The elements of military hygiene; especially arranged for officers and men of the line

Front matter

DATE

TITLE

PAPER

Preface

THERE can be little or no doubt that the sanitation of the army would be greatly improved if line officers and enlisted men should become more interested in the subject, and codperate more freely and intelligently with medical officers in the efforts to promote it.

This book is written in the hope that it may both inform and interest them and so gain for the medical officer the sympathy and codperation that he always needs, but now too seldom has. It is also hoped that medical officers themselves, especially those of the volunteer service and militia, may find the book useful in their dual capacities of administrators and teachers.

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Part I.—the Recruit And His Environ

MENT I. THe Recrvit ‘ ; : ’ ' Bg II. PersonaL HyYGIene . : , : ; 20 Ill. Foops AND THEIR PREPARATION . : . odo IV. THe HyGiene or tHe BARRACKS . ; 54. V. Camps . A 5 : ; : : wane VI. Tat Hycienre or Movinea Troors . wo LOL

PART IJ.—THE CAUSES OF DISEASE

IX. Tae Ivmepiate or Excitina Causes or DISEASE . : : ; : : « +156 X. DisEASE CARRIERS . : § : : . 180

Part Ii.— The Prevention And Control Of Epidemics

XI. Toe DEFENSES AGAINST DisEASE IN GENERAL 199 XII. TyPHorp AND OTHER WATER-BoRNE DisEAsEs 213 XIII. Arr-BorNE AND FomitEs-BoRNE DisEAsES . 239 XIV. Insect-BorRNE DIsEAsES . : , ae 20 fi XV. VENEREAL DISEASES . : : : . 281 INDEX ; ; : : ; : a OLE

PART I

“ Health and a good constitution are better than all gold ; and a strong body than wealth without measure.” Ecciesrasticus 30: 15.

MILITARY HYGIENE

Chapter I The Recruit

One of the principal factors in military hygiene is the individual soldier, or, as he comes from civil life, the recruit. If he enters the service in good physical condition, in good health, and with sufficient intelligence to apprehend and apply the instruction he receives in military hygiene, the problem is almost half solved. The final acceptance or rejection of recruits now rests almost entirely with medical officers ; but in certain ways line officers exercise a considerable influence in the matter: in the acceptance at the recruiting station, and in requesting special authority to enlist because of special qualifications. For these and other reasons it is important that they should keep well informed as to the requirements necessary and the qualifications desirablein recruits. We will therefore briefly consider some of these.

The age limits for first enlistments are from eighteen to thirty-five years. Preferably men should be chosen between twenty-three and thirty years. Before the age of twenty-three years most men are immature, their muscles are not hardened, their hearts not so strong, their minds not disciplined by experience, their appetites and emotions not under control; while their susceptibility to impressions from their environment is such as to make it undesirable to limit their associations exclusively to adult unmarried males.

Age

After the age of thirty years the man’s habits of body and mind are fixed, he takes instruction less readily, his body may have begun to deteriorate, particularly if it has not been well cared-for, and, in many instances, he seeks the service as a refuge, after failing in other walks of life. Many good men may be obtained before the age of twenty-three and between the ages of thirty and thirty-five, but in general the case is thought to be as stated.

The size of the recruit is not a matter of the greatest importance, provided that the development is normal and the man strong and active, except as it applies to assigning him to duty. It is obvious that a very large and strong man is better suited for coast-artillery work than for the cavalry, and that a small, wiry man is in that respect better for the cavalry. The proportions of weight and chest measurements to height are published from time to time in general orders, and those proportions usually represent very well those of strong, well-developed men. An increase of weight, if associated with great breadth of shoulder and large chest measurement, is not necessarily harmful, being usually indicative of strength and endurance. The sturdy, stocky Japanese coolie exemplifies this. Obesity, whereby the man is burdened with his own weight, is of course objectionable.’

Size

1 The following table copied from the Medical Record of September 5, 1908, and compiled from the data of the Mutual Life Insurance Co. of New York, by its Chief Medical Director, is interesting as indicating somewhat “ the influence of overweight and underweight on vitality.” The weights considered normal by the insurance company are somewhat in excess of those prescribed by the War Department, the inorease averaging about 10 pounds at the ages 25-29, and for heights

The chest should be freely mobile, that is, both sides should move freely, symmetrically, and equally, in expanding and contracting. The measured Ch chest expansion should generally corre- oat spond with the figures published in the general orders; yet it should be remembered that one man with very ordinary lung capacity may, by use of the shoulder and below 70 inches. A weight 20 per cent below the average is considered “ underweight,” and 20 per cent above the average, ‘‘ overweight.”

Table showing the Percentage of Deaths in all Classes, and some Individual Diseases, among Overweights and Underweights, and the General Experience of the Mutual Life Insurance Company.

Over- Under- General Causes of Death. weights. weights. |Experience.

Class I. General Diseases — Acute 9.67 9.28 8.90 Typhoid fever . 5 4.00 3.06 3.94 Malarial fever 1.27 pia | 1.24 Influenza : * 1.47 2.04 1.00 Class II. General Diseases — ‘Chronic 13.07 24.59 19.56 Tuberculosis . il 2.93 16.98 12.42 Cancer)... 3 4.40 5.57 4.18 Diabetes A 3.40 0.65 125 Class III. Diseases of the Nervous System 19.08 12.16 17.44

Cerebral Congestion and

Hemorrhage, Cerebral Softening, Paralysis . 14.14 8.47 12.32

General Paralysis and other forms of mental alienation 1.80 0.84 1.30

Class IV. Diseases of the Circulatory System . 16.01 11.69 11 85 Organic diseases of the heart 12.94 8.54 10.76

Class V. Diseases of the yet aang MV BLOMIG setae ke te 8.54 15.78 11.86 Pneumonia. 6.87 12.34 9.03

Class VI. Diseases of the Digestive Bystem . 10.61 8.54 10.19 Cirrhosis of Liver tes 3.47 0.65 1.00

Clags VII. Diseases of the Genito-urinary System . 12,01 7.42 8.78

Bright’s Disease and Nephritis . 11.07 5.30 6.66

Class IX. Diseases of Skin and Cellular SE i Ae a 1.20 0.47 . 0.50 CIMRSE Nee OLURAGGIE S) .) .) 6s) ve es None 2.04 1.50 Class XII. Violent causes ...... 7.07 5.57 7.42 WOARUBIIOSies oh cs «e's 4.20 3.43 5.21 Suicides SE alt enact a's 2.87 2.14 2.20

Class XIII. Tll-defined ° ° e ° e ° e 2.60 2.50 3.98 back muscles and retraction of the abdomen, show an apparent expansion of 34 inches, while his companions with a capacity as great, may, through ignorance of tricks or of what is desired, show only 14 inches. It is desirable that the chest be fairly large, to afford ample room for the free working of the heart and lungs, as on such finally depend both strength and endurance. A generally well-developed and strong man will show well-developed and prominent chest muscles.

Certain types of chest frequently indicate a predisposition to, or the actual existence of, disease, and demand careful consideration even when not constituting actual causes for rejection. The long, narrow chest, with prominent or “ winged” shoulder-blades, depressed or - flat below the collar-bones, and forming an acute angle at the divergence of the ribs below the breastbone, frequently marks a predisposition to consumption.

A large, barrel-shaped chest, as deep from front to back as transversely, and showing a relatively small movement, is often associated with emphysema and — asthma.

A chest more prominent on one side than on the other is apt to be associated with curvature of the spine, or old or chronic pleurisy.

Marked prominence or depression of the breast-bone, especially if associated with “‘ beading,” or lumps on the ribs near the breast-bone, frequently results from rickets, and may be accompanied by other bone deformities.

The abdomen should be well muscled, and firm when Ab Aowisa the applicant is standing. It should move easily and naturally in respiration, should not be pendulous, and should be firm, particularly in its lower parts, just above the groin. Weakness here will be indicated by a bulging if the patient strains, as at stool, or if he stands on his toes and coughs hard. Such bulging, especially if it be marked or shows a tumor-like swelling, indicates a predisposition to, or the actual existence of, a hernia.

The umbilicus or navel is another frequent site of hernia, and should be noted in that connection, as should any abdominal scars resulting from operations, as for appendicitis. Another, though less frequent, site of hernia is the femoral. This is shown by a fullness or swelling in the lower part of the groin, in the highest part of the thigh rather than in the lowest part of the abdomen.

Large masses or tumors that can be felt through the abdominal wall, or that can be seen to produce inequality or fullness, are causes for rejection.

Distention or prominence of the veins on the surface of the abdomen, or a varicose condition of them, is generally an evidence of impaired circulation or liver disease, and should cause rejection.

Hemorrhoids, or piles, while apparently not connected with the abdomen, are the result of distention of the rectal veins, and may be due to liver disease, to abdominal tumors, to constipation, or other intra-abdominal conditions. They are manifested as tumors, usually of a bluish color, within or about the anus, which vary in size from that of a small pea to that of a man’s thumb. Of themselves they are not a cause for rejection unless of large size or producing symptoms, but their presence should always be noted. Internal piles are not visible, and usually make their presence known by burning or irritation in the rectum, or by the passage of blood in the stools. In examining for them, note should also be made of other abnormal conditions of or about the anus, such as fissures or cracks in the skin and mucous membrane; fistulas, little openings near the anus from which there may be a slight discharge of pus or fecal matter; or abscesses or boils. Any of these conditions may so disable the man as to unfit him for . service.

A history of abdominal trouble, such as severe indigestion, gallstone colic, vomiting of blood, should cause rejection.

The examination of the head is very important, as revealing defects in most of the special senses and as Flead offering important evidence as to the man’s

character, habits, and abilities. The -evidence on the latter points is to be gained largely from the shape of the head and the expression of the features, and, while such evidence is not always reliable, certain heads and faces are so distinctly indicative of stupidity or vice that there should be no hesitation in rejecting their possessors. Then, too, hideous or disgusting deformities should at once cause rejection, for the sake both of the victim and those with whom enlistment would associate him, even though they are not of a character to incapacitate directly. The vision and hearing should be tested in strict accordance with the regulations governing the subject, and failure to meet the requirements is cause for rejection.

In addition to the test for vision, however, the eyes should be examined for any signs of inflammation, redness, watering, drooping of the lids, scars or deformities, granulations, styes or boils, undue prominence of the eyeball, inability to move the

Eyes eyes in all directions, and discoloration or blurring of the cornea.

The ears, in addition to the tests for hearing, should be examined for any discharge, whether watery or purulent, and if present it should be a cause for rejection.

The nose should be examined as to its freedom from obstruction, by having the applicant close first one side and then the other with his fingers and then breathe and blow through the free side. Incidentally this may call attention to a foul-looking discharge or a foul-smelling breath, either of which may justify rejection. A sunken or much scarred nose is often an indication of syphilis, while a red, bulbous nose, even if not indicating alcoholism, is sometimes an indication of indigestion. It should be noticed that the man habitually breathes through his nose.

The mouth and throat should always be M

. outh carefully examined.

The condition of the ¢eeth is the first point to be noted here. It is desirable that all should be pre-— sent and good, but there must be at least

: a, Teeth enough to permit of proper mastication of _ the food, and for this purpose at least four grinders are demanded, two above and two below, and so disposed as to permit their effective use. Enough of the front teeth should also be present to permit of the biting of food and to preserve the symmetry of the face. At times men are accepted with no upper teeth, but wearing plates. This should only be done by special authority and in special instances. Insufficient or poor teeth are apt to produce digestive disturbances, particularly on campaign, when hard bread may be issued,

Ears

Nose and when the preparation of the food in general may not be as good as in garrison. The examination of the teeth should not only relate to their presence and the presence or absence of cavities, but also to their state of cleanliness. Neglected, filthy teeth and gums may seriously menace the general health, while they certainly predispose to loss of teeth, and, in many instances, indicate general carelessness or filthiness. Sores or ulcerations on the lips, tongue, gums, or inner sides of the cheeks should be carefully noted, as they may indicate syphilis or other general disease, and should at least lead to further and more careful search for syphilis. The same remark applies to milk-white patches, seen especially on the tongue.

In ill-kept mouths the gums may be spongy and bleed spontaneously or on pressure, or pus may exude from between them and the teeth; or they may be greatly retracted and expose the roots of the latter.

In these and other cases the teeth may all be present, yet in such poor condition as to forbid proper mastication, or to threaten their early loss.

The most common and easily detected throat trouble is enlargement of the tonsils. This condition usually indicates a liability to frequent attacks of sore throat, and should always excite inquiries as to this, and while not necessarily a cause for rejection, unless very marked, should be noted as a point against desirability. Ulcers, white patches, membranes, and an appearance of acute inflammation in the throat, should cause rejection.

Hoarseness, or loss of voice, or cough, should at least delay, and if persistent prevent, acceptance.

Gums

Throat

THE RECRUIT a

Numerous scars on the tongue, lips, and cheeks, unless clearly and certainly accounted for otherwise, should cause rejection as being prob- . ably due to bites during epileptic fits, or to syphilitic or other ulceration.

Too much importance should not be attached to a coated tongue, but a raw-looking, bright red, or tremulous one should direct careful scrutiny to the general condition and the habits.

Enlarged lymphatic glands, or “kernels,” are most frequently noticed in the neck or under the jaw. They are frequently indicative of inflammation or ulceration in other nearby regions, especially the mouth or throat, and their presence should lead to careful examination for such conditions; but at times their presence is indicative of a general infection, such as syphilis. Usually, if the enlarged glands are numerous, or the enlargement great, they constitute a proper cause for rejection. When the enlargement is localized at one part of the neck only, it points to an infection entering at a part near it. Thus such a gland at the angle of the jaw may be due to inflammation of a tonsil of the same side ; one under and near the jaw to a bad tooth, etc.

The scalp should be carefully examined as to its cleanliness and general care, for the presence of lice, which may be seen as such or may be revealed by the “nits” or eggs, little whitish bodies attached firmly to the hairs; for ringworm, scabbiness or scald-head, patchy baldness, wounds or sears, etc. I'he presence of vermin is a cause of rejection in two ways, as indicating a lack of personal care, and as a danger to be introduced into crowded barracks.

Tongue

Lymphatics scalp

Superficial suppurative scalp diseases should generally cause rejection, as being contagious or as being caused by scratching excited by lice. Patchy baldness, if the patches are sharply defined and the skin is smooth, clean-looking, and not scarred, is apt to be harmless. If the skin is inflamed and scarred, and stumps of broken hairs are present, it should cause rejection. Irregular and incomplete baldness occurring in patches or tracts, giving at times a “‘ moth-eaten” appearance, is most apt to be due to syphilis, and should cause careful examination for other signs of that disease.

The upper limbs should be examined as to their development and musculature, their free mobility in all joints and in all directions, the presence of all bones and joints, and a reasonable amount of dexterity and strength. Atrophy or wasting of a group of muscles or a part, inability to bend or make free use of a joint, and similar defects, should be carefully looked for, as they may otherwise be missed. Loss of one or more joints of a finger, swelling and deformity of a joint (baseball finger), or stiff contracted fingers are not uncommon, and, if in the fourth or fifth fingers, are not serious matters, though they should be noted. If in the second or third fingers, the matter is more serious, yet the applicant will usually be able to handle a gun and perform his other duties. Loss of a thumb is aserious defect, and in most instances would justify rejection. All deformities from badly united fractures or other causes should be noted, and should cause rejection unless the applicant can demonstrate his ability to execute the movements necessary in the performance of his duties.

The legs should likewise be examined as to their

Arms

‘development, musculature, size, mobility, etc. The applicant should be required to move all the joints, to jump, hop, and otherwise demonstrate his’ability to use his limbs. Marked deformities, such as clubfoot, shortening of one leg, stiffness, marked swelling or marked limitation of motion in a knee or hip, should at once cause rejection. Less marked deformities, such as knock-knee, bow-legs, crooked shins, etc., need not cause rejection unless manifestly interfering with the free use of the limbs, or rendering the subject’s appearance ludicrous or unmilitary. Here, again, marked wasting of a part or of a group of muscles will often be found due to a joint lesion, a paralysis, or other nervous trouble, that would serve to disqualify the applicant. In addition to these defects, common to both arms and legs, the lower extremities are subject to other affections rarely or never seen in the upper.

Varicose or dilated veins are often seen. They usually show as swollen, bluish, and more or less tortuous vessels beneath the skin, and may be individually as large as a man’s finger. They are most commonly seen on the lower legs, but are not very rare in the space behind the knee, and may extend up the inner side and _ front of the thigh to the groin. If marked, they should cause rejection. If only slight, and in otherwise desirable applicants, they may be passed, but should always be noted. At times they cause the appearance and persistence of very chronic ulcers, which occasionally bleed, pain, or otherwise disable the man. Such ulcers are especially apt to show on the front or to the inner side of the lower half of the leg. They are long in healing, are apt at any time to break open again, and when healed

Legs and Feet usually present brownish, discolored scars. Such ulcers, or such scars if accompanied by varicose veins, should cause rejection. The legs are especially prone to chronic ulcerations, which may be caused by syphilis, tuberculosis, leprosy, and other infections. In general these are causes for rejection.

A rough, nodulated, tender pyreehsTe i is not an unusual sign of syphilis.

The feet require particularly cattll examination, as on their integrity, usefulness, and strength (or what we might call their durability) depends a large part of the man’s capacity for “soldiering.’”’ The best known and probably the least important of the foot-ills is corns. They are best known because most persons at some time have at least one, and they are one of the least important ills because in most instances they cause not even serious inconvenience, and they usually disappear with the use of properly fitting shoes and ordinarily good care of the feet.

If numerous and painful, however, or if soft corns, situated between the toes, they may justify rejection.

Sweating feet, which soften, blister, redden, and burn, may cause rejection, as they are not apt to stand much marching.

Stinking feet may justify rejection in most instances, as constituting a nuisance in barracks.

Bunion, an inflammatory and deforming joint-affection, usually at the base of the great toe, will, if very marked, disqualify.

Hammer-toe, a condition in which a toe is flexed and the end presses on the floor, while a knuckle projects above, is very apt to cause lameness and may justify rejection.

Overlapping toes may disqualify in a somewhat similar manner.

Deformities of the arch of the foot are very important. It may be too high, so that the weight is borne on the ball of the foot and the heel, the intermediate parts remaining clear of the ground. This is a relatively rare condition, but may disqualify. A common condition is the opposite, or flat foot, wherein the whole length and breadth of the foot touches the ground and the arch is almost or entirely obliterated. Such a foot in a white man is usually a poor marching foot, and, unless the applicant is a desirable man and states that he is a good walker, and that the foot never gives him trouble, it should cause rejection. When passed, its existence should always be noted, in case the man should be discharged for it later. The condition is more common but less important in negroes, but it may cause trouble in them also, particularly in the course of long marches.

Another type of weak foot is not really flattened but tends to rotate outward, thus bringing the inner margin of the foot nearer to the ground and more directly under the weight of the body, where a greater weight comes upon it, causing it to tire and eventually to break down and become flat. It may justify rejection.

The genitals should be well-formed and normal. Both testicles should be present and in the scrotum ; it should be possible for the applicant to retract his foreskin, and the penis should not show gross deformities, such as the opening of the urethra being placed far back from the end. Scars on the penis should prompt investigation as to their nature, whether syphilitic, chancroidal, or otherwise. The man should be required to express the contents, if any,

Genitals from the urethra. Pus should at once cause rejection, as should any ulcers or sores on the penis, redness, puffiness, or signs of marked irritation about the urethra, or the presence of vermin, commonly known as crab-lice. Inflammation of the glans beneath the foreskin, and venereal warts, while not in themselves disabling, will often justify rejection as capable of exciting suppurative buboes, and as resulting from venereal disease or uncleanliness, or both.

Buboes are swollen and inflamed lymphatic glands, and are found in the groin. They may be single or multiple, on one or both sides, and may vary in size from that of a small cherry to that of an orange. While not all groin buboes are venereal, the great majority of them in applicants for enlistment are, and they justify rejection, even though the applicant insists, as he probably will if his venereal disease is not plainly evident, that they are due to “ strain.”

Varicocele is a condition of enlargement of the veins of the scrotum. It is most often found, and is apt to be most marked, on the left side. The condition frequently causes no symptoms, though it is often said to cause pain, and is apt to be pleaded as an excuse from arduous duty. If present, it need not cause rejection unless very marked or unless the applicant says that it produces symptoms, but when passed it should always be noted, and the applicant be made to agree to be operated upon if symptoms begin, or if the condition comes to interfere at all with his duties.

Hydrocele is an enlargement of the scrotum, usually on one side, caused by an outpouring of clear fluid into the membranous sac surrounding the testicle. It produces a tense, painless, and often translucent swelling, which may at times be hard to distinguish from a tumor of the testicle or a hernia. Any one of the conditions, however, may suffice to exclude the applicant in time of peace.

While not much reliance can be placed on an applicant’s denial of venereal disease and his assertions as to perfect genital health, he should be questioned on the subject, and should be asked as to the frequency of urination and his ability to pass a good stream of urine. Dribbling or inability to pass a good stream, or to hold or control his urine, should cause rejection.

The skin will necessarily be noticed and examined during the examination previously described. One of the first and most important points to be Skin noted is its cleanliness. A dirty, foul, stinking skin usually indicates the type of man not wanted in our army, and it justifies rejection without further examination. Certain men, however, appear with their skins soiled with sweat and dust simply because of lack of opportunities for cleanliness, and if their general appearance and their stories indicate that they are desirable men, they should be given an opportunity to bathe and then be examined. It must not be forgotten that a filthy man may bathe for examination, but reveal his usual habits by his linen. However revealed, filthy habits should cause rejection.

A skin showing the marks of severe and generalized scratching is usually indicative of disease or vermin infestation, and is therefore objectionable.

All forms of contagious skin‘ diseases, such as ringworms and syphilitic eruptions, should cause rejection, or, in the person of an enlisted man, call for prompt treatment. As the line officer cannot be expected to differentiate such affections, he will be on the safe side if he treats them all as suspicious, though he should if possible learn to recognize acne, the common ‘“‘ pimply”’ eruption seen on the chests, backs, and faces of many young men. It is usually not a severe affection, and as it may coexist with good health and good habits, it should not cause rejection.

While a few men who are not really physically fit get into the service, there are a good many more who are morally or mentally unfit, and they are the men who later spend much of their time in the guard-house or who swell the | number of desertions. Against this class of men the recruiting officer works at a disadvantage. Unfortunately, almost any man, no matter what his character, can get letters of recommendation, so that such letters are really of little importance, and the officer is forced to rely largely on his own ability to judge men by appearances, — a notoriously unsafe thing, and an almost impossible thing for some individuals. Some aid is obtained, though, by attention to the applicant’s general bearing, his facial expression, his quickness of apprehension, the condition of his person and his clothing, and such evidences of alcoholism, venereal disease, good habits, and truthfulness as the examination may bring out. When a man declares that he never drinks, although’ his breath is strong with alcohol at the time, or that he has never had venereal disease, though he shows a scar on his penis and another in his groin, or has a suppurative bubo that he says is due to a strain, the inference is fair that he is a liar and undesirable.

Under our system of voluntary enlistment, and as long as there are plenty of applicants, it is better to

Character reject all those about whom the officer cannot feel well satisfied ; and this whole chapter is based on such an assumed condition of affairs. In time of war, or when the supply of applicants for enlistment is not up to the demands, many men can be passed who would be excluded under our assumed conditions; but in all such cases they should only be passed by medical officers exercising great care, and every defect should be noted, both as to its presence and its degree, as constituting a possible ground of application for a pension.

The man being in the service and any defect coming to his commanding officer’s attention, he should be referred to a medical officer to have it corrected if practicable, but at any rate to have it noted, in the interests of justice to the man and to the government, and, if it be sufficiently serious, to have the man discharged before he breaks down in time of stress, with possibly serious results.