139
REPORTS AND PAPERS
Lastly, I invite attention to certain circulars issued by me and to reports and papers rendered by medical officers which illustrate the work of the Medical Department and the many difficulties under which it was accomplished:
CIRCULARS FROM THE OFFICE OF THE SURGEON-GENERAL OF THE ARMY.
[Circular No. 1.]
WAR DEPARTMENT, SURGEON-GENERAL`S OFFICE,
Washington, April 25, 1898.
In time of war a great responsibility rests upon medical officers of the Army, for the result of a campaign may depend upon the sanitary measures adopted or neglected by commanding generals of armies in the field. The medical officer is responsible for proper recommendations relating to the protection of the health of troops in camp or in garrison, and it is believed that, as a rule, medical officers
140
of the United States Army are well informed as to the necessary measures of prophylaxis and the serious results which infallibly follow a neglect of these measures, especially when unacclimated troops are called upon for service in a tropical or semitropical country during the sickly season. In Cuba our armies will have to contend not only with malarial fevers and the usual camp diseases-typhoid fever, diarrhea, and dysentery-but they will be more or less exposed in localities where yellow fever is endemic and under conditions extremely favorable for the development of an epidemic among unacclimated troops. In view of this danger the attention of medical officers, and of all others responsible for the health of our troops in the field, is invited to the following recommendations:
When practicable camps should he established on high and well-drained ground not previously occupied.
Sinks should be dug before a camp is occupied, or as soon after as practicable. The surface of fecal matter should be covered with fresh earth or quicklime or ashes three times a day.
New sinks should be dug and old ones filled when the contents of the old ones are two feet from the surface of the ground.
Every man should be punished who fails to make use of the sinks.
All kitchen refuse should be promptly buried and perfect sanitary police maintained.
Troops should drink only boiled or filtered water and coffee or tea (hot or cold), except where spring water can be obtained which is pronounced to be wholesome by a medical officer.
Every case of fever should receive prompt attention. If albumen is found in the urine of a patient with fever it should be considered suspicious (of yellow fever), and he should be placed in an isolated tent. The discharges of patients with fever should always be disinfected at once with a solution of carbolic acid (5 per cent) or of chloride of lime (6 ounces to gallon of water), or with milk of lime, made from fresh quicklime.
Whenever a case of yellow fever occurs in camp, the troops should be promptly moved to a fresh camping ground located a mile or more from the infected camp.
No doubt typhoid fever, camp diarrhea, and probably yellow fever are frequently communicated to soldiers in camp through the agency of flies, which swarm about fecal matter and filth of all kinds deposited upon the ground or in shallow pits, and directly convey infectious material, attached to their feet or contained in their excreta, to the food which is exposed while being prepared at the company kitchens or while being served in the mess tent. It is for this reason that a strict sanitary police is so important. Also because the water supply may be contaminated in the same way, or by surface drainage.
If it can be avoided, marches should not be made in the hottest part of the day- from 10 a. m. to 5 p. m.
When called upon for duty at night or early in the morning, a cup of hot coffee should be taken.
It is unsafe to eat heartily or drink freely when greatly fatigued or overheated.
Ripe fruit may be eaten in moderation, but green or overripe fruit will give rise to bowel complaints. Food should be thoroughly cooked and free from fermentation or putrefactive changes.
In decidedly malarious localities, from 3 to 5 grains of quinine may be taken in the early morning as a prophylactic, but the taking of quinine as a routine practice should only be recommended under exceptional circumstances.
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 fire.
[Circular No. 3]
WAR DEPARTMENT, SURGEON-GENERAL`S OFFICE,
Washington, D. C., May 18, 1898.
For the information of chief surgeons in organizing the medical department and hospital corps of their commands, the following, relating to the duties of medical officers in the field, is published.
Duties of chief surgeons of corps.-The chief surgeon of a corps is held responsible for the proper and effective management of the medical service of the command.
He should keep a register of the medical officers and hospital corps, making assignments and issuing orders and instructions with the approval of and `by
141
order` of the Major-General Commanding, if authorized to do so. He should make himself acquainted with the sanitary conditions affecting the troops, the efficiency of the field hospitals and of the ambulance companies, and should call for weekly reports of sick and wounded and of the personnel and means of transportation of the hospital corps. All reports and papers not requiring special action should be checked off and receive the stamp of his office before transmittal. Such papers include personal reports of medical officers, monthly reports of sick and wounded, of the hospital corps and of the hospital fund, and sanitary reports from chief surgeons of brigades and divisions; also the lists of wounded called for after an engagement. A copy of the action taken on all papers referred to him or forwarded by him should be made in an indorsement book. Such papers include those relating to resignations, leave of absence, or discharge on account of disability, requisitions for medical and hospital and hospital corps supplies, and all recommendations or complaints referring to the medical service or affecting the health and well-being of the troops. Copies of orders and letters should be made and placed on file, and all circulars and orders from the Surgeon-General or the Chief Surgeon of the Army should be published without delay to the chief surgeons of divisions.
Prior to a movement, the chief surgeon should verify, by personal inspection, the condition of the hospitals and of the hospital corps companies and their trains, and should make all the arrangements needful for the probable exigencies of the campaign. He should see that the assignments by chief surgeons of divisions to positions on the operating staff of the field hospitals include the best surgical skill of each division. On the march, he should accompany the staff and acquaint himself with the topography of the country; and when an engagement is imminent he should indicate to chief surgeons of divisions the localities best suited for the establishment of the field hospitals. He should inspect these from time to time, and exercise general supervision over the first aid and ambulance stations and the movement of the wounded to the hospitals. He should also supervise the movement of sick and wounded to the base or general hospitals, providing transportation and detailing medical officers and attendants for their care. When absent on such duties he should leave a competent medical officer with the staff to represent him and to inform him of important changes in the military conditions. The Commanding General should be kept informed of the work of the Medical Department, and should always be consulted in matters of importance.
Duties of chief surgeons of divisions.-The chief surgeon of a division supervises the medical and hospital corps service of the division. He should transmit official reports and papers, with the stamp of his office if routine in character, or with his views indorsed thereon if the subject appears to call for this action. He should have frequent personal communication with the chief surgeon of the corps, and should endeavor to carry out the views of the latter on behalf of the troops. His usual position is with the staff, but he should make frequent visits to the division hospital and the ambulance company, to oversee their work. He should detail one medical officer in rotation as officer of the day, who, on the march, should keep him informed of any noteworthy occurrence, and who, in camp, should visit each regiment of the division to report on its hygienic and sanitary conditions. Before an engagement he should see that the field hospital is properly established and that the operating surgeons and their assistants are at their proper stations. During and after the engagement he should supervise the movement of the wounded from the ambulance stations to the hospitals.
Duties of chief surgeons of brigades.-The chief surgeon of a brigade is the adviser of the brigade commander in all medical and sanitary questions concerning the command. He should call for a weekly (or daily, as maybe required) report of sick and wounded from regimental surgeons, and of the detailed members of the hospital corps on duty with them. He should forward the formal reports of these surgeons, and promulgate orders from brigade and higher authorities. He should keep careful watch over the health of the brigade, reporting in writing from time to time, as may be required, and consulting in emergencies with the chief surgeon of the division. During and after an engagement he should supervise the work at the first-aid stations and the removal of the wounded to the ambulance stations, unless on account of his superior ability, he has been assigned to duty at the operating tables, in which case a competent officer should be detailed to represent him temporarily on the staff of the brigade.
Duties of regimental surgeons.-The regimental surgeon is in sanitary matters the adviser of the regimental commander. On the march and in camp he should examine the sick with a view to their proper treatment and disposition. He is responsible for any unexpendable medical and hospital property issued for the use of the regiment. His supplies of medicines, etc., should be renewed by requisition
142
on the surgeon in charge of the hospital. Members of the hospital corps on duty with the division are detailed to duty with him. Daily, after sick call, he should send a morning report of sick and wounded and of the hospital corps to the regimental commander, with a duplicate to the chief surgeon of the brigade. He should keep, as a register of sick and wounded, a retained copy of the monthly report forwarded through the offices of chief surgeons to the Surgeon-General. Cases treated in the division field hospital should be borne on this report as so treated. He should forward monthly or when his official station has been changed a personal report on a memorandum slip, After every engagement a list of wounded of the command should e forwarded. If the regimental surgeon is, by order of the chief surgeon, placed on temporary special duty, the senior medical officer with the command will perform the duties of the regimental surgeon. During an engagement he should serve at the first-aid stations.
Duties of surgeons in charge of division hospitals.-The surgeon in charge of a division hospital is responsible for the care of the sick and wounded on the march and in camp, and for the comfort and general welfare of the wounded when brought to the hospital by the ambulance service. He should direct the unpacking of the wagons for the establishment of so much of the hospital as may be necessary, and the subsequent repacking when the march is to be resumed. He should superintend the admission, return to duty, or transfer to base hospitals of his patients. As commanding officer of the hospital corps detachment he should keep the accounts of the enlisted men on duty at the hospital. He should make timely requisition for medicines, medical and hospital stores, supplies and property for the care, expenditure, and use of which he is held responsible. He should supply regimental and other medical officers of the division with such articles as may be required and are available for the treatment of the sick. He should send a daily report of sick and wounded and of the hospital corps to the chief surgeon, and transmit to the Surgeon-General similar reports for the month, with a statement of the hospital fund. After an engagement he should forward lists of wounded, and on sending patients to base hospitals he should furnish transfer lists to the senior surgeon accompanying them. Medical officers may be assigned to assist him in time management of the hospital. One of these should act as executive officer, aiding the surgeon in charge in the work of supervision, and having special charge of the records. Another should superintend the cooking and diet of the hospital, drawing rations from the Subsistence Department, and issuing them for use and keeping the accounts of the hospital fund. He should also have special charge of the hospital stores, and of such articles of property as are connected with the cooking and serving of food. Others should be assigned as attending surgeons to care for the sick on the march and in camp, and during an engagement to look after the management of the wards, and to make notes of operative procedures, deaths, and of the progress of cases for subsequent report to the surgeon in charge and entry on the records of the hospital.
Duties of medical officers in command of ambulance companies.- The medical officer, in command of the ambulance company is charged with the care of the pay, clothing, and subsistence of his men, and is held responsible for the care of ambulances and other wagons; tents; horses, mules, forage, etc. His subaltern officers assist him in the discharge of these duties. During and after an engagement he is responsible for the safe and speedy transportation of the wounded on litters and in ambulance wagons from the field to the hospital by way of the first-aid and ambulance stations, which latter he should organize.
Medical officers of the Volunteer Army should make themselves familiar with the provisions and requirements of the Manual for the Medical Department, the paragraphs of Army Regulations relating to the Medical Department, the Drill Regulations for the Hospital Corps, and the chapters in Part I of the Handbook for the Hospital Corps, by Deputy Surg. Gen Charles Smart.
[Circular No. 4.]
WAR DEPARTMENT, SURGEON-GENERAL`S OFFICE,
Washington, May 31, 1898.
The Quartermaster-General has been authorized to provide filters for the use of the Army. The filters recommended by the Surgeon-General are the Berkefeld cylinder and the Maignen asbestus filter. These filters are intended to supplement each other, and the use of both is required to obtain a plentiful supply of water free from the germs of disease. Medical and company officers should
143
??
have a thorough understanding of the intention and action of each of these filters, that the full benefit of their use may be insured to the troops.
The Berkefeld filter is a specially prepared earthenware cylinder, through the pores of which the water has to be forced by the exercise of considerable piston pressure. The pores are so small that they exclude or filter out, not only all particles which would give a turbidity or cloudiness to the water, but those more minute particles which are the active agents in the production of typhoid fever and other camp diseases. The filter is, therefore, an efficient filter, but the smallness of the pores which gives it its efficiency constitutes an objection to its use in practice. Its pores speedily become choked by a coating of filtered particles. If greater pressure be used to increase the rapidity of filtration, the connections of the cylinder may become strained and the filter be rendered valueless, while if the cylinder be removed and its surface scrubbed, it is exposed to the risk of fracture unless handled with the utmost care.
The Maignen asbestus filter has larger pores than the other. Water passes through it more readily and under slight pressure. The coarser particles which give a cloudiness or turbidity to a water are strained out, but as the germs of disease are not excluded, the filtration from a sanitary point of view is not efficient.
It will be seen, however, that the Maignen filter may be put advantageously to use in preparing water for purification by the Berkefeld cylinder. By straining out the particles which otherwise would choke the Berkefeld filter, it enables the latter to operate as rapidly as itself and does away with the necessity for increased pressure or frequent interruptions for scrubbing the porous cylinder.
To use the two filters in combination, the bucket or other receptacle containing the unfiltered water and the asbestus filter should be securely fixed at a height of 5 or 6 feet from the ground. From this bucket, the clear but not necessarily pure water is delivered by the rubber tube of the filter into another bucket properly placed to receive it, and to admit of the pumping of the filtered water through the Berkefeld cylinder into vessels for storage or use.
t has been found that asbestus-filtered water can be rendered sterile by the Berkefeld apparatus at the rate of about 5gallons in twelve minutes, the pump working easily.
The outer covering of the Maignen filter should be kept free from deposits of clay or other matters by brushing or scrubbing. If need be, the outer casing of asbestus cloth may be removed, washed, and replaced. The filter as a whole may be sterilized when necessary b boiling in water. When not in use it should be exposed to the air as much as possible.
The Berkefeld filter is worked by placing the pump in the vessel containing the asbestus-filtered, water, with its nozzle resting firmly on the bottom. The piston is then worked without jerking, while counter pressure is made with the left hand on the top of the barrel. To keep the cylinder in perfect condition, when thus used, it should be sterilized every fourth day. The thumbscrews on top should be unloosed, and the cylinder, having been lifted carefully from its metal case, should be put in water of ordinary temperature, which should be brought to the boiling point and kept at this temperature for five minutes. When removed from the hot water it should be allowed to cool before being replaced for use. The cylinder is liable to become cracked and useless by sudden changes of temperature. If a cracked or worn-out cylinder has to be replaced, time small wheel should be unscrewed from the lower end of the old cylinder and screwed upon the new one. The nut at the bottom of a cylinder should never be unscrewed.
[Circular No. 5]
WAR DEPARTMENT, SURGEON-GENERAL`S OFFICE,
Washington, August 8, 1898.
The attention of medical officers is invited to Circular No. 1 from this office, dated Washington, April 25, 1898.
The extensive prevalence of typhoid fever in camps of instruction indicates that the sanitary recommendations made in this circular have not been carried out. If medical officers have failed to make the proper recommendations as indicated, the responsibility rests with them. If the recommendations have been made and not acted upon by those having authority in the various camps, the responsibility is not with the Medical Department, but these recommendations should be repeated and commanding officer surged to move their camps at frequent intervals and to maintain a strict sanitary police.
144
[Circular No. 6.]
WAR DEPARTMENT, SURGEON-GENERAL`S OFFICE,
Washington, August 12, 1898.
Chief surgeons of army corps, of divisions, and of smaller independent commands are expected to make timely requisition for medical supplies. It must be remembered that some delay is often unavoidable in putting up supplies at the supply depots and in their transportation to the point at which they are needed. In an unexpected emergency telegraphic requisition must be made and supplies will be sent by express; but it must be remembered that this mode of transportation is very expensive and that failure to make requisition in advance of immediate needs entails unnecessary expense upon the Government. Division and field hospitals in which typhoid fever and other serious cases are treated should be liberally supplied with all articles necessary for the treatment and comfort of the sick. The field supply table applies only to mobile commands and division hospitals to accompany them on short notice.
[Circular No. 7.]
WAR DEPARTMENT, SURGEON-GENERAL`S OFFICE,
Washington, September 5, 1898.
The attention of chief surgeons and of all medical officers on duty with troops in the field is called to the following paragraphs from the Manual for the Medical Department:
`92. When accumulations of organic material undergoing decomposition can not be removed or buried, they may be treated with an antiseptic solution or with freshly burned quicklime. Quicklime is also a valuable disinfectant, and may be substituted for the more expensive chloride of lime for disinfection of typhoid and cholera excreta, etc. For this purpose freshly prepared milk of lime should he used, containing about 1 part, by weight, of hydrate of lime to 8 of water.
`93. During the prevalence of an epidemic, or when there is reason to believe that infectious material has been introduced from any source, latrines and cesspools may be treated with milk of lime in the proportion of 5 parts to 100 parts of the contents of the vault and the daily addition of 10 parts for 100 parts of daily increment of feces.`
Quicklime should be purchased in such quantities as may be necessary for the purpose of carrying out these instructions, and vouchers sent to the Surgeon-General of the Army for payment from the medical and hospital appropriation.
