animals' mouths, and, if necessary, give them the word to go, dropping the hand to them at once until the vehicle is fairly off. The wheelers ought to start the wagon, and this can be eft"ected by touching them with the whip, if they require a hint. It is never safe to start without having the whip in the right hand, ready for immediate use. The whip is to the driver what the leg is to the rider, that is, it keeps the team up to their bits. As soon as the team is going straight, take the right hand off the reins, at the same time keeping it close by, ready for any emergency. PULLING UP 419. When you want to pull up, shorten all the four reins by passing the left hand up to the right, or else by pulling all the four reins through from behind, as before explained ; then, having tlie right forefinger on the near lead rein, the middle finger on the near( wheel, and the lower fingers of the right hand on the off reins, pull both hands back toward the body, and if necessary lean back a little. DRRIXG 405 Should the team be getting the better of you, and you find that you can not stop it, it will be found a great assistance to place the right leg over all the four reins, as you may be able to stop them by the extra power and leverage by the position of th leg. Of course, it is understood the brake has been applied. A FEW HINTS 420. Always keep a steady pressure on the reins. Never move left hand from reins, even though the right may be holding them in front, as it is very difficult to get the left hand back into its place again with the reins in the right places. Lead reins should seldom be removed from left hand. Grip the reins tightly with the third and little fingers to prevent thek slipping. Alter position of the bits if the team pulls hard. See to it that your wagon is always well greased. Always take a pull at the team to steady it just before you arrive at the crest of a hill, and begin to descend slowly, holding the leaders steady, and with just enought traction to keep their singletrees from hitting them. In crossing ruts and turning corners be careful that the leaders are out of draft ; otherwise the pole may be snapped off or the wheelers pulled down. If, while going down a hill, and especially when near the bottom, you find a wheeler slipping on his hocks, do not try to pull him up, but drop the hand and allow the team to go a trifle faster. RULES OF THE ROAD 421. Always keep to the right when meeting vehicles. On a narrow road a loaded team has the right of way, and it should be given ungrudgingly. On overtaking a vehicle, pull out to the left and pass it at a steady- pace and without cracking your w'hip or coming in too close. When followed closely by another vehicle and both are at a good pace, signal with your whip if you are about to slacken your gait or change your direction. When approacb.ing a railroad crissing. bring your team to a walk ; halt if necessary, but always look and listen. Re courteous in observing the simple rules of the road ; give plenty 406 RIDING, PACKING, AND DRIVING of room to others, and do not forget tliat a smile or a pleasant laugh will do more for you than a growl or a surly remark. Horsemen, as a lule, possess good dispositions; meet them at least half-way. CARE OF DRAFT ANIMALS IN THE FIELD 363. Constant and intelligent supervision of adjustment of the bearing parts of harness, packs, and saddles is productive of better results than medication in keeping" transportation animals in service- able condition. 364. In preparing for the field it is well to bear in mind that nearly all animals in a command lose flesh rapidly for the first ten days of a march, and that during this period the adjustment of all parts of the harness, more especially the collars, should be given close attention. 365. If the march should happen to be a continuous and a sever one, it may be noticed that about the sixteenth day draft animals appear suddenly to become very lean in the muscles of the shoulders, back, abdomen, and croup. If a fair amount of forage is avaiable they cjuickly improve to a certain point, where they remain station- ary and continue to do hard work without noticeable change under an intelligent system of watering and feeding. They are now in v.'orking condition. 366. J rater on the march whenever a good opportunity to do so presents itself, never forgetting, however, that a warm animal should be watered but sparingly, and that such a watered animal should not be allowed to remain stationary even for a few minutes, as this induces laminitis ( founder), due to contraction of the internal blood vessels by the cold water taken and the consequent increase of blood pressure in the legs and feet where it can not. while the animal is inactive, be taken care of by the system. Laminitis (founder) is due to congestion of the feet. ^6"/. Fecdius:;. — Soon after reaching camp, ofifer a little hay. Water before feeding grain when possible. OfTer grain immediately after watering, and then place before the animals what remains of the hay for that day. The morning watering must of necessity be governed by circumstances. If absolutely sure of water on the road, say one hour after breaking camp, it would be a needless waste of time and energy to water immediately before or after the morning feed on the line. 368. Midday baiting. — As little as i pound of grain per animal. DRIXIXG 407 taken from the daily allowance and given in charge to each driver, fed at the noon halt, will have a wonderful effect for good on the animals of a command. At this halt the careful driver will add a few handfuls of grass, and at the same time look over his collars and breeching with a view to their readjustment. 369. Collars of steel are preferable to leather for military use when properly adjusted and cleaned. When improperly adjusted they are inferior to the leather article. Steel collars are adjusted by means of bolts and plates. Leather collars by means of top straps and hames. When these methods will not produce the desired results the use of collar pads must be resorted to. Felt collar pads are not desirable, as they soon become stiff and hard. A collar shbuld fit snugly to the sides of the neck without com- pressing it, and its bearing surface should rest squarely on the bed of muscles situated on the front of the shoulder. A\'hen in position there should be a space between its lower part and the windpipe sufficiently large to comfortably admit the insertion of the open hand, back up, as far as the wrist. All collars should be furnished with a neck plate of zinc for the protection of the top of the neck against rubbing. To prevent blistering of the top of the neck on hot, sunny days it will be found that wet sponge or a wet piece of folded gunny sack, properly secured to the top of the collar and wetted at intervals, is effective. The bearing surface of steel collars should not be scraped unless considered absolutely necessary to remove accumulated dirt due to negligence. If scraped they should be boned smooth and then slightly oiled. Leather collars may be easily cleaned with a damp sponge. They should be thus cleaned each evening. A careful man will not let his collars remain on the ground overnight, but will hang them on the pole, or put them in some safe place where he will protect them from the rain and the dust of the camp. 370. Alecks and shoulders. — On arrival in camp let collars remain in position for about 15 minutes. Their weight on the hot. tender skin affords sufficient pressure to prevent the formation of swellingN so often observed after the collar is suddenly removed. Normal, circulation will establish itself gradually under collar pressure alone and the skin of the shoulders and neck will regain its tone and elasticity. 408 RIDING, PACKIXG, AND DRIVING After removal of the collar, bathe the shoulder and neck with clean water ; this to remove sand and dust that would otherwise remain in the hair, where it may not be reached with the horse brush. Salty water, or a weak solution of vinegar in water, when applied to the shoulders and neck, acts as a tonic to the jaded skin. Animals with narrow, lean shoulders should not be placed in the collar. For these, if they must be harnessed, a breast strap (Dutch collar) should be used.' When putting- on a collar, see that the mane hangs naturally beneath the neck plate. If the collar is a steel one, be careful when snapping it in place that the skin of the upper part of the neck is not pinched between the neck plate and the collar itself. If swellings appear on the shoulders, use massage to remove them, and in addition apply a cold-water pack during the night ; a wet sack properly adjusted and held in place will answer the purpose. If a gall appears, do not grease it. Wash it with water and soap, dry thoroughly, and apply a weak solution of alum (one-half ounce to a pint of water) or a solution of aloes in water (one-half ounce to the pint). If the animal must be worked, use a chambered (cut-out) pad over the spot to remove pressure. Greasy ointments serve as a trap for dust and sand. 371. Traces. — \'erify the length of traces frequently. Do not depend on the chain links as a guide in hitching. Leather traces stretch considerably in wet weather. A difterence of half an inch in the length of traces will cause trouble on the shoulder of the .shorter side. It is also liable to produce lameness due to irritation of extensor muscles. If the point of attachment of the trace to the collar should be too high, it will cause a downward pull on top of neck, with its consequent irritation. If too low, it will cause the collar to '' ride." and nearly all the pressure will be on the point of the shoulders and on the windpipe. The number of sore-shouldered draft animals in a command on the march is an excellent standard by which to judge the horseman- ship of the personnel. 372. Breeching. — The breeching should be fairly loose, otherwise it is liable to chafe the quarters and to interfere with the free play of the muscles. It should be taken up as the animals become thin. Martingales should not fit too snugly, as they are very liable to chafe the soft, thin skin of the under part of the body. DRIVIXG 409 373. Yoke straps should be adjusted with a view to the height of the pair. They should never be permitted to trespass on the bearing surface of the collars. 374. Back St raps should be so adjusted as not to let the saddles ride the withers, but at the same time there should not be sufficient strain on them to cause the crupper to irritate the under part of the tail. 375. Bellybands and cinchas should never be unduly tightened, a-; they cause cinch sores near the elbow and quarterstrap sores beneath the ring shields. When a cinch gall appears, remove the cause, keep the place clean, and apply a solution of aloes or alum in water. Either of these will stimulate the gall and deter insects from alighting on the wound. 376. Bearing reins should be of such a length that the animals may have free use of the muscles of head and neck. Bearing reins are not a necessity. 377. A driving bit should be smooth and jointed. It should be so adjusted that it will not lift the corners of the mouth. If placed too high in the mouth, the animal uses his molar teeth to press against it, and gains for himself the reputation of a hard-mouthed puller. 378. Beware of thread ends in collar pads and of knots in head- stalls, throatlatches, bellybands, cinchas, and surcingles, and be care- ful that buckles are not turned toward the skin. These readily pro- duce irritations and abrasions, and are plain evidence of negligence and carelessness on the part of the rider or driver, as well as loose supervision on the part of those superior in rank. 379. To keep his animal in the collar and off the lead line should be the aim of each driver. This can be accomplished with little trouble, barring accidents, if the harness is kept in proper shape and fit and necks and shoulders are kept clean. Wagons in the field should be inspected at the end of each day's m.arch. and, if practicable, all necessary repairs made promptly. Particular attention should be given to discovering the loss of nuts and to replace the missing: a good supply of nuts and a few extra bolts should be carried in the tool box. The axles should be greased daily and care taken to remove the old before putting on fresh urease. 410 RIDING, PACKIXG, AND DRIXIXG List of articles carried on each wagon : Number Axe, front of wagon i Axle nuts, in tool box 2 lUicket G. I., under rear of wagon i Sponge, in tool box I Currycomb and brush, in tool box I Cases axle grease, in tool box 2 Extra hames, in tool box 2 Lantern, in water bucket i Wagon wrench, in tool box i Open links, in tool box 3 Pole, on side of wagon i Reach, on side of wagon i Pickax, on side of wagon i Three-eights or one-half inch rope, on side of wagon, ft 150 Spade, on side of wagon i Ilame straps, in tool box 3 Hame strings, in tool box 3 Shoe for each foot of each animal, previously fitted, in Uk>\ box. i Horse-shoe nails, in tool box Singletrees, under wagon 2 Doubletree, under wagon i Ball strong twine for harness repairs I Harness: The harness should be examined daily, and any defect or weakness should be repaired at once. \\'hen removed from the animals at night, harness should be placed where it will dry and not be thrown upon the ground. The collars should be carefully wiped off and the dirt removed from the remainder as far as practicable. Harness should be thoroughly cleaned at least twice a month. For this purpose use a bucket, lukewarm water, sponge, harness soap, harness dressing, neat's-foot oil. and lampblack. For ordinary cleaning, the following should be observed : Provide a rack to hang the harness on. XMien no lietter arrangement is at hand, insert one end of the wagon pole between the spokes of one of the hind wheels, above the hub. Strap it to the axle and hang the harness on the ])ole. Dampen the sponge in water and pass it over the harness until th.e dirt has become soft. Rinse out the sponge as often as DRIVING 411 necessary, renewing the water when it is dirty. Then rub the sponge on the harness soap until a good lather is obtained, and give the harness a good heavy coating of it, and rub it until all dirt is removed. Then work up a thick soap lather, coat the leather part of the harness with it, and allow it to dry without further rubbing. \\'hen dry, put on a light coat of harness dressing with a clean sponge, touch lightly, only enough to spread the dressing, and do not rub. When harness is dry and hard from neglect, after cleaning as above, take a pint of neat's-foot oil for each single set of harness, pour the oil into a pan and mix it with lampblack in proportion of one teaspoonful to each pint of oil. Stir this mixture until it has a glossy black appearance. In cold weather the oil siiould be warm. Apply with a small sponge, rubbing it well in. When thoroughly dry, apply harness dressing as previously described. PART IX ARMY REGULATIONS All soldiers are required to be familiar with so much of Army Regulations and the Articles of War as is contained in the Soldier's Handlwok. The following course is for noncommissioned officers and candi- dates for these grades. MEDICAL DEPARTMENT THE HOSPITAL CORPS 1404. The members of the Hospital Corps will be enlisted for and permanently attached to the Medical Department. In time of war the corps will perform the necessary ambulance service under such officers of the Medical Department and assistants as may be detailed for that duty. 1405. Sergeants, first class, and sergeants are appointed by the Secretary of War on the recommendation of the Surgeon General, after having passed a satisfactory examination as hereinafter pre- scribed. Corporals, lance corporals, and privates, first class, upon recommendation of their detachment or organization commanders are appointed (i) by the Surgeon General, if serving with troops under the immediate supervision of the War Department; (2) by the department surgeon or by the division surgeon of a mobilized division, if serving with departmental or divisional troops. Acting cooks are appointed by the commanding officer of a company or detachment of the Hospital Corps in such numbers as are allotted to the company or detachment by the Surgeon General, or by the department or division surgeon, by authority of the Surgeon General. Sergeants, first class, and sergeants are given warrants signed by the Surgeon General." Corporals are given warrants signed by the (413) 414 ARMY REGULATIOXS officer who appoints them. Ordinarily a warrant issued to a non- commissioned officer of the Hospital Corps confers grade under all assignments; but a limited warrant may be issued conferring grade for service only with a field hospital company, ambulance company, or company of instruction designated therein. Upon relief from assignment to such companies a limited warrant ceases and deter- mines, and the noncommissioned officer holding the same reverts to his previous grade in the Hospital Corps. No person shall be designated for examination for appointment as sergeant, first class, except by written authority of the Surgeon General. The candidate must have served as a sergeant not less than twelve months or as a hospital steward of volunteers or have acted in that capacity during and since the war with Spain for more than six months. No person shall be designated for examination for appointment as sergeant except by written authority of the Surgeon General, if serving with troops under the immediate super- vision of the \\^ar Department, or of the department surgeon, or the division surgeon of a mobilized division, if serving Avith depart- mental or divisional troops. The examination of a candidate for appointment as sergeant, first class, or sergeant will be conducted by a board of medical officers at the station where the candidate is serving. H the proper number of medical officers to constitute the board is not available at the station of the candidate he will be sent to the nearest station where a board can be convened. \Mien the examination is for a limited warrant, the commanding officer of the organization in which the candidate is to serve will constitute the board. In all cases the report of the board will be forwarded directly to the officer authorizing the examination. The allowance of enlisted men of the Hospital Corps of each grade as fixed by regulations and orders will not be exceeded, except by special authority of the Secretary of War. The proportion of privates, first class, to privates will not exceed two to one. 1406. A sergeant first class stationed at a place where no post return is made will make such personal reports as the Surgeon General may direct. 1407. Sergeants first class, though liable to discharge, will not be reduced. Sergeants, corporals, lance corporals, and privates first class may be reduced by sentence of a court martial, by the Surgeon MEDICAL DEPART.MEXT 415 General, by a department surgeon, or the division surgeon of a mobilized division. 1408. To test the capacity of privates of the Hospital Corps for the duties of noncommissioned officers, the Surgeon General and chief surgeons may api)oint lance corporals, who will be obeyed and respected as corporals ; but no detachment shall have more lance corporals at a time than enough to make the proportion of all noncommissioned officer's present for duty one to four privates of the Hospital Corps. Lance corporals are on the same footing regarding reduction as croporals. 1409. The commander of a field army, or of a division or brigade acting independently, is charged with the full control of the transfer from the line, the enlistment, reenlistment, and discharge of members of the Hospital Corps of his command. 1410. Enlistments for the Hospital Corps will be made in the grade of private. Sergeants first class, sergeants, corporals, lance corporals, and privates first class may be reenlisted in their re- spective grades and their warrants and appointments continued in force, provided they reenlist on the day following that of discharge. Each enlistment and continuance will be noted on the warrant or appointment by the surgeon. Recruiting officers at general recruit- ing stations may accept applicants for enlistment or reenlistment in the Hospital Corps upon the authority of the Surgeon General and will be guided by his instructions in making the physical examination of such applicants. Applicants may be accepted with a vision of 20/70 in each eye, correctible to 20/40 with glasses, provided that no organic disease exists in either eye. After enlistments recruits will be forwarded to such stations as may have been designated for them by the Surgeon General. 141 1. Enlisted men of the line, musicians excepted, may be trans- ferred to the Hospital Corps as privates by the commander of a division, separate brigade, or department, on the application of the surgeon of the post or command, forwarded through military chan- nels. The application will state the age, character, physical con- dition, and habits of the soldier, date of expiration of current enlistment, and whether made for an existing or prospective vacancy. li the soldier be over forty years of age his special qualifications for transfer will be stated. 1412. Married men will not be enlisted as privates in or trans- 416 ARMY REGULATIONS ferred to the corps, and no sergeant who is married shall be rc- enlisted without special authority. 1413. Members of the corps will not be required to perform any military duties other than those pertaining to their corps. They will be instructed in such drills, both foot and mounted, as are necessary for their efficiency. They will not be required to attend ceremonies, except when directed by the commanding officer, and will ordinarily be inspected and mustered at the hospital. The forms of inspection will be in accordance with the prescribed drill regulations for the Hospital Corps. 1414. To meet the requirements of epidemics or other emergen- cies and to fill vacancies, members of the Hospital Corps may be transferred by the department commander, the quota of each post, as prescribed by paragraphs 1439 and 1440, not being permanently exceeded. Such transfers will be reported to the Surgeon General. 1415. Accounts of pay and clothing of members of the Hospital Corps will be kept by the surgeon under whose immediate direction they are serving. All members casually at a post, camp, or other station, are under the immediate orders of the surgeon except prisoners, who will, however, be borne on the muster rolls, morning report, and returns of the hospital corps detachment. If discharged, their final statements will be prepared by the surgeon. 1416. At every permanent military post there will be at least one noncommissioned officer of the Hospital Corps, and an additional noncommissioned officer for every additional four privates of the Hospital Corps. 1417. At every permanent military post there will be at least four privates of the Hospital Corps, six privates when the strength of the garrison is 200, and two privates additional for every additional 100 of strength. They will be assigned to the respective duties con- nected with the hospital service by the surgeon of the post. 1418. The number of noncommissioned officers and privates of the Hospital Corps to be stationed at general hospitals, arsenals, engineer stations, and independent posts will be determined by the Surgeon General under the direction of the Secretary of War. 1419. Special instruction in the methods of rendering first aid to the sick and wounded will be given to all enlisted men of the Signal Corps and of the line of the Army by their company officers for at least twelve hours in each calendar year. MEDICAL DEPARTMENT 417 1420. All men of the hospital corps will be instructed under the supervision of the surgeon of the post in the duties of litter-bearers and the methods of rendering first aid to the sick and wounded, and in the various subjects pertaining to the sanitary soldier. GARRISON AND FIELD SERVICE 1427. Ambulances are vehicles provided for the service of the medical department. They will be furnished and repaired by the Quartermaster Corps. They will be used only for the following purposes : The transportation of the sick and wounded and the absolutely necessary nurses or attendants on duty therewith ; the recreation of convalescent patients ; the instruction of the Hospital Corps in the duties of the ambulance service, and in the field in urgent cases, for the transportation of medical supplies. All persons are prohibited from using them, or requiring or permitting them to be used for any other purpose. Ambulances will always be subject to the call of the surgeon, in garrison, and of the medical officer on whom responsibility for the transportation of the sick devolves, in the field, whose duty it shall be to report to the commander of troops any violation of the above-mentioned provisions governing their use. When practicable, in garrison, they will be housed near the hospital. 1428. Ambulances complete will be issued and classed as follows : 1. For mobile army troops, to accompany troops in the field. 2. For post purposes exclusively, c. g., for Coast Artillery sta- tions, recruit depots, certain mobile army stations which would require ambulance service after withdrawal of mobile army troops therefrom, military prisons, supply depots, etc. Department com- manders will see that such of these posts as require ambulance service are provided with ambulances which do not belong to the divisional or other sanitary train of the mobile army. 3. For general hospitals and for reserve supply. Ambulances under class i will be furnished in numbers pre- scribed for war basis in Tables of Organization ; under classes 2 and 3 the number of ambulances to be supplied will be determined by the War Department on recommendation of the department com- mander as regards class 2, and of the Surgeon General, as regards class 3. 1429. At each post one or more privates of the detachment Hos- 27 418 ARMY REGULATIONS l>ital Corps will be designated by the surgeon as ambulance driver ( nly for ambulances not l^elonging to organized anil)ulance com- panies. In addition to his other duties he will care for the ambu- lance, its equipment, and harness, and see that they are ready for immediate use; and in the field he will care for the animals also. In garrison, when it is necessary to use the ambulance for any transportation purposes, the commanding officer, on the ai)plication of the surgeon, will see that the requisite animals are provided by the quartermaster and placed at the disposal of the surgeon. At sta- tions of organized ambulance companies, class 2 ambulances may be used for garrison ambulance service or the ambulance company may furnish the garrison ambulance service, at the discretion of the post commander. 1431^. Transportation assigned to mobile army troops for sani- tary purposes is classed as follows : 1. The sanitary combat train. (A pack mule to carry equipment for the regimental aid station.) These pack mules are pro\-ided in time of peace and are assigned to the organizations indicated in the Tables of Organization. They will be placed at the disposition of the surgeon when needed for drill of the Hospital Corps in, packing, and will habitually accompany the combat train of the organizations to which they are assigned, both in peace and war. 2. Ambulances of class i, paragraph 1428. These are marked with the words " Sanitary Train Division," and with the number of the ambulance company to which assigned. Ambulance companies operated in peace are equipped with their quota of ambu- lances, and the remaining ambulances of the divisional sanitary train are attached in time of peace to combatant organizations of the division by the department commander. Ambulances so attached are available for garrison service in peace when required, as well as ambulances of class 2, and will be cared for by ambulance drivers designated by the surgeon. When the division is assembled, these ambulances accompany the organizations to which attached, join the companies to which they are assigned, and complete the ambu- lance equipment of the sanitary companies not operated in time of peace. 3. Wagons pertaining to the divisional sanitary train. These will be marked with the words " Sanitary Train Division " and the number of the company to which assigned. Companies belong- MEDICAL DEPARTMENT 419 ing to the sanitary train which are operated in peace are equipped •with their quota of wagons. In addition, wagons of the divisional sanitary train are attached to combatant organizations, as prescribed in Tables of Organization, for the transportation of the camp in- firmary. When the division is assembled these wagons accompany the organizations to which attached and join the sanitary companies to which assigned. 1433. Hospital Corps personnel is classified as follows : 1. That portion attached to combatant organizations 2. That portion assigned to units of the divisional sanitary train and to administrative offices in the field. 3. That portion assigned to the service of the interior for service in war, which should include only the minimum of trained men. All men of the Hospital Corps will be carried on muster rolls and returns of the Hospital Corps, under " Remarks," as attached to a definite combatant organization, or as belonging to a unit of class 2, or to class 3. Department commanders will determine, on recom- mendation of the department surgeon, the numl)er of men at each post or station to be assigned to each class, within the limits pre- scribed in Tables of Organization, and the individual men will be assigned to their respective classes and those of class i attached to organizations of mobile troops by the post commander on recom- mendation of the surgeon. Descriptive lists of men of the Hospital Corps of classes i and 2 will be kept in duplicate at posts, and all other papers required when sanitary personnel accompanies troops to which attached, will be prepared in advance so far as practicable, ^ledical officers assigned to stations of mobile army troops, except those on duty with ambulance or field hospital companies, will be similarly attached to organizations [)y the post commander on recom- mendation of the surgeon. Combatant organizations will carry attached sanitary trot ps in red ink on their muster rolls and returns. 1434. On the march each medical officer will habitually be attended by a mounted private of tiie Hospital Corps. Riding horses author- ized in Tables of Organization will not be permanently allowed and assigned in time of peace for Hospital Corps men attached to com- batant organizations. When practicable, the Quartermaster Corps will furnish horses for members of the Hospital Corps on duty in the field who are authorized to be mounted. 1437. No person, exce])t the proper medical officers or the officers, 420 ARMY REGULATIONS noncommissioned officers, and privates of the ambulance service, or such persons as may be specially assigned by competent military authority to duty therewith, will be permitted to take or accompany sick or injured men to the rear, either on the march or elsewhere. 1438. When members of the hospital corps are detailed for ser- vice in the field during Indian wars, or when left with the sick or wounded under circumstances which justify the expectation that their rights under the Geneva Convention will not be recognized, commanding officers will issue to members of the Hospital Corps revolvers or other available firearms. GENERAL HOSPITALS 1439. General hospitals will be under the exclusive control of the Surgeon General and will be governed by such regulations as the Secretary of War may prescribe. The senior medical officer on duty therein will command the same and will not be subject to the orders of local commanders other than those of territorial depart- ments to whom specific delegation of authority may have been made. The commanding officer of a territorial department may order to any general hospital located within the limits of his department and to the General Hospital at Fort Bayard, N. Mex., any cases of sick- ness and injury among officers and enlisted men under his command that are appropriate for treatment at such hospital. Officers and enlisted men on the active list of the Army who shall have been transferred to a general hospital for treatment only will, when fit for duty, be returned to their proper posts or commands by the commanding officer of the hospital, unless he shall have been other- wise instructed. 1440. Hospital transports, boats, and railway trains, after being pro]3erly assigned as such, will be exclusively under the control of the Medical Department, and will not be diverted from their special purposes by orders of local or department commanders or officers of other staff corps. SERVICE OF HOSPITALS 1447. The senior surgeon is charged with the management and is responsible for the condition of the hospital, which will be at all times subject to inspection by the commanding officer. The senioi MEDICAL DEPARTMENT 421 surgeon of the post will inspect the hosjiital every morning, and on Saturday will also inspect the detachment of the hospital corps. 1450. Patients will, if possible, leave their arms and accouter- ments with their companies. 145 1. Whenever a soldier is detached from his company or other organization or station for treatment or observation by and under control of officers of the Medical Department, his company or other immediate commander will send the soldier's descriptive list direct to the medical officer in charge of the hospital or other place to which the soldier is or has been sent. If the list is not received by such medical officer in due time, he will make a direct call upon the proper officer to furnish the list. If no change occurs in the soldier's military status or accounts while he is under control of the Medical Department, his original descriptive list will be transmitted to the several officers under whose charge he comes in the course of sub- sequent transfers, should such ensue, from hospital to hospital, by hospital ships, hospital trains, or otherwise, or when he is sent to an organization or station for duty. In case the soldier is returned or sent to, or receives a furlough at the expiration of which he is to return to or join, a particular company or other organization or station, the list will be sent directly to the immediate commander of such company or other organization or station. \\'hen an original descriptive list is transmitted as hereinbefore directed, it will be transmitted within, and by successive indorsements upon, a wrapper whereon each responsible officer will state expressly that there has been no change in the soldier's military status or accounts since he came under the charge of that officer, will specify the period covered by that statement, and will state what disposition was made of the soldier. Each officer so transmitting a descriptive list will retain a proper record of his action. If, however, changes occur in a soldier's military status or accounts while he is detached from his company or other organi- zation or station and is under the control of the Medical Depart- ment, the responsible medical officer will at once open a new descrip- tive list from the data shown on the old descriptive list received from the officer last previously responsible in the case, and will make such additional entries on the new list as the facts may require. For his own protection, the officer making the new list will retain and file, with the records of the place at which the new list is made. 422 ARAH' REGULATIONS the old list with its wrapper, if there is any, bearing the indorsements of officers previously responsible. If subsequent transfers of the same soldier are made before or when he passes out of the control of the Medical Department, the new list so opened will be closed by the proper entries thereon and filed w^ith the records of the place at which it was made, and a duplicate of the list so fded will be transmitted from each responsible officer to another by wrapper indorsement, as hereinbefore prescribed, so long as no change in the list is required. Whenever a soldier detached from his company or other organi- zation or station and under control of the Medical Department passes out of that control, his descriptive list (new or old, as the case may require under the foregoing provisions of this paragraph) will be forwarded at once by the responsible offxer as follows: (a) In case of discharge, death, retirement, capture, desertion, return to duty, or upon receiving a furlough at the expiration of which the soldier is to return to his company or other organization or station, or upon being dropi)ed, to the soldier's company or other immediate commander; (b) in case of transfer to another company or other organization or station, the list (new or old, as the case requires) to the immediate commander of the company or other organization or station to which, and a copy of the list, including copies of any wrapper indorsements pertaining thereto, to the immediate com- mander of the company or other organization or station from which, the soldier is transferred; (r) in case of transfer to the Government Hospital for the Insane, to the Adjutant General of the Army. In the cases of soldiers detached from their comjianies or other organizations or stations and under the control of the Medical De- partment action will be taken by the proper medical officers as follows: If a soldier is discovered to be a deserter from the Navy or Marine Corps, paragraph 133 will be complied with; if a soldier is discharged, final statements will be furnished him; if a soldier dies, paragraph 162 will be complied with. 1452. Sick or wounded soldiers, discharged while in hospital, will be entitled to medical treatment in hospital, and to the usual ration during disability, or for the period considered proper for them to remain under treatment, but a discharged soldier who has left the hospital will not be readmitted except upon the written order of the commanding officer. MEDICAL DEPART:vIEXT 423 1453. Recently discharged soldiers, needing hospital treatment, who arrive in New York City, San Francisco, or other port on Government transports, may be sent to one of the military hospitals in the vicinity, and rations in kind drawn for them while undergoing treatment. 1454. Tents, clothing, hospital furniture, and other stores used in the treatment of contagious diseases, will be disinfected or burned upon the recommendation and under the supervision of a medical officer. 1455. The Secretary of War may, on the recommendaiton of the Surgeon General, order gratuitous issues of clothing to soldiers who have had contagious diseases, and to hospital attendants who have nursed them, to replace articles destroyed by order of the proper medical officer to prevent contagion. 1457. Civilian employees at military posts, including employees of post exchanges, may be furnished the medical supplies prescribed for them by a medical officer under such regulations as the Surgeon- General may establish in accordance with law. 1458. A civilian employee on duty at a station where other than army medical attendance cannot be procured is entitled, when necessary, to admission to hospital. 1462. The surgeon of a post or command, or the commanding offi- cer of a general hospital or other sanitary formation, will keep, account for, and expend the hospital fund, according to the instruc- tions of the Surgeon General, exclusively for the benefit of the sick in hospital and of the enlisted men of the Hospital Corps and mem- bers of the Nurse Corps on duty therein. HOSPITAL BUILDINGS 1466. When alterations of or additions to hospitals are necessary the surgeon of the post, after obtaining from the quartermaster an estimate of cost, will transmit plans and specifications, with proposed modifications, through military channels, to the Secretary of War. Similar action will be taken upon quarters for sergeants first class. 1468. Estimates for new construction, betterments, and repairs in connection with hospitals, Hospital Corps sergeants' quarters, and other buildings, structures, and systems payable from the appro- priation for " Construction and repair of hospitals " or " Hospital stewards' quarters " will be prepared separately, but in the same 424 ARMY REGULATIONS manner and forwarded at the same time as the estimates pertaining to other appropriations of the Quartermaster's Corps. These estimates will be prepared by the quartermaster, to whom the surgeon will furnish in writing a statement showing the items required. When the work has been completed the surgeon will report to the Surgeon General whether or not it was performed according to the estimate and will furnish to him a statement showing the material and balance of allotment remaining. Approved plans or estimates for construction or repair will be altered only by authority of the Secretary of War. SICK CALL 1471. At sick call the enlisted men of each company who require medical attention will be conducted to the hospital or infirmary by a noncommissioned officer, who will give to the attending medical officer the company-sick-report book containing the names of the sick. The medical officer, after examination, will indicate in the book, opposite their names, the men who are to be admitted to hos- pital and those to be returned to quarters, what duties the latter can perform, with any other information in regard to the sick which he may have to communicate to the company commander. The senior medical officer of the command will make a daily report of the sick and wounded to the commanding officer. MEDICAL ATTENDANCE 1473. Medical officers and contract surgeons on duty will attend officers, enlisted men, contract surgeons, contract dental surgeons, members of the Nurse Corps (female), prisoners of war and other persons in military custody or confinement, and applicants for enlistment while held under observation ; also, when practicable, the families of officers and enlisted men ; and at stations, or in the field, where other medical attendance can not be procured, civilian em- ployees. Medicines will be dispensed to all persons entitled to medical attendance, and hospital stores to entlisted men and hospital matrons, also to officers at posts or stations where they cannot be procured by purchase. 1474. Medical officers and contract surgeons at their stations will furnish medical attendance to officers and enlisted men on the MEDICAL DEPARTMENT 425 retired list, but they will not be required to leave tbcir stations for that purpose. Medicines, dressings, etc.. will be supplied to retired officers and enlisted men from army dispensaries on medical officers' prescriptions. MEDICAL SUPPLIES 1487, The routine issue of disinfectants is prohibited. 1488. Damaged or unserviceable medicines, medical books, sur- gical or scientific instruments and appliances, pertaining to the Medical Department, will not be presented to an inspector for con- demnation until authority for so doing has been obtained from the department surgeon, or, if with a mobilized division, from the division surgeon. ARTIFICIAL LIMBS 1490. Every officer, enlisted man, or employee of the military forces of the United States who. in the line of duty, or through dis- ease contracted in service, shall have lost a limb, or the use of a limb, will receive once every three years an artificial limb or appli- ance, or commutation therefor, if he shall so elect, under such regulations as the Surgeon General of the army shall prescribe. The money value allowed as commutation is, for a leg. $75 ; for an arm, foot, and apparatus for resection. $50. 1491. Necessary transportation, including sleeping-car accommo- dations, required for travel to place where artificial limbs may be fitted, will be furnished by the Quartermaster's Department, the cost to be refunded from any money appropriated for the purchase of artificial limbs. 426 GENERAL MEDICAL ADMLNISTRATIOX MANUAL FOR THE MEDICAL DEPARTMENT Part I — General Medical Admixlstration ARTICLE II — EDUCATION AND TRAINING Field Hospitals and Ambulance Companies 157. A limited number of field hospitals and ambulance com- panies are maintained in time of peace to provide trained organiza- tions for duty with the troops when they are on field service and to afford a means for training officers and men of the sanitary service in the work of the sanitary field organizations. So far as practi- cable men trained in these organizations should constitute that por- tion of the Hospital Corps personnel at posts which is assigned to units of the divisional sanitary train on mobilization. (See Army Regulations: Hospital Corps.) In the training of these organizations special attention should be given to those elements of field work for instruction in which only limited facilities are afforded at posts, such as the practical use of the articles of field equipment, lines of aid, equitation, care of animals, and the use of the pack saddle. 158. The personnel of these organizations in time of peace com- prise two classes : (i) A permanent cadre, consisting of such num- ber of noncommissioned officers and men as are deemed necessary to maintain continuity of policy and method in instruction; (2) tem- porary personnel attached to these organizations for purposes of instruction. (a) Details of organization of field hospitals and ambulance com- panies are given in Tables of Organization. 163. Records of class work will be kept for each individual in each subject of the course, preferably upon loose sheets appropriately ruled or in a blank book adapted to the purpose. (a) The relative standings of men pursuing the same courses, as determined by their average monthly standings, will be published monthly to their respective classes. 164. Privates first class and privates who obtain a final mark of 70 per cent in each subject of the course, will be given certificates of proficiency on Form 60. (a) Any man who, after two months' instruction, shows such MEDICAL DEPARTiMF.XT 427 mental incapacity and inaptitude as to render his further attendance on this course of instruction useless, will be reported to the Surgeon General for his action. (b) Men who fail to attain proficiency in any subject may, in the discretion of the officer in charge of instruction, be required to go over the subject again. 165. Enlisted men of the permanent personnel who shall have taken the prescribed course and obtained certificates of proficiency will not ordinarily be required to take the course again ; but should it subsequently appear probable that any such enlisted man, having a certificate of proficiency, is nevertheless not proficient in one or more of the subjects, he may be required to take the course therein once more. If upon the second course the soldier does not show proficiency, his former certificate will be canceled by writing across its face the words: "Canceled for failure to qualify in (naming the subject or subjects) on second course, to , 19 ." This notation will be signed by the officer in charge of instruction. Failure to qualify on such second course will be reported at once to the Surgeon General with a view to securing the soldier's transfer to post duty, it being the aim of the department to retain in the permanent personnel only such qualified men as will be a constant example of efficiency to the men of the temporary personnel attached for instruction. Should, however, the soldier taking such second course in whole or in part be again found pro- ficient a new certificate of proficiency will not be given him, but a notation of the facts will be made in his descriptive list. A third course will be required in no case. Lack of efficiency in practical work after a second course will indicate the necessity of other measures of discipline. DISCIPLINE AND DUTIES OF THE SOLDIER 168. Instruction in discipline — including character, conduct, mili- tary bearing, obedience, and general efficiency — is to be taken up at once when the recruit joins the detachment, and never ceases, being given by commissioned and noncommissioned officers in connection with the soldier's daily round of duties and continued as long as he remains in the service. 169. Instruction in the duties of the soldier will cover the Article^ of War. the soldier's handbook, the orders and regulations in regard to saluting, the granting of indulgences, arrest and confinement, the 428 GENERAL MEDICAL ADMLXISTRATION wearing of uniforms, etc. Besides the few hours of formal teaching provided for in the first regular winter course in garrison every opportunity should be taken at all times to impart information in these various subjects. BEARER DRILL AND FIELD WORK I/O. Instruction in drill and field work will be given throughout the year for one hour a week. All members of the detachment will attend it unless excused by the surgeon for some special reason. (a) This instruction includes all the subjects in Part I of the Drill Regulations and Service Manual for Sanitary Troops and all the usual employments of fieldwork, especially — Uses of the first-aid packet. Uses of other articles of the individual equipment of the Hospital Corps soldier. First-aid treatment of fractures in all regions of the body. The methods of transporting wounded in peace and in war. Organization of the ambulance company. Work of the ambulance company during an action. Establishment of aid and dressing sta- tions. Collection, care, and transportation of the wounded from the firing line to the field hospital, with the tagging of patients and the treating of them as indicated, using first-aid equipment and extemporized materials. Use and care of articles of field hospital equipment. Pitching and striking tentage and packing field equipment. 171. Full advantage should be taken of the summer marching and encampment of troops to impart the above instruction. (a) Occasionally, throughout the year, all available men should be taken out for marches with and without the litter. CARE OF ANIMALS AND EQUITATION 172. Men of the Hospital Corps will be instructed in the care of animals and in equitation as prescribed in Army Regulations and in General Orders. WINTER COURSES OF INSTRUCTION IN GARRISON 173. The regular winter courses of instruction in garrison com- prise a period of 34 weeks from November i to June 30. Acting cooks will be required to attend those in cooking only. All the other MEDICAL DEPARTMENT 429 men of the detachment will take the prescribed courses, except '' qualified " men, men excused by the Surgeon General from further instruction under the provisions of paragraph 178a. and the abso- lutely necessary attendants in the hospital, such attendants being detailed as far as practicable from the " qualified " men and those excused by the Surgeon General. Night nurses, when on duty all night as such, will be considered " necessary attendants '' within the meaning of this paragraph. 174. The winter courses are as follows: Course No. i. — For privates first class and privates. Subjects: Duties of the soldier, hours 8; anatomy and physiology, hours 16; first aid, hours 20 ; nursing, hours 36 ; total, hours 80. Course No. 2. — For selected privates first class and privates. Subjects: Cooking and diet cooking, hours 12; materia medica and pharmacy, hours 24 ; elementary hygiene, hours 8 ; clerical work, hours 12; total, hours 56. (a) The following textbooks will be used for study and refer- ence : Mason's Handbook for the Hospital Corps ; Drill Regula- tions and Service Manual for Sanitary Troops ; Manual for the Medical Department ; Army Regulations. 175. Practical performance of the work they are being instructed in should be required of soldiers pursuing the winter courses. While tb.eoretical teaching by lectures, demonstrations, and recitations from textbooks has its place, it should be regarded as a secondary one. 176. The sequence of the subjects will be determined by the de- partment surgeon, who will consider the climatic and other condi- tions in his department in arranging the year's instruction. 177. Each subject will be finished before taking up another, and upon its conclusion an oral examination therein will be held by the instructor, under the direction of the surgeon. 178. Records of class work in the winter courses will be kept in a blank book adapted to the purpose. Every soldier taking the courses will be marked in each subject thereof daily. (a) Men who obtain a final mark of 70 per cent in any subject will be classed as " qualified " in that subject. Men who fail to obtain 70 per cent will be required to take the course the following year. If they again fail, their names will be reported to the Surgeon General, who may in his discretion excuse them from subsequent courses. 430 GENERAL MEDICAL ADiMlXISTRATION (b) Men who obtain a final mark of 70 per cent in each subject of one or more of the winter courses will be given certificates of proficiency therein on Form 60a. 179. Men who have previously qualified will be examined at the beginning of the winter courses to ascertain whether they continue qualified. If a soldier is found still proficient on such examination, that fact will be noted in his descriptive list and he will be excused from instruction in that subject; but a new certificate of proficiency will not be given to him. If, however, he is found deficient in any subject or subjects he will be required to take the ensuing course of garrison instruction therein. 180. The aggregate number of hours of instruction in bearer drill and field work, in care of animals and equitation, and in th« regular garrison courses given during the period of a return of the Hospital Corps, Form 47, to each soldier carried thereon, will be noted in the appropriate column opposite his name on the return. INSTRUCTION IN THE FIELD 181. In the field special attention should be given to field work, to include the care of animals, equitation, use of field appliances, camp sanitation, establishment of lines of aid in battle, etc. In the field no limit is to be placed on the amount of time to be devoted to this instruction. ARTICLE IV — HOSPITALS AND MEDICAL ATTENDANCE 210. Patients will not be transferred from one ward to another without the authority of the commanding officer of the hospital. The transfer of a case from one ward to another will be reported to the office with the next ward morning report of the ward from which the case is transferred. All that is necessary is to report the patient's name, rank, company, and regiment or corps, and state the fact that he has gone from one ward to the other, designating them. No special form is provided. A memorandum will suffice, or a register card, Form 52, may be used. Upon the receipt at the office of the notice of transfer a memorandum thereof will be made on the back of the register card, which will thus always show what ward the patient is in. 211. To facilitate and assure the prompt and proper distribution MEDICAL DEPARTMENT 431 of patients, each ward surgeon will every morning, immediately after his morning round of the ward, forward to the office a morn- ing report of the ward on P'orm Ji, which will be accompanied l)y diagnosis slips for new admissions, by all change of diagnosis cards, by the clinical records of all ca.-es completed in the ward or which depart from the ward otherwise than by transfer to another ward, and by the notices of cases transferred to other wards since the preceding rei)ort. The ward morning reports, being of no perma- nent value, may be destroyed after they have served their purpose. EFFECTS OF PATIENTS 221. The commanding officer of the hospital is responsible that due care is observed in safeguarding the money, valuables, clothing, and other effects of patients admitted to hospital. Money or other valuables will be receipted for by the commanding officer or by an officer designated by him, and, when practicable, deposited in the hospital safe or in a bank. Enlisted men are forbidden to retain money or other valuables received Irom patients for safe-keeping. (a) In the presence of the patient, or of another enlisted man in case the patient is unconscious or insane, his clothing and other effects will be tagged (Form 76) for identification and listed in duplicate on the patient's property card (Form 75). This list with the effects will then be sent to the individual in charge of the store- room for patients' effects. He will retain the original list and turn the duplicate in to the record office, or give it to the patient as the regulations of the hospital may provide. In the smaller hospitals the duty of caring for patients' eft'ects as outlined above will devolve upon the wardmaster; in general or other large hospitals it will be performed as directed in paragraph 303. 222. The soiled clothing of patients will be washed, before it is put away, as a part of the hospital laimdry (par. 267). When there is reason to suspect that the clothing is infected such measures of disinfection as may be necessary to protect the command will be taken and accounts for the expenses incident thereto will be for- warded on Form 330, W. D., for settlement, with an explanation of the circimistances. 223. When the patient goes to duty, is furlough jd, or is discharged from the service the surgeon will restore his effects and take his receipt. 432 GENERAL MEDICAL ADAILXISTRATION 224. When the patient is transferred from a hospital his eftects will, if he is able to take care of them, be restored to him. When he is unable to take care of them, they will be intrusted ta the rank- ing officer or soldier in whose charge the patient is put. A list of the effects will be furnished to such ranking officer or soldier, who will give his receipt therefor to the transferring officer. On arrival at destination said custodian of the effects in transit will turn them over, with the list, to the commanding officer of the receiving hospital, and take his receipt therefor. 225. In the event of the death or desertion of enlisted or commis- sioned patients or of military prisoners in hospital, their effects will be disposed of in accordance with the provisions of Army Regulations. 226. The effects of deceased civilian patients, if claimed within a reasonable time, will be delivered to their legal representatives. If not claimed within a reasonable time, they will be sold by the hospital council and the proceeds taken up and accounted for with the hos- pital fund. Should claim thereafter be made within three years for the proceeds, the same may on the authority of the Surgeon General be paid over to the legal representatives of the deceased. A similar procedure will be followed in the case of effects abandoned by civilian patients upon their departure from the hospital. Watches, trinkets, personal papers, and keepsakes of civilians will not be disposed of as long as there is a fair prospect of finding their right- ful owners. PUBLIC PROPERTY IN THE POSSESSION OF PATIENTS 227. Public property brought into the hospital by the patient will also be listed in duplicate on his property card, Form 75. If his disability is so slight as to require treatment for a few days only, the property will be kept intact, tagged, and restored to him upon his return to duty, taking his receipt therefor; otherwise, it will, if practicable, be turned over at once to his commanding officer, whose receipt should be obtained. If such transfer is not practicable, the following action will be had : d ) The medical officer will take up on his return the medical property in the soldier's possession and forward his receipt therefor to the account-able officer; (2) if the medical officer is accountable for quartermaster or ordnance prop- erty, he will take up on his quartermaster or ordnance napers all MEDICAL DEPARTMENT 433 property belonging to those departments brought in by the "patient ; otherwise he will transfer such property to the nearest representa- tives of those departments, whose receipts therefor should be ob- tained; (3) the patient's commanding ofificer will be immediately notified by mail of the action taken under (i) and (2), (See also pars. 640 and 649.) 228. Hospital clothing will be worn by patients only during their stay in hospital. Each article will be marked as hospital property. When very sick soldiers are transferred from one hospital to another the hospital clothing necessary for their comfort may be sent with them, properly invoiced, and accompanied by a check list, giving the names of the men in whose possession it is. Under the provisions of this paragraph, crutches and similar articles may. if necessary, be similarly transferred with the patient from one post or hospital to another. (See pars. 496 et seq.) 229. Upon the discharge from service of men permanently dis- abled, they may retain the surgical appliances then in their use which are necessary for their comfort and safety, and the accountable officer will drop the same from his next return of medical property, submitting a certificate explaining the circumstances as a voucher for so doing. DESTRUCTION OF INFECTED PROPERTY 230. Infected clothing and other articles which can be immersed in boiling water, or otherwise disinfected, without material injury, should be disinfected and not burned. Articles destroyed to prevent contagion must be accounted for by the affidavit of the officer responsible, setting forth fully the circumstances necessitating such destruction. (See par. 502.) MESS MANAGEMENT 231. The food .supplies for the hospital personnel and patients consist of rations issued by the Quartermaster Corps, of articles pur- chased with or derived from the hospital fund (see pars. 248 to 262), and of products of the hospital garden. 235. Each ward surgeon will, every morning, immediately after the first round of his ward, fill out a diet card. Form 73, covering the diet requirements of his patients for the ensuing 24 hours. Bills of fare for regular., light, and liquid diets should be made out and 28 434 GENERAL MEDICAL ADMINISTRATION posted in the wards and kitcliens. Additional articles not included in these diets are to be ordered for special cases only. (a) The diet cards from the wards will be sent promptly to the hospital office, where the necessary card or cards will be made out covering- the meals of the hospital personnel. All the cards will thereupon be turned over to the noncommissioned officer in charge of the mess in season for his action toward the preparation of the day's dinner. Additional cards for newly admitted patients or newly arrived personnel will be made out promptly when necessary and sent to the noncommissioned officer in charge of the mess without delay. The diet cards may be destroyed after they have served their purpose ; usually they will have no value beyond the day of their date and the following day. 236. Each hospital mess will be placed under the immediate charge of a competent noncommissioned officer. (a) It will be his duty to receive and care for all articles of food for the mess, and he will be held responsible for their proper dis- position. He should be provided with suitable apparatus for pre- serving perishable foods and a suitable storeroom for the balance, and should secure them by proper locks. He will issue daily from the stores to the kitchen the articles required by the diet cards and will see that the food is cooked as indicated thereon. He will keep such record of his receipts and issues as the surgeon may prescribe according to the needs of the particular hospital, no special form therefor being provided. He will be responsible for the condition and cleanliness of the kitchen and cooking utensils, and the kitchen force will respect his orders accordingly. He will be responsible also for the cleanline-s and discipline of the messroom, the service of the meals therein, and the distribution of food to wardmasters for patients unable to leave the wards ; and for the cleanHness of the naperv and table utensils used in serving the food. He will see that table clothing and utensils used for patients suffering from infectious disease are properly disinfected before being returned to the storerooms for further use. He will be provided with a suffi- cient number of assistants to assure the prompt and efficient per- formance of these duties. 237. A mess account on Form 74 will be kept by the noncom- missioned officer in charge. It should be filed at the end of every month with the retained hospital fund papers for that month. In- MEDICAL DEPARTMEXT 435 ordinate gains m the plus column would indicate undue economy in the diet, while, on the other hand, continual losses in the minus column would signify mismanagement of the hospital fund or im- proper care of the food supplies. Tlie commanding officer of the hospital should inspect this record at frequent intervals, with a view to keeping constantly informed in this respect. (a) When there is more than one mess, a consolidated mess account on the same form for the entire hospital should he kept in the office, the noncommissioned officers in charge of the several messes being required to report daily the data therefor. 238. For methods of preparing food for both sick and well, refer- ence should be had to the authorized Handbook for the Hospital Corps and the Manual for Army Cooks. DISPENSARY MAN.XGEMEXT 240. All prescriptions will be written in the metric system. They will be placed on file in three separate files, as follows: (i) Pre- scriptions for alcohol or alcoholic li([uors and for medicines con- taining opium or any of the salts, derivatives, or preparations of opium or coca leaves. (2) Prescriptions for civilians which do not include articles of the preceding class. (3) All other prescriptions. Prescription files will be subject to inspection by inspectors and post commanders at all times. (a) In connection with file (i) a record will be kept of the dis- pensary receipts and expenditures of each article specified therein. Unless otherwise authorized by the Surgeon General, this record will be made on blanks of Form 17a, adapted as may be necessary to the purpose. A separate slip will be kept for each foriu in which the liquor or drug is sui)plied, as " Morphiuc-e sulj)has, powder " or " Morphinae sulphas, lo-mgm. hypo, tablets." The date of receipt thereof from the storeroom will be noted in the left-hand colunm and the amount, in the proper metric unit, in the debit column. The expenditures will be noted by entering the prescription num])er in the left-hand column and the amount expended in compounding the prescription in the credit column. At least once a month the slips will be balanced and the quantities remaining on hand will be verified by a medical officer and the facts noted over his signature. 241. Active poisons, alcohol, alcoholic liquors, and all habit- forming drugs will be kept under lock and key in a separate closet. 436 GENERAL MEDICAL ADMLXISTRATION 242 Civilian employees of the Army stationed at military posts may purchase medical supplies when prescribed by a medical officer. (a) Medicine charges for employees not in hos])ital will be as follows: In ordinary cases, 25 cents for each prescription; in the case of rare and expensive medicines, dressings, appliances, etc., at such increased rate, to be determined by the surgeon, as will reim- burse the United States their cost. {b) Medicine charges for civilian employees in hospital are fixed at 25 cents a day in Army Regulations. HOSPITAL FUND 248. The hospital fund is derived — (i) From commutation of rations of patients and members of the Nurse Corps. (2) From savings on rations of the Hospital Corps. (3) From dividends from post exchange. (4) From dividends from post garden. (5) From money received for the subsistence of officers and civil- ians treated in hospital. (6) From sales of property purchased with liospital fund (par. 259), or products pertaining to the hospital fund (vegetables from hospital garden, etc.). 249. In addition to the post exchange dividends due the hospital detachment, the exchange council, with the approval of the com- manding officer, shall determine the amount, if any, to be turned over to the surgeon for the sick in hospital. (See Appendix: Post Exchange Regulations.) 251. The hospital fund is regarded as a company fund, and is applicable generally to similar purposes, in the interest of enlisted men of the Hospital Corps, and of the sick under treatment and members of the Nurse Corps on duty in military hospitals. 254. The officer commanding the hospital will see that due economy in expending the fund is observed, and that expenditures are not made for improper purposes. Receipts will be taken for all pay- ments. 255. Gratuities to hospital cooks and assistant cooks may be au- thorized by department surgeons or the Surgeon General when the amount of the hospital fund on hand justifies such expenditure. (a) A gratuity of not exceeding $10 a month rriiay be paid from MEDICAL DEPARTMENT 437 the hospital fund to the hospital gardener, when authorized by the department surgeon or the Surgeon General. (b) Vouchers for gratuities will cite upon their face the date and source of the authority for paying them. ICE FOR HOSPITALS 263. The chief use of ice in hospitals is as an article of food or for the preservation of food. For such use it should be obtained from the Quartermaster Corps, from the ice plant, if one is available, as provided in existing orders (see Appendix: Ice), or as an issue under Army Regulations, when authorized ; or by purchase from the hospital fund. 264. Ice required for medical administration proper, such as for ice baths of the sick, for medical photographic work, etc., should be procured from the Quartermaster Corps ice machine, if one is avail- able, or be obtained by purchase at the cost of the medical and hos- pital appropriation. Routine purchases of ice for medical purposes will not be made without the previous authority of the Surgeon General, or, in the Philippine Department, of the department sur- geon. Accounts for emergency purchases will invariably be acconi- Ijanied by a separate statement of their necessity. Accounts for ice for medical work will be stated on Form 330 or Form 330a, W. D., will show in the officer's certificate (taking care not to encroach upon the approval space to the right of the $ sign) or on the blank fold on the back of the form, specifically what the ice was for — as, e. g., for use in the treatment of sick in hospital, for use in developing photographic negatives for identification work, etc. — and will be forwarded, with one invoice of articles purchased. Form 12, to the department surgeon, or if from a command under the immediate supervision of the War Department, to the Surgeon General, unless otherwise directed by him. IIOSPIT.XL MATRON 265. Authority for the employment of hospital matrons is given by section 1239. Revised Statutes. Their compensation of $10 a month and a ration in kind or by commutation is established by sections 1277 and 1295. 266. It is the duty of the hospital matron to mend and keep in 433 GENERx\L MEDICAL AUMIXISTRATIOX repair the table, hand, and operating linen, the bedding and the hospital clothing- belonging to the Medical Department, including the linen of the dentist's ofifice, and to do the hospital laundry, or so much thereof as possible up to a minimum of 500 pieces a month, from time to time, as the same may be required by the surgeon. (a) In the case of matrons on duty at the larger posts and at general hospitals the Surgeon General may modify or waive so much of this provision as requires the laundering of a minimum of 500 pieces of hospital linen a month in addition to all the mending. 267. The hospital laundry comprises: First, the linen, clothing, and bedding belonging to the Medical Department, as above enu- merated; second, the washable clothing of patients admitted to hos- pital, which requires cleansing before it can be put away (par. 222 ) ; third, the white coats and trousers of the enlisted attendants (par. 470); fourth, the uniforms (par. 93^ of the Nurse Corps soiled while on public duty. (a) Soiled blankets, spreads, and other heavy pieces should not be allowed to accumulate, but should be washed a few at a time as they become soiled, so as to equalize the matron's work. 268. The compensation of the matron being fixed by law, no extra compensation for performing any of the duties incident to her em- ployment can be allowed, nor can other persons be employed at the expense of the United States to do her work or any part of it. (a) Matrons are forbidden to farm out their w'ork to other persons. (h) Matrons are not entitled to leaves of absence or to pay and rations while absent or while unable to perform their duty. (c) Matrons who are unable or unwilling to meet these require- ments should be discharged. 269. When the number of pieces to be laundered is more than the matron can do (having in mind the minimum of 500 pieces a month above required) the excess .may be put out under the provisions of paragraphs 270 to 278. A\'hen it would be an economy and advan- tage to put the entire laundry out instead of the excess only, the facts should be reported to the department surgeon for his informa- tion with a view to obtaining the necessary instructions and au- thority for further action. For the purpose of this report the matron's total compensation, including pay and allowances, is re- MEDICAL DEPARTMENT 439 garded as equivalent to $i8 a month, of which $3 may be taken as for the mending, and the balance, $15, for the laundering. LAUNDRY WORK NOT DONE BY MATRONS 270. The excess laundry at hospitals where there are matrons and the entire laundry at other hospitals (except those with laundry plants or otherwise provided for under special instructions from the Surgeon General) may be put out to private launder ies. When com- petition is not had the responsible officer will ascertain the lowest prices current in the vicinity for good hand or machine work and govern his action accordingly. 271. Individual laundrymen and laundresses may be employed under this authority without advertising for proposals, provided they do the work in person, the same being regarded as personal services within the meaning of section 3709, Revised Statutes. The vouchers wall bear a notation showing that the work was done by the creditor in person. 278. Vouchers for laundry at a hospital where there is no matron will contain in the officer's certificate the notation " No matron at post." (a) Vouchers for excess laundry at a hospital where there is a matron will be accompanied by a statement showing the matron's name, the kind and number of pieces laundered by her and put to hire, respectively, during the period covered, and by a certificate that she was unable to do any of the laundry put out. The.-e will be separate from the vouchers, which should contain no reference thereto. GENERAL HOSPITALS Officer of the Day 297. The officer of the day will be assigned to duty for a tour of 24 hours, during which he will always be accessible for cases of emergency and to meet the requirements of the duties hereinafter stated. He will be notified by the adjutant of his selection for duty on the day preceding that on which his tour begins. He may be required to perform his regular duties when they will not conflict with the performance of his duties as officer of the day. 440 GENERAL MEDICAL ADMLNISTRATION 298. Three noncommissioned officers will ordinarily be detailed permanently as assistants to the officer of the day, and there will be at all times one noncommissioned officer and one pri\-ate on duty in his office. The noncomm.issioned officers will report to the officer of the day at the beg'inning of their respective tours of duty and will in no case leave the office until the arrival of their relief. 299. At an hour to be designated in hospital orders the old and the new officers of the day will report to the commanding officer, the old officer of the day to render his report, the new officer of the day to receive such instructions as the commanding officer may wish to give. At the expiration of his tour of duty the officer of the day will report in writing to the commanding officer the hours at which the prescribed inspections were made ; any breaches of discipline, infraction of the hospital rules, neglects or disorders that may have occurred during his tour of duty ; and any other occur- rences which should properly be brought to the attention of the commanding officer. 300. The officer of the day will make a general inspection of the hospital at such hours as the commanding officer may direct. Dur- ing this inspection he will note any disorder or neglect and, if prac- ticable, will immediately correct the same. He will satisfy himself iha^ the watchmen or guards are familiar with their duties and are performing them satisfactorily. During his tour of duty he will inspect at least one of the meals served in each hospital mess. He will receive the reports of the roll calls required by orders. On the outbreak of fire he will assume charge until the arrival of the fire marshal or of the senior officer present at the hospital. In the absence of the ward surgeon he will examine the body of any patient who may die during his tour of duty and order its removal to the morgue, notifying the adjutant of his action. 301. The officer of the day will examine and admit all incoming patients. If the officer of the day is temporarily unavailable, the noncommissioned officer on duty in the receiving office will notify the adjutant of the arrival of patients, and the adjutant will act in his stead or designate another officer to act temporarily as sub- stitute for the officer of the day until he is again available. In no case will a patient be admitted and assigned to a ward until he has been seen and examined by the officer of the day or some regularly designated substitute. MEDICAL DEPARTMENT 441 (a) If there is any doubt as to the ward to which he should be assigned the patient will be held in the receiving ward for disposi- tion by the chief of the medical service. The officer of the day will receive money and valuables from patients on admission and will turn them over to the registrar for safe keeping. An attendant from the receiving office will conduct incoming patients to the wards to which they have been assigned, care for their baggage and equip- ment, and turn over to the wardmaster the patient's admission slip. (See par. 209.) 302. The noncommissioned officers on duty with the officer of the day will keep a card index of patients in hospital and will enter gains and losses on the morning report of sick. (Form 71.) 303. Upon the admission of a patient to hospital the noncommis- sioned officer will secure his efifects, other than money and valuables, list them in duplicate on the patient's property card (Form 75), tag them for identification (Form 76). and turn them over to the noncommissioned officer in charge of the store room for patients' effects. The latter will sign both lists, retain one of them and return the other, which will be filed in the registrar's office. Upon the departure of a patient from hospital the wardmaster will notify the noncommissioned officer on duty, who will obtain the list of the patient's effects from the registrar's office, and upon their delivery to the patient obtain his receipt, which will be returned to the registrar's office for file. (See par. 221.) 304. All public property left by patients at the hospital will be turned over to the quartermaster, who will dispose of it as indicated in paragraph 227. 305. In time of peace the noncommissioned officer on duty will have charge of the Hospital Corps men on duty as watchmen. He will satisfy himself that they have been properly instructed and understand their orders. He will maintain quiet and order in the hospital and will notify the officer of the day of any unusual occurrence. 306. In time of peace the hospital will be guarded by Hospital Corps men detailed as watchmen under the officer of the day and his noncommissioned assistants. In time of war the necessary guard will ordinarily be performed by a permanent detail of sani- tary troops, and for this purpose the Hospital Corps personnel will be increased. 442 GENERAL MEDICAL ADMLMSTRATION (a) When this detail from the sanitary troops is not available the necessary guard may be obtained on request from the department commander. When the commander of such a guard is a commis- sioned officer he will confer with the commanding officer of the hospital as to the character of the guard duty desired by the latter, but will exercise no control over the sanitary formation. If such a guard is not accompanied by a commissioned officer it will be reported by the noncommissioned officer in charge to the command- ing officer of the hospital and will be placed under the immediate command of the officer of the day. ARTICLE V — DEPARTMENT LABORATORIES JVater 357. The specimens should, when practicable, be collecied by a medical officer. If the water to be examined is delivered through pipes or is pumped from a well or cistern, the local supply pipe and all pump connections should be emptied by allowing the water to run for 15 minutes before taking the samples. 358. Bacteriological examinations. — Samples of water for bac- teriological examination should be collected in bottles furnished for the purpose. Each bottle is sterilized before leaving the laboratory, and the glass stopper is protected by a piece of heavy sterilized mus- lin securely wired to the neck of the bottle. The stopper should not be removed until immediately before the bottle is filled. (a) In taking specimens from a faucet or pump (after emptying the supply pipes and connections conformably to par. 357) a small, gentle stream should be allowed to flow, the stopper taken out, the bottle grasped near the bottom, held in an upright position, and the stream permitted to flow into the bottle until it is filled to the shoulder. The stopper should then be replaced; both it and the cloth should be secured by carrying the wire several times around the neck of the bottle and twisting the ends tight. The stopper must be handled only by the square cloth-covered top. The lip of the bottle must not be brought in contact with the faucet or spout, nor should the neck of the bottle or naked part of the stopper be per- mitted to come in contact with any object during the manipulation. MEDICAL DEPARTMENT 443 The projecting flange is designed to protect the plug of the stopper, which it will do if the stopper, after withdrawal, is held by the top in a vertical position. The stopper should not be laid down and the cloth should not be handled by the fingers except in the act of secur- ing the wire about it. When well water is to be examined the bottle should be filled directly from the bucket constantly in use for drawing the water, and from no other vessel. {b) On account of the labor involved and the possibility of error, bacteriological examinations of water collected in any other than the prescribed receptacles will not be made. (c) Each package should be plainly marked to show the source from which the sample is taken and the date of collection. (d) The case should be marked, " Water for bacteriological ex- amination," and it should be forwarded by mail at the earliest moment. (See par. 355a.) 359. Chemical examinations. — The quantity of water forwarded for chemical examination should be not less than 3 liters. The receptacles for transporting it should be chemically clean, and all vessels used in its collection should be as clean as it is possible to make them. (a) Glass-stoppered bottles of suitable size are l^est adapted for the preservation of a sample of water in its original condition. In pouring the water into bottles it should not come into contact with the hands of the operator or with anything not essential to the operation. Bottles should be filled to within an inch of the stop- pers; the stoppers should be carefully rinsed and inserted and secured with a canvas cover tied tightly around the neck of the .bottle. Sealing wax or similar material should not be used to secure the stoppers. (b) If no proper receptacles are available at the post or camp suit- able bottles may be obtained upon application to the officer to whom the specimens are to be sent for analysis. Bottles so obtained should •when filled be repacked in the box in which they came, reversing the cover, which should have the laboratory address thereon. The package should be tagged or labeled to show the place and date of collection. (c) Water for chemical analysis should be shipped, immediately after its collection, by express. A Medical Department bill of lad- 444 GENERAL MEDICAL AIJ.MLXISTRATJOX ing will be made for each such shipment and the carrier's signature taken thereto upon turning over the package for transi)ortation. Until a special form shall have been provided therefor Form 153, Q. M. C, may be adapted to the purpose by altering the symbol " W. Q." in the upper right-hand corner to read " W. Medical," followed by the number of the bill. The consignor should in every case fill out the instructions for billing at the foot of the bill of lading, specifying therein that the freight charges are to be vouched to the Surgeon General, Washington, D. C., and should immediately mail the bill to the consignee, who will upon receipt of the articles accomplish the bill and surrender it to the carrier. The consignor should at the time of shipment furnish the carrier with a shipping order (Form 156, Q. M. C.), and mail a memorandum of the bill of lading (Form 154, Q. M. C.) to the Surgeon General, with infor- mation as to the purpose of the shipment unless the same is clearly revealed by entries on the bill. ARTICLE VIII — RECORDS, REPORTS AND RETURNS — REGIS- TER AND REPORT OF SICK AND WOUNDED The Register 427. A full record of the sick and wounded of every military post or station and separate command which is attended by a medical officer or private physician will be made on register cards, Form 52 ; but this requirement will not be applicable in time of war to troops or commands in the theater of operations, except camp hospitals (or field hospitals acting as such), evacuation hospitals, base hospitals and other immobile sanitary formations on the line of communfca- tions. (See pars. 575 to 582.) These cards collectively constitute the register of patients, and a case carded on them is said to be on the register. (a) The commanding officer will provide the surgeon with any information the latter may not have which is necessary for preparing and completing the register. 428. A register card will be made : (a) For every person admitted to the hospital for treatment. (b) For every officer and enlisted man with the command, includ- ing retired officers and soldiers under assignment to active duty. MEDICAL DEPART^^IENT 445 who, though not admitted to the hospital, is excused on account of sickness or injury from the performance of his mihtary duty, or of some part of it, such as attendance on certain calls, drills, target practice, mounted duty, etc. (c) For every officer and enlisted man with the comm.and who, though not excused from duty, is prescribed for or treated, or placed under observation with a view to treatment or, in the case of an enlisted man, to discharge on account of disability, if his disability is of such a character as to have a probable bearing on his subsequent medical history : Provided, That a case once carded for record only under this provision will not again be carded for record only on the same register except when necessary to comply with the provisions of sections {d), (e), (/), and (h) of this paragraph. For example, every case of venereal disease or insanity, or suspected venereal disease or insanity, which comes under observation or treatment, will, unless previously on the register or otherwise required to be registered, be carded for record only under this provision. (d) For every officer and enlisted man with the command, not currently on the register, who is retired or discharged for disability, or dies. (e) For every officer and enlisted man with the command, not currently on the register, who is sent to another station or command for observation or treatment. (/) For every officer with the command, not currently on the register, who departs from the command on sick leave. (g) For every officer and enlisted man whose case is received by transfer conformably to the provisions of paragraphs 214 to 217. (/;) I'^or e\ery retired officer, retired soldier, former officer, or former soldier with the command but not in the hospital who dies. 429. Except as required by paragraph 428 a case prescribed for but not admitted to hospital or excused from duty will not be registered. 430. Cases under treatment by the dentist will be entered on the register of sick and wounded only when such entry is required by the provisions of paragraph 428. 431. \Mien an officer or soldier sick in hospital is retired from active service, wholly retired from service, dismissed, or discharged, his case as an officer or soldier will be ch sed ( par. 450) and a new 446 GENERAL MEDICAL AD^IIXISTRATIOX card made for it covering his continuance in hospital under his new status. (a) If an api)Hcant for enlistment sick in hospital is sworn in as a soldier, his case as a civilian will be closed and a new card made for his case as a soldier. (b) .Appropriate cross references from the old to the new cards, and z'ice versa, will be made in these cases. 432. The register cards will be made day by day as the cases are taken up. (See pars. 208a and 209.) They will be kept in two files, the current file and the permanent file. (a) The current file will consist of the register cards of uncom- pleted cases arranged in dictionary order according to the surnames of the patients. It constitutes a ready index to all cases currently on the register. Cards will be transferred from the current file to the permanent file immediately upon their completion and the prepara- tion of their report cards. (b) The permanent file will comprise all the register cards of com- pleted cases. The cards therein will be filed in the serial order of their register numbers. (c) A card index to the register will be kept on Form 52a, one index card for each individual patient whose name appears in the register. . When a register card is started and its number determined the index will be searched for previous admissions of the patient. If an index card for the patient is found, the new number will be entered thereon, and the number of the last previous admission will be noted on the new register card (par. 443). If no index card for the patient is found, one will be at once prepared. The index cards will be filed alphabetically in dictionary order according to the sur- names of the patients. 433. Cases taken up on register cards should be borne thereon until finally disposed of. (See par. 450.) 434. The cards will be legibly written in indelible black ink, using the typewriter when practicable. (a) Entries must not be crowded, ^^'hen the space provided on the front of the card under any heading is not sufficient to complete an entry thereunder, the record thereof will be continued on the back of the card, or, if still more space is required, upon an exten- sion slip. The extension slip must be of the same size as the card. MEDICAL DEPARTMENT 447 and be pasted to the lower margin of the back of the card, using about one-half an inch for the seam ; this will place the seam at the top of the card when the latter is filed. W'hen an entry is continued its two parts should be connected by cross references, using a small letter in parenthesis, thus, (a), so that the record can be readily followed. 435. The senior medical officer is responsible for the correctness and safe-keeping of the register. He will sign or initial all register cards completed during the period of his responsibility; but at gen- eral hospitals or brigade posts, or when specially authorized by the Surgeon General, he may designate one or more junior medical .officers to sign or initial them, preferably in each case the officer in attendance thereon. (a) When, in the absence of a medical officer, the command is attended by a civilian physician, he will sign the cards for the cases completed under his care. 436. Alterations and additions when necessary to correct or com- plete the record may be made in the register cards of uncompleted cases at the discretion of the senior medical officer of the command for the time being. A change of diagnosis will be indicated in the space " complication, seq., etc.," giving the date of the change, and the original entry under " cause of admission " will not be disturbed. A change of diagnosis in such cases requires no authentication, as its date places the responsibility for it. Other changes should be authenticated by the initials of the officer who makes them. (See par. 213.) (a) Alterations and additions to the register cards of completed cases may be made in like manner by the medical officer who was responsible for the card at the time it was completed if he is still the senior medical officer of the command. If he has been super- seded the card will not be changed, but a successor who concludes, upon information received, that the card is erroneous in any par- ticular may file a supplemental card therewith of the same size as the register card, indicating thereon such conclusion and the information or reasons upon which it is based. The supplemental card should be headed " Supplemental card. No. ," inserting the register num- ber of the register card, and should be dated and signed by the officer filing it. A cross reference to the supplemental card identi- fying it by its date may appear upon the register card, but it will be 448 GENERAL MEDICAL ADMINISTRATION a reference only, thus, " See supplemental card dated ," and contain none of the matter recorded on the supplement. (See pars. 462, 463, and 464.) REPORT OF SICK AND WOUNDED 457. The report of sick and wounded comprises, (i) the report sheet (l-^orm 51), which provides for general information and numerical tabulations concerning the command and the civilians therewith; (2) the nominal check list (Forms 510 and 51^) for a chronological list of cases registered; (3) the report cards (Form 52) for details of the several cases. 458. Subject to exceptions similar to those indicated in paragraph 427, this report is required monthly from every military post and separate command which is attended by a medical officer or civilian physician. It will be rendered separately for regular and volunteer troops, that of regulars to embrace all data pertaining to civilians. It will be forwarded before the fifth day of the next succeeding month as follows : From a general hospital or other independent post or command direct to the Surgeon General, unless otherwise ordered by him ; from a transoceanic Army transport to the medical superintendent of the transport service at the transport's home port, for transmittal to the Surgeon General ; and from any other organ- ization or hospital to the department surgeon for like transmittal. (a) When a hospital is closed or a command is discontinued a report covering the unreported period of service, giving the begin- ning and the end thereof, will in like manner be forwarded within five days thereafter. (b) If there has been no case on sick report, either remaining from last report or admitted during the month, Form 51 will never- theless be forwarded. It will give the name and strength of the command, etc., with such remarks as may be deemed of interest to the department surgeon or the Surgeon General. 459. All births and marriages occurring at the post or with the command and all deaths among the civilians with the command will be recorded on the report of sick and wounded under the heading " Births, marriages, and deaths." 460. A report card is required for every case registered during the month, and if the case is not completed until a subsequent month a MEDICAL DEPAR'niEXT 449 second report card will be forwarded with the report for the month during which it is completed. With the report for December, repc>rt cards will be forwarded also for all cases remaining December 31 which were registered previous to December. (a) A duplicate of the report sheet and of the nominal list will be retained with the medical records of the post or command. At a permanent post the duplicate report sheets will be filed in and form a part of its medical history. (See par. 412.) {b) The senior medical officer will fill in and sign the certificate at the foot of the first page of the report sheet. (See par. 400.) The report cards will be initialed as provided in paragraph 435 for reg- ister cards. If there is neither medical officer nor civilian physician with the command when the report is to be made, the officer in charge of the property of the hospital will make the report over his own signature and initial the cards. (f ) Alterations should in every instance be authenticated by the initials of the officer or physician who signs the report and initials the report cards respectively. ARTICLE IX — SUPPLIES AND MATERIALS — GENERAL PROVISIONS 475. In preparing returns, requisitions, invoices, and receipts per- taining to medical and hospital supplies, the nomenclature, order of entry, classification, and weights and measures of the supply table will be followed. To facilitate the handling of these papers one line of writing only will be placed in each interlinear space. No letter of transmittal is required with them. REQUISITIONS Post Medical Supplies 477. Annual requisitions for post medical supplies will be pre- pared on Form 33, for the year commencing January i, unless some other date is designated by the Surgeon General. (a) They will be forwarded not less than 20 days before the beginning of the year, to the department surgeon, in quadruplicate, 29 450 GENERAL MEDICAL ADAILXISTRATION or in the case of general hospitals and indei)cnclcnt posts direct to the Surgeon General in triplicate. 4/8. Articles of which a definite allowance is given on the supply table will be required for on the annual requisition except as other- wise provided in paragraph 486. No remark will be made opposite the name of any article that a special kind or special make or pattern is wanted, as the annual requisition is intended to include only such articles as are kept on hand in supply depots for issue, and not such as have to be specially purchased ; the latter when wanted must be asked for on special requisition. (a) Only such quantities will be asked for as probably will be needed during the year, computed on the basis of original packages. rVactional parts of a bottle or package will not be asked for. The quantities asked for, plus the quantities on hand, must not exceed those specified in the table for the official population most nearly corresponding to that of the post or command. The quantity of each article on hand, as verified by a medical officer in accordance with paragraph 512a, will be stated and will be deducted from the quantity allowed annually by the supply table (ignoring for the purpose of this deduction fractional parts of bottles and packages on hand ) to ascertain the balance which may be asked for, if needed. (b) Before forwarding an annual requisition it will be carefully examined and compared with the supply table to see that it has been correctly made out in strict accordance with these regulations and to avoid the delay that its return for correction will occasion if they are not complied with. 479. The local prevalence or rarity of certain diseases, as well as the quantity or number on hand of each article, will be considered in the preparation and approval of annual requisitions. 480. The smaller posts will not need all the articles included in the supply table. The surgeon is not expected to require for an article merely because it is listed. He should call only for what there is reason to think he will need. 481. The department surgeon to whom an annual requisition is forwarded will see whether it is prepared in accordance with the above regulations. If it i"^, he will approve and forward one copy direct to the medical supply depot designated for his territory by the Surgeon General ; if it is not, he will alter it to conform to these MEDICAL DEPARTMENT 451 regulations, and then forward it to the depot approved as altered. In either event, he will forward the second copy of the requisition, with the action taken by him noted thereon, direct to the Surgeon General. He will retain the third copy in the files of his office and will return the fourth copy to the surgeon with his modifications, if any, noted thereon. 482. Special requisitions for post medical supplies are annual, quarterly, or emergency. They will be made on Form 35, but separately from those for field medical supplies and those for dental supplies. The same number of copies will be executed, and they will be forwarded to the department surgeon or to the Surgeon General direct, as in the case of annual requisitions from the same posts or hospitals. (See par. 4770.) 483. Except as otherwise provided in paragraph 486, articles not on the supply table which will be needed during the year will be called for on the annual special requisition. It will be forwarded with the regular annual requisition. The articles will be listed in alphabetical order, and the necessity for them will be fully explained in the column of " Remarks." To avoid delay in filling these requisi- tions a full description of special articles, instruments, and appli- ances required for will be given in " Remarks," together with a state- ment of their cost or approximate cost, as ascertained from dealers' catalogues or other reliable sources of information. \\'hen unusual drugs or chemical reagents are called for similar information as to their cost will be furnished. 484. Except as otherwise provided in paragraph 486 and in the footnotes to the supply tables, articles on the supply table of which no allowance is stated, or which are issued " as required," will be called for on the quarterly special requisition. FIELD MEDICAL SUPPLIES 489. Requisitions to replenish field medical supplies or to replace unserviceable field equipment at permanent posts will be executed in triplicate, on Form 35, and will be forwarded to the department surgeon, or, in the case of an independent post or station, direct to the Surgeon General. (a) The department surgeon who receives a requisition in tripli- cate for field medical supplies in conformity with this regulation will 452 GENERAL MEDICAL ADMINISTRATION promptly forward the same, with his recommendations indorsed on each copy, to the Surgeon General. In the Philippine and Hawaiian Departments the department surgeons are authorized to act upon them as upon requisitions for post supplies. (Jne copy of the requisition will be returned to the surgeon wMth modifications, if any, noted thereon. 490. Requisitions from permanent posts for field medical supplies should be unnecessary except immediately following active military operations or as the result of changes in the supply tables. USE AND CARE OF MEDICAL PROPERTY 514. The stock of alcohol, alcoholic liquors, opium, and the salts, derivatives, and preparations of opium or coca leaves will be kept in a locked closed in the storeroom and only issued to the disj^ensary in unit containers from time to time as may be necessary, upon the written order of a medical officer. (a) In the storeroom, receipts and expenditures of these articles will be accounted for in the manner prescribed for the dispensary (par. 240). 515. Field supplies and equipment will not be used as posts, except when required for purposes of instruction. 516. Field chests and appliances \\ill be frequently inspected and kept in perfect order for immediate field use. 517. The exchange of medicines with druggists is prohibited. 518. The issue of articles for use in the preparation of cleaning- mixtures, cosmetics, or perfumery, or for use with spirit lamps, etc.. is prohibited. 519. The responsible officer will cause all instruments in his charge to be examined by a commissioned medical officer at least once each month. 520. Steel and plated instruments may be prevented from rusting by keeping them in a 20 per cent formalin solution saturated with borax. 523. Blankets not in use should be frequently examined and prop- erly protected. When stained but otherwise in good condition they should be continued in service. Hospital bedding will not be used by meml)crs of the Hospital Corps, except when on duty in the wards. 524. AMien a typewriter is to be transported the ribbon spools MEDICAL DEPARTMEiNT 453 should be removed and packed separately, tlie carriage of the machine securely tied to the base in such a manner that it can not move in any direction, and the steel rods or blocks for locking the carriage placed in position. Medical officers will be held responsible for damages to typewriters which result from careless packing. 525. Rubber and flexible catheters and bougies will be kept in talc or glycerin to preserve them. 526. When the canvas in litters becomes soiled it will be removed from the litters, washed, and replaced. When it becomes torn or unserviceable new canvas of the proper size should be applied for to replace it. Part II — The Sanitary Service in \\'ar ARTICLE VIII — THE SANITARY SERVICES IN WAR — GENERAL CORRESPONDENCE, REPORTS, RETURNS AND RECORDS Records of Sick and Wounded 567. During and after an engagement diagnosis tags will be attached to all wounded and dead as soon as practicable. They will be made out in duplicate. 568. In the case of wounded the primary purpose of the tag is to advise the medical officers under whose observation the wounded successively come of the treatment previously given at the several points of relief on the field or on the way to the rear. 569. The tag will be made out by the first medical officer or member of the Hospital Corps who treats the man previous to ad- mission to a hospital on the line of communications. ( It is unneces- sary to tag a patient who is admitted to a hospital on the line of communications without having been previously tagged.) If the ]iatient is badly hurt, the identification tag may be utilized to obtain the necessary information concerning his name, rank. etc. The original diagnosis tag will be attached to the patient's clothing. 570. The dead found on the field will be tagged in each case by the Medical Department troops who first reach the body, in order 454 THE SANITARY SERVICE IN WAR tliat other medical personnel may not lose time examining it. The tag- will be attached to the clothing of the deceased. 571. The duplicates of the diagnosis tags will be disposed of as follows: (a) Those made out by the sanitary personnel of an organization for the ofticers and soldiers of their own command will be retained by the surgeon until disposed of as provided in j^aragraph 574. ( /' ) Those made out for officers and soldiers of other comnianas will be transmitted as soon as possible after the close of each day of an engagement to the division surgeon accompanied by the check list directed to be sent to that officer by paragraph 579. 572. The original tags will be disposed of as follows: (a) Those of wounded who are returned from aid stations to the firing line without going farther to the rear will be removed and retained by the regimental surgeon. (b) Those of wounded who are returned to their organizations direct from dressing stations (par. 682) or from the station for slightly wounded (par. 714a) will be removed upon their reporting for duty and be turned over to the surgeons of their several organiza- tions, respectively. (c) Those of wounded who are admitted to a tield hospital and retained there for definitive treatment will be removed and for- warded to the division surgeon. If the patients are subsequently transferred to the line of communications, they will not be retagged, •but will be accompanied by transfer lists in regular form (par. 5S3). (d) Those of wounded who are being evacuated from the zone of the advance will not be disturbed until the patients are admitted to hospital on the line of communications, when the tags will be re- moved, stamped with the name of the admitting hospital, and the date of receipt of the patient, and forwarded immediately to the division surgeon of the division to which the wounded belong. (c) Those of wounded who die while in transit from the field to hospital (the death in each case being noted on the tag as required by the printed instructions in the tag book), and the tags attached to the dead found on the field, will be removed when the bodies are prepared for interment or equivalent disposal, and will be sent like- wise to the division surgeon. 573. The division surgeon will cause the tags received by him in MEDICAL DEPARTMENT 455 compliance with paragraphs 571 and 572 to be distributed without delay to the senior medical officers of the commands to which the men tagged belong, so that they may be available in accounting for officers or soldiers who would otherwise be carried as missing on the returns of their organizations. 574. Having served their purpose in completing the records of the organizations, all the tags, both originals and duplicates, will be for- warded with the next periodical lists of sick and wounded therefrom. 575. The register of patients prescribed by paragraph 427 and the monthly report of sick and wounded by paragraph 458 are not required from mobile troops or commands in the theater of opera- tions. In lieu thereof a record or list of the sick and wounded with every mobile command in the theater of operations which is accom- panied by a medical officer will be kept day by day by such officer on Form 53, as directed in the following paragraphs and in the in- structions printed on the form. Field hospitals immobilized and acting as camp hospitals, evacuation hospitals, base hospitals, supply depots, contagious disease hospitals, field laboratories, and other similar sanitary formations will not be regarded as mobile units within the meaning of this paragraph, but will keep tlie register of patients and render monthly reports of sick and wounded in accord- ance with the regular rule. 576. The list of sick and wounded will contain a record of the following cases : (a) Every officer or soldier with the command who is excused from duty on account of sickness or injury, or who receives a wound of any character in action whether it involves excuse from duty or not. (b) Every officer or soldier with the command, not currently on the list, who is sent to another command or place for observation or treatment. (c) Every officer, not currently on the list, who departs from the command on sick leave. (d) Every officer or soldier with the command, not currently on the list, who is retired, or discharged for disability, or die? : and every civilian with the command who dies. 577. In determining the cases to be entered on the list of sick and wounded under the provisions of paragraph 576, officers and soldiers 456 THE SANITARY SERVICE IN WAR who are killed or wounded in action will be considered as with the command by whose sanitary personnel they are tagged. The names of such officers and soldiers will therefore not necessarily appear on the list of sick and wounded of their own organization. (See par. 5790.) 578. Except as provided in paragraph 580, the list of sick and wounded will be made in duplicate, and at the end of the month covered by it the original thereof will be forwarded through medical channels to the Surgeon General. The duplicate will be retained. 580. Stations for slightly wounded will make a single copy of the list of sick and wounded. At the end of each day and when the station is closed the list will be sent at once to the division surgeon. 581. Evacuation ambulance companies should include in their list of sick and wounded only such cases as pertain to their own personnel and such cases as may, under exceptional circumstances, fall into their hands without having been previously tagged by other sanitary formations. 582. Hospital trains and hospital ships make complete lists in regular monthly form only of cases occurring among their own per- sonnel and, in the case of a hospital ship, of cases admitted thereto for definitive treatment. 583. Where patients are transferred from mobile organizations at the front to the line of communications a nominal list of them should if practicable be prepared in duplicate by the transferring officer, the original of which should be receipted and returned to him by the receiving officer. Extra carbon copies of so much as may be per- tinent of the transferring officer's regular list on Form 53 miay be made for this purpose. Transfers from camp hospitals in the zone of the advance, should there be any such, will be accomplished by regular transfer cards (par. 575). (a) The duplicates of the nominal lists mentioned, or the transfer cards as the case may be, furnished as above to an evacuation ambu- lance company, will be turned over to the evacuation hospital or other sanitary formation to which it delivers the patients. Similar disposition will be made by a hospital train or hospital ship of the nominal lists or transfer cards received by it. 584. Should a hospital train or hosjiital ship receive patients unac- companied by nominal lists or transfer cards, the commanding officer MEDICAL UEPARTAIEXT 457 of the train or ship will as soon as practicable prepare a nominal list of such patients on Eorm ^^ (separate and apart from his regular monthly list of sick and woundedj for disposition as above provided. Should the preparation of such a list be inipracticable he will list the patients who seem to be in danger of death so as to be able if death occurs to report the necessary details. PART X CLERICAL WORK Not all sanitary soldiers will make good clerks, but selected pri- vates first class and privates who show special aptitude are required to take the course. The nature, objects, and methods of preparation of the follow- ing reports and records are to be explaii?ed to the class and copies prepared and critized. Each member of the class should be re- quired to prepare various reports. The list includes the usual reports and returns required of officers of the Medical Department in lime of peace (for reports made under field-service conditions onlv, see par. 558, M. M. D.): Name of report, etc. (a) Daily. (1) Surgeon's morning re- port of sick. (2) Morning report, de- tachment of Hospi- ♦al Corps. (3) Daily sick report, de- tachment of Hospi- tal Corps. (b) Trimonthly. (i) Trimonthly report of enlistments. (c) Monthly. (i) Personal report of medical officer, den- tal surgeon, acting dental surgeon, 01 contract surgeon. (2) Return of the Hos- pital Corps. Form No. 71, M. D. 332, A. G. O. 339, A. G. O. iS A. G. 6.. Letter 47a, M. D. To whom sent. C. o. C. o Kept at hospital. I to The A. G. ; 1 retained. to S. G. through D. S. or I di- rect. I to S. G. through D. S. or direct; I retained. Remarks. Made after sick call. Returned by the adjutant to the hospital. Do. At recruit depot* and depot posts made by com- manding officer. At other garri- soned posts and stations made by recruiting officer. See pars. 12, 13. 18, 19, 32, and 5S- Monthly return for field use only. See par. (459) 460 CLERICAL WORK Name of 'eport, etc. Form No. II To whom sent. Remarks. (c) Monthly — Con. (3) Efficiency report of 62, M. D 2 I to D. S. or tu .See par. 99. nurses. a. G. ; I re- tained. (4) Return of the Nurse Corps. 63, M. D 2 do See par. 98. (s) Pay rolls, enlistea 366, W. D.; 366a, 3 3 to C. I returned to sur- men. W. D. geon to be re- tained. (6) Pay roll, Army Nurse 334, W. D.; 3340, 3 2 to paying Q. Corps. VV. D. M.; I retained. (7) Ration return of ma- 223, Q. M. C... 2 I to C. 0. ; memo. tron and others ra- kept at hospital. tioned separately. (8) \'oucher for commu- 331, W. D 3 2 to C. I original and i tation of rations of memorandum. enlisted men, Army Nurse Corps, etc., in hospital. (9) Statement of hospital 49, M. D 2 I to D. S. or to See pars. 260, fund. S. G. ; 1 re- tained. 261, and 262. (10) Report of sick and 51 M. D.; 51a, M. 2 I to S. G. through See pars. 4S7 to wounded. D.; 51b, M. D.; 52, M. D. D. S., or direct; 464. I retained. (11) Report of dental 57, M. D 2 I to S. G. through See par. 473. work. medical chan- nels; I retained. (12) Sanitary report .... so, M. D ~ \ I to The A. G. through military channels; 1 re- tained. See pars. 414 to 417 (13) Report of medical 265, A. G. 2 I to The A. G.; i examination of ap- retained. plicants for enlist- ment. (14) Report of progress of repairs to hos- Letter I S. G See par. 245. pital. (is) Report of progress do I S. G Do. of repairs to quar- ters of sergeants first class. Hospital Corps. (16) \'oucher for hospital 330 or 330a, \V. D. 2 2 to D. S. or to I original and i laundry not done by the S. G. mem oranduni. hospital matron. See par. 277. (17) Account current ... 320b or 320, W. D. 2 I to S. G. ; I re- tained. -Xccompanied by the appropriate vouchers. (18) Report of issues of medicine to- civil- Letter I I to S. G.; in See par. 244. Philippine De- ians. partment to D. S. (19) Requisition for for- 218, Q. M. C -' 2 to C. age. (20) Report of ordnance 94. 0. D 2 I to Q. M., who charges on muster pays the detach- and pay rolls. ment; I re- tained. (21) Statement of charges 208, Q. M. C... 3 2 to Q. M.-, I re- tained. quartermaster prop- erty. (22) Report of meteor- Weather Bureau.. I Through director From designated ological observations. State section Weather Bureau to S. G. posts. See par. 527. CLERICAL WORK 461 Name of report, etc. (J) BiMOHTHLY. (i) Muster roll, detach- ment of Hospital Corps. (2) Muster roll, soldiers in hospital. (3) Return of the Hos- pital Corps. (c) QUARTFRLY. (i) Special requisition for medical supplies. (2) Requisition for table- ware and kitchen utensils. (3) Certificate of break- age, china and glassware. (/) SEMIA^fNUALLY. (i) Return of ordnance and ordnance stores. Form No. (2) Statement of charges for ordnance prop- erty on muster and pay rolls. (3) Return of horse equipments. > (4) Requisition for blanks' 37 M. D. 21, A. G. O .... do 47, M. D 33, M. D 166, Q. M. C... 207, Q. M. C... 18, O. D.; i! cover. 86, O. D... i8a, O. D. (g) Annually. NALLV — Con. (20) Reservist's descrip- tive card. Form No. 443. A. G. O... (21) Notification of trans fer to .\rmy reserve.! (22) Allotment of pay... 38> Q- M. C (.23) Discontinuance of allotment of pay. 559. A. G. O. 38, Q. M. C. 39, Q. M. C. (24) Report of soldier's Letter deposit. j (25) .\dvice of soldier's 8a, Q. M. C. deposits. ! (26) Report of transfer, 1X0 form desertion, or death; scribed, of soldier having! deposits. I (27) Final statement, en- listed man. j (28) Notification of dis- charge, enli-ited man. (29) Discharge certificate, enlisted man. C30T Certificate of dis- ability. (3 1 ) Furlough (32) Statement of service. (m) Certificate of in- debtedness of em- ployee for hospital service. (34) Special requisition for medical sup- plies. 370, W. D... 3, A. G. 0.. 523, A. G. 526, A. G. 527, A. G. O. 17, A. G. O. 66, A. G. O. 15. A. G. O. 49», M. D. 35. M. D. M. C... (35) Requisition for cloth-i 213, Q ing fin bulk). 1 ''36) Requisition for cloth- 165, Q. M. C ing (individual). '37) Statement of cloth- ing. i6sb. Q. M. C. f3S) Requisition for ord- 386 O. D nance. I ( 3<)) Return of medical 17, M. D. ; 17a, propertv. SX. D. : f;h, M. I D.: i-f. M. D. 3v,- To whom sent. Remarks. I to reservist; i to See Appendix: office where rec- Army — Re- ords are kept. serve. I to The A. G. di- Do. rect; i retained.] I to Q. G. ; I re-' taincd. ] Q. G I Notation of dis- c o n t i n- uance made on retained copy of allot- ment of pay. C. o. roll. Q. G. Q. G. with pay As prescribed on the form. Paying Q. M Soldier C. o. do To accompany charges against enlisted man for trial by court-martial. As required by Army Regula- tions. 4 or 3 I 4 to D. S. or 3 to I the S. G. 3 to Q. M. direct. 2 to Q. M. direct. I i Retained to C. O.; t re- tained. to S. G. ; I re- tained. In urgent cases report by tele- graph. See Army Regu- lations: Final payment, en- listed tnen. To be given by field officer of soldier's regi- ment or corps, or by the command- ing officer when no field officer is pres- ent. returned to surgeon to be retained. See par. 485. Separate slips for each man drawing cloth- ing. Filed with req- uisition to which it per- tains. See par. 507. 464 CLERICAL WORK Name of report, etc. (h) Occasionally — Con. (40) Report of survey... (41) Inventory and in- spection report. (42) Special sanitary re- port. (43) Report on officer or enlisted man who has been in general hospital three months. (44) Report of appear- ance of epidemic dis- ease at or near a military post or sta- tion. (45) Report of appear- ance of epidemic disease in a military command en route to new station. (46) Notification to local board of health of appearance of in- fectious disease at a military post. (47) Reports of births... (48) Reports of deaths. . . (49) Special reports of in- teresting cases. (50) Report of change of combination of lock of hospital safe. (i) On Breaking up of Hospital. (i) Current periodical re- ports and returns to be completed. (2) Retained records Form No. 196, A. G. O I, I. G. D.. Letter Manuscript . Letter .... do .... Letter or local form. V. S. 109. V. S. 98.. Letter ...do c " To whom sent. 3 to C. O. 2 to inspecting officer. To The A. G. through mili- tary channels. 2 to S. G I to C. O. ; I to D S.; 1 to S. G. 3 copies as in pre- ceding case; ad- ditional copy to surgeon of new station. Board of health.. To Director of Census. . ... do S. G. through medical chan- nels. S. G. Number of copies and disposition as at the end of full stated peri- ods in each case. The .'\. G. with schedule. Remarks. See .Army Regu- lations. See par. 416. See par. 287. See par. 201. Do. See par. 203. See par. 401. Do. By the attending physician. See pars. 421 and ^ 422. See par. 247. LIST OF RECORDS The following list includes all the principal records required to be kept in military hospitals in addition to retained copies of reports, returns, etc. : (i) Register of sick and wounded (Form 52). (2) Clinical records (Forms 55, a to u). (3) Prescription files (par. 240). (4) Register of dental patients (Form 79). CLERICAL WORK 465 (5) Correspondence records (pars. 402 to 406). (6) Record of instruction of the Hospital Corps (pars. 163 and 178). CORRESPONDENCE RECORDS The record card system, as prescribed in War Department orders, will be used for recording and filing the correspondence at the offices of department surgeons, unless otherwise directed by higher authority, and at general hospitals, medical supply depots, and such other offices as may be specially authorized to emi)loy it. The correspondence book system, as prescribed in War Depart- ment orders, will be used for recording and filing the correspondence of all post hospitals and other sanitary formations not mentioned in the preceding paragraph, except those for which some other system is specially prescribed. All the usual reports and returns required of medical officers in time of peace are given in paragraph 398, M. M. D. Such of these as are applicable to the changed conditions will be made in time of war. The following special reports and forms are required only during campaign : (a) Daily' field report of sanitary personnel and transportation (Form 82). — This report will be made daily to the proper medical superior by the senior medical officer of every organization in the field, a copy being retained. Telegraphic report of the data called for thereon may be required if necessary. (b) Daily field report of patients (Form 83). — This report will likewise be rendered daily, as in the preceding case. {c) Monthly reports from diz'isional sanitary inspectors required by paragraph 747a, M. M. D.. Form 50. {d) Reports of the sanitary inspections of Medical Department organisations required by paragra])h 7480, M. M. D.. Form 50^. (e) Certificate of identity (Form 61). — This certificate is issued to those who are entitled to wear a brassard but who do not wear a uniform. (See pars. 542 and 543. M. M. D.) (/) Diagnosis tags. — On the battlefield diagnosis tags are apjilied to all sick, wounded, and dead and are used in recording and report- ing casualties. (See pars. 567 to 574, ^I. M. D.) (g) List of sick and icounded (Form 53 ). — With the exceptions noted in paragraph 575, M. M. D., this form will be used as a sub- 30 A66 CLERICAL WORK stitute for Forms 51, 51a, 516, and 52 in reporting and recording the sick and wounded in the theater of operations. (h) Return of casualties (Form 149, A. G. O.). — This report is made after every action in which casuaUies have occurred, by the commanding officer of each independent organization. Casualties pertaining to the personnel of the organization making the report only should be included. Regimental surgeons furnish regimental commanders with infonnation necessary for the preparation of the report. (/•) In the case of Medical Department units which have quarter- master accountability such additional records, reports, returns, etc., as are required by the Quartermaster Corps must be kept and made. The various blank forms for the preparation of the papers re- quired by the several departments concerned are enumerated in paragraphs 961 to 965, M. M. D. They must be obtained as indi- cated therein for time of peace or, in the case of troops in the theater of operations, as prescribed in paragraph 551&. M. M. D. Medical supply depots on the line of communications will make returns, reports, and records similar to those of home depots. In addition they will make to the surgeon, base group, the daily field reports of sanitary personnel and transportation required by para- graph 558, M. M. D. PART XI MINOR SURGERY The noncommissioned officer of the hospital corps must very frequently act as the surgeon's assistant, performing such duties as in civil life are assigned to a physician. He may have to take entire charge of the anesthetic, or act as the first, second, or other assistant. Indeed, the occasions are not infrequent when a small detachment is in the field without any medical officer, and the non- commissioned officer himself may have to do minor operations and permanently arrest hemorrhage. CHAPTER I ANESTHESIA, GENERAL AND LOCAL An anesthetic is an agent that abolishes sensation. It may be general or local. The former affects the whole system and produces unconsciousness and muscular relaxation. The latter aft'ects only the part to which it is applied, destroying the sensation of the locai nerves. The principal general anesthetics are ether, chloroform, ethyl chloride, and nitrous-oxide gas, the latter being used almost exclu- sively by dentists. Before commencing the administration of any anesthetic every- thing should be made ready ; the patient should not have had any food, except perhaps a cup of coffee or bouillon, for five or six hours before commencing anesthesia. His head should rest on a low pillow covered with a towel, and the skin of the face, around the mouth and nose, which is liable to be irritated by the anesthetic, should be protected by vaseline. On a small table to the right of the anesthetizer should be placed the appropriate articles, ether or chloroform, a screw gag, lever (467) 468 MINOR SURGERY gag, tongue forceps, swab-holder and swab, towel, teaspoon, sterile water, a hypodermic syringe ciiarged with two milligrammes of strychnine, hypodermic tablets of morphine, di,e pad and sometimes also a perineal strap for additional security in large hernias. After a truss is adjusted, its efficiency should be tested by MINOR OPERATIONS, CONTINUED 483 seeing whether it will hold up the hernia when the patient stands, sits, lies down, bends over, descends stairs, etc. To measure for a truss place the end of the tape over the point where the hernia escapes, and carry it around the pelvis midway between the anterior superior spine of the ilium and the great trochanter, and back to the starting point. Toothache: When there is a cavity it should be cleaned out with a little absorbent cotton on the end of a probe or match, and the cavity then plugged with a bit of cotton dipped in phenol, creosote, or oil of cloves. The tooth should not be extracted unless there is no chance of obtaining the services of a dentist for a considerable time and mean- while the pain is unbearable. To extract a tooth see that a forceps is selected which is adapted to the particular tooth ; in the sets of forceps furnished the army the particular forceps for each tooth is indicated on a card. For- ceps of which the bite has a plain curve on each side are adapted to teeth with a single root, such as the incisors and canines ; those of which the bite has a projection on the outer side are for the upper molars, the projections being intended to fit between the outer roots ; and those with a projection on both sides are for the lower molars. The gum should be separated from the neck of the tooth with a lancet, and the forceps pushed down between the gum and the tooth until they reach but do not grasp the border of the alveolus. In order to avoid breaking oflf the crown, the pressure of the forceps must be only sufficient to keep them from slipping. The tooth is then loosened a little by a rotary motion for the incisors and canines, and an inward and outward rocking motion for the other teeth, and extracted by a steadily increasing pull as nearly as possible in the direction of the axis of the tooth. The head and jaw of the patient should be steadied by the left arm and fingers of the operator. Two kinds of electric batteries are usually furnished in the army medical department; a galvanic or continnous-cnrrcnt battery, and a faradic or interrupted-current apparatus; sometimes the two are combined. To care for batteries properly it is necessary that their mechan- ism should be studied. After use the elements or poles should 484 MIXUR SURGERY always be lifted out of the liquid, and care should be taken not to spill the liquid in handling. With dry-cell batteries it is only necessary to see that the circuit is open when the battery is not in use, but electrodes should be dried or wrapped in some protective before they are put away lest they cause swelling of the box or rusting of the connections. The essential parts of a galvanic battery are the cells which con- tain the liquid, the elements which dip into the liquid, the cords which conduct the electricity, and the electrodes, usually covered with sponges, through which the electricity is applied ; faradic bat- teries have in addition a coil and an interrupter. The sponges should be well moistened with water before use. To exercise muscles in paralysis the faradic current is usually given about ten minutes at a time. One of the moistened sponges is placed at any part of the limb and the other is moved about with a massaging motion ; the skin also should be well moistened. The galvanic current is given as directed by the surgeon. CHAPTER IV ADHESIVE PLASTER, STRAPS AXD STRAPPING As many of the uses of adhesive plaster are so important, it is thought best to devote a chapter of minor surgery to a detailed consideration of its various applications. To hold splints in place, especially in the upper extremity, it is much superior to bandages, as it allows the fractured parts to be Fig. 26a. — Application of Adhesive-Plaster Strips to Retain Splints. seen; for this purpose two or three strips about an inch wide are used, and applied as shown in Fig. 262. In the lower extremity webbing straps with buckles are better than adhesive straps to hold the splints in position but the adhesive plaster is used for purposes of extension in fractures of the thigh. For this purpose there should be provided two strips of plaster, each two inches wide and long enough to reach from the seat of the fracture to the malleolus ; to each strip is sewed a webbing strap of the same width as the plaster and six inches long ; three strips, each an inch and a half wide and long enough to encircle the limb, (485) 486 MINOR SURGERY just above the malleoli, just above the knee, and just below the fracture respectively; and two strips an inch and a half wide, and long enough to encircle the limb spirally from just above the mal- leoli to just below the fracture. After the limb has been washed, shaved, and dried, the first two straps are applied to the middle of each side of the limb from just below the fracture to the malleoli ; then the last two straps are ajjplied spirally in opposite directions to keep the first from slipping, and lastly the three remaining straps are applied in a circular manner as indicated (Fig. 263). A band- age is applied over all. A spreader of wood, about two inches wide and sufficiently long to clear the malleoli, is attached to the webbing straps; the Fig. .'63. — Strapping for Extension in Fracture of the Thigh. Spreader has a hole in the middle through which passes a cord which plays over a pulley; to the outer end of the cord is attached a weight. In fractures of the ribs a broad swathe of plaster is used, wide enough to extend about six inches on each side of the fracture and long enough to reach three-fourths of the distance around the chest (Fig. 264). The patient standing or sitting, with his hands on top of his head, one end of the swathe is fastened just over the spinal column ; with the other end in his hands the surgeon walks around the patient applying the swathe smoothly and very firmly. Or strips of plaster about four inches wide may be used, each strip overlapping the pre- vious one about one-third. In fracture of the clavicle a Sayre dressing (Fig. 265) is espe- cially useful in the field. Prepare three strips of plaster, each three or four inches wide and long enough to go one and one-half times around the body. Encircle the upper arm just above the middle with a strip of bandage wider than the plaster; place a folded towel ADHESRE PLASTER, STRAPS AND STRAPPING 487 in the axilla, and a couple of layers of gauze sprinkled with talcum wherever the skin surfaces would come in contact. Pin a loop of one of the plaster strips, sticky side out, around the upper arm over the bandage ; then, while an assistant holds the shoulders back, carry the other end of the strip across the back, under the sound axilla, and over the front of the chest back to the starting point. Now place the hand of the injured side on the sound shoulder; take Fig. 264. — Strapping the Chest for Fractured Ribs. the second strip and, starting at the back of the sound shoulder, carry it obliquely across the back, under the elbow of the injured side, supporting it, and up over the injured forearm and hand to the starting point. The third strip is carried circularly around the body holding the arm to the side. W^here the second strip crosses the elbow a slit should be made in the strip to secure the elbow, which must here be protected from cutting by the edges of the plaster with a little cotton batting. Over the whole a \'elpeau bandage may be applied. 488 MINOR SURGERY Strapping a sprained ankle has already been fully described, page 90. A sii'ollen testicle after the acute inflammation has subsided is best treated by strapping. The straps should be a half-inch wide and ten or twelve inches long; the operator isolates the affected testicle by encircling its upper part with the thumb and index fingers ^(A Fig. 265. — Sayre's Strapping for Fracture of Collar-bone. Back view. Fig. j66. — Strapping tlio Testicle. of the left hand, and replacing the encircling fingers with a strap of plaster. He then covers the testicle with a series of recurrent strips, and reenforces the latter by circular strips ( Fig. 260). To bring the edges of a n'ound together in the absence of sutures, straps of plaster one-fourth to one-half an inch wide may be used. As the plaster is not aseptic the wound itself must be protected from contact with the plaster by a narrow strip of sterile gauze. To remove plaster straps from a wound, both ends of the strap must be detached simultaneously so as not to tear apart the edges of the wound. When a good deal of plaster has to be removed, especially if the part is hairy, a little ether or alcohol should be dropped under the edges of the plaster as it is raised; this will cause it to come away without any pulling. Any remaining plaster may be washed off with ether or alcohol, and the skin then dusted with talcum. INDEX Abduction, 49 Abscesses, 475 Acacia, 290 Acetabulum, 42 Acetanilid, 291 Acid, acetic, 291 boric, 291 citric, 291 gallic, 291 hydrochloric, 291 hydrocyanic, 291 nitric, 291 oxalic, 291 phosphoric, 292 salicylir, 292 sulphuric, 292 aromatic, 292 tannic, 292 tartaric, 292 Acids, mineral, 287 organic, 287 Active principles, 287 Acupuncture, 478 Adeps benzoatus, 292 Adrenalin chloride, 292 Admission of patients, 10 Advance group, 28 medical supply depot, 31 Administrative zones, 12 Adduction, 49 yEdes calopus, 356 Aids in horsemanship, 381 Aid stations, 22 Alcohol, 293 wood, 293 bath, 161 Alimentary principles, 62 canal, 63 Albuminates, 62 Alcoholism, 128 Alkalies, 288 Alkaloids, 2S7 Aloes, 293 Alum, 293 Ambulances, 417 Ambulance companies, 426 Ammonia water, 294 aromatic spirits, 294 bromide, 294 carbonate, 294 chloride, 294 nitrate, 294 Anaesthesia, 467 local, 467, 470, Anaesthetics, 288 Antitoxin, diphtheria, 477 Ankle joint, 42 Anatomical neck, 44 Anthrax, 95 Antipyrin, 294 Antitoxins, 252 Antidotes, 137. 288 Anthelmintics, 288 Anodynes, 288 Antipyretics, 288 Antiseptics, 288 Astringents, 288 Apparatus, compressed air, 234 electric, 234 restraint, 234 steam sterilizing, 236 infusion, 236 blood pressure, 238 Apomorphine, 294 Apples, baked, 279 Apothecaries' weight, 324 Aqus, 318 Argyrol, 295 Arsenic, 295 Arachnoid, 55 Arteries, 74 Army regulations, 413 Artificial limbs, 425 respiration, 130 (489) 490 INDEX Asafetida, 295 Aspidium, 295 Aspirin, 295 Astragalus, 42 Aseptic, 243 Atomizer, hand, 208 Autoclave, 245 Atropine sulphate, 295 Avoirdupois weight, 323 Bacon, fried, 283 Balsam tolu, 310 Baking food, 268 Baker, 161 Bandaging, 185 rules for, 189 Bandage, plaster, 198 roller, 188 Scudder, 194 tailed. 197 triangular, 185 Velpeau, 193 Bacteria, 200, 242 Bacilli, 242 Ball and socket joint, 41 Base group, 28 hospital, 29 medical supply depot, 30 Baths, alcohol, 161 Brandt, 160 electric light. ]C)2 hot air and steam, 158 local, 162 sedative, 158 sponge, IS7 Batteries, electric, 483 Bearer drill, 428 Bed-bugs, 145 Beds, fracture, 154 operative, 153 Bed-sores. 155 Beef broth, 274 juice, 273 scraped, 280 steak, broiled, 280 tea, 274 Belladonna extract, 296 plaster, 296 Belt web, 241 Bismuth, suhgallate, 296 subnitrate, 296 Bistoury, 208 Biers' cups, 172 Bile, 67 Blanc mange, 281 Bladder, urinary, 86 Blisters, 173 Blood, 71 specimens, 479 Blue mass, 302 ointment, 302 Boiling, food, 267 Boils, 474 Bone, 37 Bottle drop, 238 Bougie, 208, 319 a boule, 208 filiform, 208 Brain, 53 Brass, to clean, 144 Bread making, 268 Broiling, 268 Broth, chicken, 274 clam, 275 Bronchi, 81 Brown mixture, 300 Buchu, fluidextract, 296 Burns, 123 Bridle, to, 377 Caffein, citrate, 296 Calcium, precipitated phosphate (>f. 296 Calomel, 301 Callus, no Camphor, 296 and opium pills, 296 Camps, 364 concentration, 17 hospitals, 17 infirmaries, 23 Cantharidcs, plaster, 297 Capsicum, ^•97 INDEX 491 Carbuncle, 475 Carbolic acid, 305 Cardamoni composita tinctura, 297 Carminatives, 288 Carpus, 44, 45 Caries, 38 Cartilage, 38 Cascara sagrada, fluidextract of, 307 tablets, 307 Case operating, 238 emergency, 240 Cataplasma, 319 Catheterization, 167, 481 Catheter, 208 Catlin, 208 Caustic holder, 208 Cauter}', Paquelin, 173 Cement, 46 Cerata, 318 rosini, 297 Cerebellum, 55 Cerebrospinal meningitis, 254 Cerebrum, 53 Cesspools, 349 Chalk, prepared, 299 Chafmg, 366 Chancroid, 255 Chartae, 318 Chartulae, 319 Chejne Stokes respiration, 178 Chicken, minced, 280 stewed, 280 Chilblain, 125 Chloral hydrate, 297 Chloroform, 297 administration of, 409 Chocolate, 281 Cholera, 254 Chromic acid, 297 Chrysarobin, 297 Chyle, 63 Chyme, 67 Cinchona, compound tincture of, 297 Clamps, pile, 210 towel, 210 Clap, 368 Clavicle, 45 fracture of, 486 Clean floors, 144 metals, 144 porcelain, 144 Clerical work, 459 Cocaine, hydrochloride, 297 Codeine sulphate, 298 Colchicum seed, fluidextract of, 298 Colodion, 298, 318 Copaiba, 298 Capillaries, 75 Colation, 316 Coffee, 2^z Cold pack, 160 Collars, horse, 407 CoUes' fracture, 44 Collyrium, 319 Colon, 65 Color blindness, 60 Combat, duties in, 20 Compounding, 334 Compound cathartic pills, 306 Compression of the brain, 127 Compresses, cold, 171 Concentration camps, 17 Concussion of the brain, 126 Condyles, 41, 44 Conjunctiva, 59 Connective tissue, 50, 148 Contagious, 200 Contagious diseases in hospital, 29 Contusion, 90 Convalescent camps, 29 Convolutions, 52 Cooking, 266 Cooler, prostatic, 210 Copper arsenite, 299 Cornea. 59 Correspondence, records, 465 Cotton, 367 Counter irritants, 171 Crematories, 352 Cresol, 298 compound solution of, 299, 303 Creos(3tc, carbonate, 298 Crystalline lens, 59 49^ INDEX Cubeb, 299 Cups. dry. 172 Biers'. 172 Curette, 208 Custard, baked, 276 Cuticle, 50 Cutting shears, 210 Darnall filter, 341 Death, signs of, 151 Decantation, 316 Decoctions. 313, 318 Dentine. 46 Derma. 50 Desiccation, 317 Diagnosis tags, 240, 255 Diaphragm, 50 Diaphoretics. 288 Diets, full or house, 263 hquid. 263 light. 263 special, 263 serving of, 148 Digitalin, 299 Digitalis, tincture of, 299 Diphtheria antitoxin, 477 Director, 212 Discipline, instruction in, 427 Disease, prevention of, 355 Disinfectants, 289 Disinfection of the hands, 249 rooms, 206 tents. 207 Dislocations, 41, 103 Dismount, to, 380 Dispensary management. 435 Dispensatory, 311 Distillation, 316, 317 Diuretics, 289 Divulsor, urethral, 212 Douche, eye, 166 nasal, 166 spinal, 166 Drainage of wounds, 249 Dressings, dry, 245 wet, 245 sterilizing, 246 Drill, bone, 212 Driving, 393. 398 four in hand, 401 Drowning, 134 Duties of the medical department, 13 noncommissioned officers, 16 Dura mater, 57 Dyspnoea, 178 Dysentery, 254, 361 Ear, 58 Effects of patients, 431 Egg and sherry, 273 lemonade, 273 nog, 2-2 omelet, 275 poached, 275 soft cooked, 275 Electric batteries, 483 light baths, 162 shock, 127 ^ Elixirs, 318 Emetics. 289 Emplastra, 318 Empyema, 478 Emulsions, 318, 320 Enamel, 6 Enema, 319 Endoscope, urethral, 212 Enlisted personnel, medical depart- ment, classification of, 3 uniform of, 6 Epsom salts, 303 Epilepsy', 128 Eruptive fevers, 361 Erythrocytes, 71 Erysipelas, 257 Ergot, fluidextract, 299 Ergotine, 299 Emetine, hydrochloride, 299 Essentia, 319 Ether, 293 administration of, 468 compound spirits. 293 spirits of nitrous. 293 Ethyl chloride, 293 Eucaine, 299 Eucalyptol, 290 Evacuation ambulance company, ZZ INDEX 493 Evacuation hospital, 33 Expectorants, 289 Extension, 50 Extracta, 318 Eye, 59 douche, 166 Faixting, 126 Fats, 61 Feeding, 385, 406 Felon, 475 Femur, 40, 41 Fevers, 177 Field desk, 241 Field hospitals, 24, 426 Fibula, 41 Filtration, 316 Flexion, 50 Fluidextracts, 318 Fomentation, 170 Foot powder, 300 Foot soreness, 365 Formalin, 303 Fowler's solution, 306 Foramen magnum, 45 Foreign bodies, eye, 119 ear, 120 nose, 120 throat, 121 skin, 121 Formaldehyde, 201 gas, 201 Forceps, bone holding, 214 bullet, 212 dental, 212 dissecting, 214 dressing, 214 ear, 214 gouge, 216 haemostatic, 216 Liston's bone, 216 mouse tooth, 216 nasal, 214 needle holder, 216 sequestrum, 218 sterilizer. 214 tenaculum. 228 tongue, 216 Fractures, 108 clavicle, 486 ribs, 486 Freezing, general, 124 local, 125 Frost bite, 125 Frontal bone, 45 sinuses, 45 Fruit stewed, 278 Fr>'ing, 268 , Fund, hospital, 436 Furuncle, 474 Gag, mouth 218 Gall-bladder, 66 Garrison and field service, 417 Gastric juice, 66 Gauze sponges, 246 General hospitals, 420 Gentian compound tincture, 300 Ginger, fluidextract, 310 Glenoid cavity, 45 Gloves, rubber, 250 Glycerin, 300 Glycerites, 318 Gonorrhea, 255 Gram, 324 Grilling, 268 Grooming, 384 Gruel, farina, 271 hard bread, 272 rice, 271 Guaiac ammoniated tincture, 301 Guaiacol carbonate, 301 Hamamelts leaves, fluidextract, 301 Harness, 355, 410 to fit, 396 Hearing, 60 Heart, 75 Head mirror, 318 Heat, use of in pharmacy, 311 exhaustion, 123 Heating, hot water, 346 steam, 347 Hemorrhage, arterial, 97 venous, 96 Hernia. 482 4!:»i INDEX Heroin hydrochloride, 301 Hinged joints, 41 Hitch, to, 398 Homatropine hydrobromide, 301 Hoffman's anodyne, 293 Horse, care of, 388 equipment, 372 Horsehair, sutures, 251 Hospital buildings, 423 clothing, 433 Corps, instruction of, 427 field, 426 fund, 436 general, 420 matrons, 437 services of, 420, 430 ships, 18 trains, 17 Hydrargj-rum chloridum corrosivum, 301 Hydrastis, fluidextract, 302 Hygiene, personal, 367 Hypodermic syringe, use of, 150 Hypnotics, 289 Hyoscine, hydrobromide, 302 Hyoscyamus, extract, 302 compound pills, 302 Ice bag, 171 for hospitals, 437 ■water, coil, l/l Icthyol, 302 Ilium, 40 Incompatibilit}', 335 Infection and disinfection, 200 Infected property, 433 Inferior maxillary bone, 46 Inflammation, 92 Tnflator, Politzer, 218 Influenza, 256 Infusions, 313, 318 saline, 476 Inhaler, chloroform, 218 ether, 218 Innominate bone, 40 Insect powder, 302 Insignia of sanitary personnel, etc., 14 Instruction, winter course, 428 in the field, 430 Instruments and appliances, 218 sterilizing, 246 cleaning, 250 Insolation, 122 Intermediate group, 28 Intestine, large, 65 small, 65 Iodine, 302 Iodoform, 302 gauze, 246 Ipecac and opium powder, 302 fluidextract, 303 powdered, 302 Irrigation, 165 of the bladder, 168 Iron and quinine citrate, 299 compound pills, 300 dried sulphate, 300 reduced, 300 soluble phosphate, 300 syrup of iodide, 300 tincture of chloride, 299 Ischium, 40 Jelly, coffee, 278 wine, 278 Joint, 40 Junket, 211 Kidneys, 85 Knives, amputating, 220 tenotomy, 220 Koumyss, 272 Laboratories, Department, 442 Lachrymal probes, 220 styles, 220 Lancet, 220 Lanolin, 292 Lard, benzoated, 292 Larynx, 81 Latin words, ss^ Laundry, hospital, 438 Lavage tube, rectum, 220 stomach, 220 INDEX 495 Lemonade, 272 Leucocytes, 71 Lice, 366 Licorice, extract, 300 compound mixture, 300 compound powder, 300 Ligatures, sterilizing, 247 Lightning stroke, 127 Ligaments, 41 Lime, 296 chlorinated, 296 Linen, 367 Linaments, 318 Line of communication, 27 Liquors, 318 Liquor creosotis compound, 303 formaldehyde, 303 Liver, 66 Liter, 324 Lithium carbonate, 303 effervescing citrate, 303 Lunar caustic, 479 Lymphatics, 68, 70 Lycopodium, 303 Lyster's sterilizing bag, 338 Magnesium carbonate, 302 oxide, 303 sulphate, 303 Malaria, 254 prevention of, 254 Malarial fever, 355, 357 Master hospital sergeants, appoint- ment of, 3 Materia medica, 287 Matrons, hospital, 437 Measles, 256 Measures, approximate, 285 Mechanical subdivision of drugs, 317 Medical attendance, 424, 431 supplies, 425 Medicines, giving of, 149, 289 dosage, 289 Medulla oblongata, 55 Meninges, 55 Menstruum, 312 Menthol, 303 Mercury corrosive chloride, 301 mass, 302 ointment, 302 ointment of nitrate, 302 oleate, 302 salicylate, 302 yellow oxide, 301, 302 Mesentery, 67 Mess management, 259, 433 Metric system, 324 Metacarpal bones, 45 Metatarsal bones, 42 Milk, albuminized, 270 peptonized, 270 porridge, 2"]"] punch, 270 sterilized, 270 Micrococci, 242 Mineral acids, 287 Minor surgery, 467, 472 Mixtures, 318 Mobilization camps, 17 Morphine sulphate, 303 Mosquitoes, anopheles, 356 aedes calopus, 356 culex, 356 Mount, to, 378, 381, 382 vlucous membranes, 50 Mumps, 256 Muscles, 48 sterno-mastoid, 50 biceps, 50 Myrrh, tincture, 304 Naphthalene, 304 Narcotics, 289 Nasal bones, 45 douche, 166 496 INDEX National formulary, 311 Necrosis, 40 Needle, aneurism, 220 surgical, 220 Neosalvarsan, 304, 477 Neutral principles, 287 Nerves, brachial plexus, 56 cranial, 58 dorsal, 56 lumbar, 56 motor, 57 sacral, 56 sensory, 57 phrenic, 56 Normal saline solution, 248 tablets, 304 Nose-bleed, 96 Nux vomica, tincture, 304 Oatmeal porridge, 276 Objects of medical department ad- ministration, 12 Occipital bone, 45 Oesophagus, 63 Officer of the daj-, 439 Oil, castor, 304 cloves, 304 cod liver, 304 cotton seed, 304 croton, 305 gaultheria, 304 orange peel, 304 peppermint, 304 santol, 305 theobroma, 305 turpentine, 305 wintergreen, 304 Oils, essential, 288 fixed, 288 volatile, 288 Ointments, 322 Olecranon, 44 Oleoresine, 318 Omentum, 65 Operating room, 245 Operations, minor, 472 after care, 244 Opium, compound tincture of, 305 poisoning, 129 Optic nerve, 60 Orangeade, 272 Organic acids, 287 Organization in war, 15 Pack saddle and packing, 389 Palate, 63 Pancreas, 66 Pancreatic juice, 67 Pancreatin, 305 Paraplegia, 58 Parietal bone, 45 Patients' effects, 431 public property, 432 Patella, 41 Pelvis. 40 Pepper, 305 Peptonizing tablets, 305 Periosteotome, 220 Percolation, 313 Periosteum, 40 Peroxide solution, 295 Personal hj'giene, 367 Personnel of the sanitary service, 13 Petrolatum, 305 liquid, 305 Phalanges, 42 Pharmacy, 287, 311 Pharmacopcea, 34 Phenacetin, 291 Phenol, 305 Phenolphthalein, 306 Physostigmine sulphate, 306 Pia mater, 55 Picric acid, 310 Piles, 475 Pills, 318, 321 Pill, carminative, 306 cathartic compound, 306 Pilocarpine hydrchloride, 306 Plague, 55 Pleura, 82 Plumbi acetas, 306 Pneumonia, 256 INDEX 497 Podophyllum, resin of, 306 Poisoned wounds, 94 Poisoning, 136 arsenic, 139 carbolic acid, 138 chloral, 139 corrosive sublimate, 139 nitrate of silver, 139 phosphorus, 13S ptomaine, 138 strychnine, 140 wood alcohol, 138 Poison oak, 140 Porcelain, to clean, 144 » Pons, 55 Portal system, 80 Position of the trooper, 378, 382 Potatoes, baked, 279 boiled, 279 mashed, 279 roasted, 279 Potable water, 337 Potash acetate, 306 arsenite solution, 306 bicarbonate, 306 bromide, 306 chlorate, 307 and sodium tartrate, 307 hydroxide, 307 iodide, 307 permanganate, 307 Potts' fracture, 42 Poultices, 169 Precipitate, 316 Preparation for operation, 243 Probe, 220 Pronation, 48 Protargol, 307 Property infected, 433 medical, care of, 452 Prunus Virginiana, fluidextract, 307 Pubis, 40 Pupil, 59 Pulmonarj^ circulation, ^2 Pulse, 177 Pyaemia, 92, 243 Pyrethrum, 302 32 QuiNiNK hydrochlorosulphate, 307 sulphate, 307 Radius, 44 Rabies, 95 Ration, 62 emergency, 359 field, 259 Filipino, 261 garrison, 259 reserve, 259 travel, 259 Recipes, 240 Records, list of, 464 and correspondence, 465 Reflex action, 57 Register, sick and wounded, 444, 455 Reins, 380, 401 holding, 400 Report, sick and wounded, 448, 453 Reports and returns, 460 Requisitions, 449 Rest station, 18, 30 Retina, 59 Retractor, 222 Rhamni Purshianae fluidextract, 28 Rhei pulvis, 308 Rhubarb powder, 308 Ribs, 42 fractures of, 486 Rice, boiled, 277 pudding, 284 steamed, 2"]^ Riding, 371 Rigor mortis, 49 Roasting meats, 268 Rochelle salt, 307 Rotation, 49 Rubber goods, sterilizing, 248 Rules for hospitals, 7 of the road, 405 Rupture, 482 Sacchari lactis, 308 Saddle, to, zil 498 INDEX Saddle blanket, to fold, 372 to put on, 373 Saline infusions, 476 Salivary glands, 64 Salol, 306 Salophch, 308 Sanitarj' soldier, instruction of, 4 Sanitary squads, 29 train, 24, 418 Santonin, 308 Sapo mollis, 308 Saw, amputating, 222 Hey's, 222 metacarpal, 222 plaster of paris, 222 Sayre's dressing, 486 Scalpel, 222 Scapula, 43 Scales, 327 Schleich's method, 471 Scissors, 224 Sclerotic, 60 Searcher, stone, 226 Sebaceous glands, 50 Septicaemia, 92 Sepsis, 200, 293 Sergeants, medical department, ex- amination, 5 first class, appointment of, 5 Serums, 252 Serum, antidiphtherium, 308 antitetanicum, 308 antimeningiticlis, 308 Service of hospitals, 420 of the interior, 17 Sewage, 349 Sewers, 349 Shock, 60, 126 Sick-call, 424 Sight, 59 Silver nitrate, 295 Sinapis emplastrum, 308 Siphon, use of, 316 Snake bite, 94 Sodium, bicarbonate, 308 bicarbonate and peppermint, 308 borate. 308 bromide, 308 carbonate, dried, 309 fluoride, 309 hyposulphite, 309 phosphate, dried, 309 salicylate, 309 Soft soap, 308 Solutions, 312 percentage, 312 saturated, 312 Sound, urethral, 224 Soup, making, 267 canned, 275 pea, 284 tomato, 285 Spanish windlass, 98 Special senses, 58 Specimens, collection of, 183 blood, 479 water, 342 Specula, 224, 226 Spinal anaesthesia, 471 canal, 39 cord, 39, 57 column, 89 douche, 166 Spinous processes, 40 Spirits, 318 frumcnti, 309 nitroglycerine, 308 Spleen, 66 Splints, III Splinters, 121 Splint bone, 45 Sponge holder, 224 Spores, 243 Spud and needle, 22^ Sprains, 44, 105 Stable duty, 384 management, 387 INDEX 499 Status of sanitary personnel, 15 Station for slightly wounded, 125 Sterilization, 200 Sterilizer, 245 Stethoscope, 228 Sternum, 42 Stirrup, 383 Stomach, 64 tube, 480 Straps and strapping, 485 Strophanthus, tincture, 309 Str\-chnine sulphate, 309 Stupe, 170 Styptics, 289 Sulci, 53 Sulphur, disinfection by, 204 lotum, 309 Sulphonal, 309 Sulphocarbolate of zinc, 310 Superior maxillary bone, 45 Supinator, 44, 49 Suppositories, 318, 322 Suprarenal gland, 88 Supplies, medical, 425, 449 Surgical neck, 44 rounds, 244 Surgery, minor, 467 Sutures, 41, 473 sterilizing, 247 Sugar of lead, 306 milk, 308 Sunstroke, 122 Symptoms, 179 Synovial membrane, 40 Syphilis, 255, 368, 477 Syringes, 226, 228 Syrups, 318 Syrup of h5-pophosphites, compound, 309 Systemic circulation, 72 Tabellae, 318 Talc, 310 Tarsus, 42 Tartar emetic, 294 Tea, 2JS Teeth, bicuspid, 46 canine, 46 incisors, 46 molars, 46 permanent, 46 pulp, 46 temporary, 46 Temporal bone, 45 Tenesmus, 181 Terebene, 310 Testicle, swollen, 488 Tetanus, 95 Theatre of operations, 18 Therapeutics, 287 Thermocautery, Paquclin, 230 Thermograph, 177 Thermometer, clinical, 176 Thorax, 42 Tj-mol, 310 iodide, 310 Tibia, 41 Tinctures, 31S Titles of medical officers, 16 Toast, dry, 276 milk, 27;^ Tolu, balsam, 310 Tomatoes, baked, 285 stewed, 285 Tongue depressor, 230 Tonsils, 63 Tonsillitis, follicular, 256 Tonsillotome, 230 Toothache, 483 Tourniquet, 232 Trachea, 81 Tracheotomy tube, 232 Traps, 349 Trephine, 2:^2 Tricresol, 298 Trional, 309 Trinitrophenol, 310 Trochanter, 41 Trocar and canula, 232 Troches, 318 Truss, 232, 482 Tuberculosis, pulmonary-, 256 Turnings, 403 500 INDEX Typhoid fever, 253, 355 Tj-phus fever, 257 Ulcers, 475 Ulna, 44 Unbridle, to, y]7 Ungucnta, 318 Unharness, to, 396 Unhitch, to, 398 Unsaddle, to, 375 Urea, 87 Ureters, 86 Urethra, 87 Urethral injections, 165 Urine, incontinence of, 182 retention of, 181 suppression of, 181 Urotropin, 301 Vaccination, antismallpox, 361 antityphoid, 252 Vaccines, 252 Valerian, fluidextract, 310 Vaporization, 316 Vaseline, 305 Veins, pulmonary, 78 systemic, 78 Venereal diseases, 368 Ventilation, 84, 344 Ventricles, S3 Veronal, 310 Vertebrae, cervical, 39 dorsal, 39 lumbar, 39 Vertebral column, 39 Vinum Xericum, 310 Ward, 367 Water, ZZ7 examination of, 442 purification, 338 taking samples, 342 Watering animals, 386 Wax, yellow, 297 Wells, izi Whey, 271 Whip, 403 Wild cherry, fluidextract, 307 Winter course of instruction, 428 Wintergreen oil, 303 Witch hazel, 301 Wounds, 91 contused, 474 incised, 473 infection of, 257 Yellow fever, 254, 360 Zinc, oxide, 310 phenolsulphate, 310 sulphate, 310 Zone of the advance, 28 ""^OF 25 CENTS AN INITIAL P'!i^ FMUURE TO RETURN '^ r- ACCESSED FOR l-/^"- PENALTY ^'"■^noOK ON THE DATE °^^;, TIJ'^/foURTH THIS BOOK ON CENTS ON THE l-^ W.LU 'NCREASE TO SO^^ ^^^ ^^^^^^H DAY DAY AND TO $»0 OVERDUE. SSL ^'"^ DEC 26 194;^ J2M ^; LD 21-50m-l,'3' 4^ 359787 BIOLOGY LIBRARY UNIVERSITY OF CAUFORNIA LIBRARY