The following lecture on Sanitation and Hygiene is taken from the book, "Military Organisation and Administration" published by Major G. R. N. Collins, 4th. Battn. Canadians Instructor, Canadian Military School, in 1918. Major Collins was incapacitated from general service in the field and was appointed to the Canadian Military School where he gave lectures to several thousands of Officers of the Canadian Forces.

MEDICAL SERVICES IN THE FIELD

SANITATION AND HYGIENE.

The first essential in keeping the soldier fit is to see that he is not subjected to any influence that will undermine his strength. These conditions may arise from the habits of the soldier, carelessness, or exposure, or they may arise from the immediate surroundings being unhealthy, either as a result of the fault of the troops or as a result of natural conditions. The supervision of the conditions under which the soldier must labour is not left to the Medical Services alone, but, as a result of instructions given in the training of Officer and man, is made a matter of duty to all concerned.

The proper steps to be taken to preserve the health of all ranks is made a part of the training given to every member of the forces.

The term "sanitation" has been commonly associated with dirt and filth, and is consequently misunderstood, whereas it is in reality a term signifying the preservation of health. This term is used to cover the subject of protecting the soldier from disease in the Army and its control is one of the measures which the Medica1 Services are responsible for. By insisting upon cleanliness in the individual and in his soundings, and by establishing the necessary authority to enable the Medical Service to enforce the sanitary laws, a machinery is created whereby this most important subject can be handled.

The importance of enforcing the strictest laws in this regard can be measured when we stop to think that an army is composed of, perhaps, millions of men and animals, for whom all the normal conveniences of life are absent. This force must be moved according to the operations, and consequently the convenience of the encampments cannot be considered, unless they be in proximity to the position upon which the tactical situation depends. Unless every precaution is taken, it is inevitable that there will arise a condition that will endanger the health of the whole force.

The various agents that cause disease may be of such a type that cleanliness alone cannot overcome the danger It may be necessary to take other precautions to protect the soldier, as is the case in swamps, where the mosquito is the agent whereby disease is spread. Under these circumstances the Medica1 Service must protect the soldier by the provision of the necessary chemicals to destroy the pest.

Under other circumstances it may be necessary to give the soldier treatment that will render him immune to attack. This is the case with such diseases as smallpox, where the preventative is gained by inoculation of the blood of the soldier with certain combative agents. In many cases it is necessary to combine the protective measures, first by issuing laws against certain practices which offer danger, and then by inoculating the soldier with a protective matter.

This is the case with enteric, where the control of the disposal of excreta and of certain contaminated foods or liquids, combined with protection of the system by inoculation, are necessary.

In all cases the Medica1 Service is responsible for studying the cause and effect of the various diseases, and for the necessary steps to minimise the danger.

The effect of diseases upon an army has been illustrated many times in history, and cannot be measured by the actual loss of life, but must be measured by the effect which it produces upon the army as a whole, and the issues for which it is fighting.

In the various British campaigns between the time of the Crimea and the South African War of 1899-1902, the losses in our forces from disease bore the proportion of nineteen cases to one of wounds by the enemy. During the South African War the average force during the two years was 208,000 men The admissions to hospital during that period were approximately 404,000, of which no less than 380,000 were cases of disease.

During the Russo-Japanese War of 1904-1905, the admissions to hospital from disease only bore the relation of two cases to one of wounds. This was largely due to the splendid organisations of the Japanese forces in regard to sanitation.

We have profited by experience, and to-day every effort is made, not only to prevent disease, but to educate the soldier to appreciate the risks, and by instruction to teach him how to avoid or nullify them.

The age and service of the soldier play a part of much importance in the statistics, and it would appear that as a result of advance in years, and consequently in discretion, coupled with training and discipline, the disposition of the soldier to succumb to disease falls in similar ratio to his service. The statistics which have been kept for many years show that disease is commoner amongst men of eighteen years of age, and of less than one year's service, while it is least amongst those of forty and over, having eight years or more service. From this it may reasonably be supposed that much of the sickness is due to lack of care upon the part of the younger soldier, but as his years and service advance he profits by training and discipline.

The principal diseases which affect the fighting efficiency of a force may be classified under several brief headings:

a) Those due to disturbance of the functions of the body, affecting the physical condition such as lack of proper nourishment, intense heat or cold, exposure; or some unknown cause, such as cancer.

(b) Those diseases which are caused by living germs or organisms which invade the body and produce the disease, and which are capable of being transmitted from one person to another, as in the cases of smallpox, scarlet fever, enteric, etc.

(c) Diseases which are caused by vegetable or animal parasites, and which are produced from local conditions, such as skin disease caused by certain fungi, intestinal worms, etc.

The protection of the soldier from those under class (a) is a matter for the Medica1 Officer on the Staff of the force, who may advise certain measures being taken in regard to. the clothing, employment, and protection of the troops in order to reduce the danger, as far as the operations will permit.

Certain restrictive laws might be formulated in regard to these cases, such as orders regarding the wearing of helmets, orders to remain under cover at certain hours of the day, or, again, control of the use of certain liquors or food. These laws would be suggested by the Medica1 Officer and enforced by the regular chain of command, whilst the M.O. would see that they were being observed, reporting cases for action when detected breaking them

The cases of the second class require much more legislation and care. In the first place the risk may be negatived by submitting the soldier to vaccination, inoculation, or injection of certain counter-agents, usually with the intention of producing a mild case of the disease which offers future protection against the more severe attack. The next measures require the control of all possible sources of infection or contagion. Thus, the known case and all contacts must be isolated, articles which may be infected properly cleansed or destroyed and all other precautions taken to prevent the spread of the disease. In the third place, precautions against the disease may be taken by making it an offence to subject oneself to possible infection from known causes of the disease. Vermin may produce typhus; hence orders regarding the cleansing of the person and clothing become necessary; milk and water from certain sources may carry enteric, and therefore must be put out of use; or the breeding of flies from carelessness may produce one of several diseases; consequently, the destruction of all refuse must be strictly controlled.

The control of disease may therefore be effected by rendering the individual immune to attack, controlling known sources of infection, and by preserving the utmost cleanliness, both of the person and surroundings.

The machinery provided for supervising these matters is entirely under the control of the Director of Medical Services and the representatives with the various forces.

On the lines of communication there is established a Sanitary Committee to co-ordinate the work of the different parts. The lines of communication are divided into sanitary sections and districts, each having a Sanitary Officer in charge. The bases are usually established as separate districts Owing to the lines being more or less permanent, much more effective work can be done than is possible in the field, and as these sections and districts will conform closely to the civil administration as to areas, there will usually be some local conveniences such as sewers, water supply, etc., whereby the sanitary condition can be considerably improved. The Sanitary Officer in charge is usually an expert, and he has a sanitary squad allotted to him to carry out his orders. He will supervise the food and water supply, disposal of sewage and refuse, disinfection, and all measures to prevent the spread of infectious disease. He reports to the Commander of the Administrative Section or Base. The sanitary squad under his control provides the skilled labour required in the performance of these duties, and will supervise the work of such labour as may be allotted to the Sanitary Services, and also act as sanitary police for the enforcement of the sanitary laws. For this purpose the men are invested with the authority of military police, and wear a badge to designate their authority.

The sanitary work on the lines of communication conforms very closely to the work of the Medica1 health authorities in time of peace, and they exercise the same authority within the district under their command, utilizing the civil administrative authorities and labour as far as possible.

The sanitary work in the field presents much greater difficulty, owing to the concentration of troops within a limited area and the absence of any local conveniences.

The personnel for the carrying out of sanitary duties consists of Sanitary Officers and their sections with the formations in the field, and the Medical Officer and sanitary squads with the units.

The Sanitary Officers are responsible for the following matters:

1. To exercise general supervision over the sanitary condition of all places occupied by the troops of the command to which they are attached.

2. To watch the health conditions of billets, camps, and bivouacs, and at once investigate the cause of any unusual prevalence of disease among the troops or the inhabitants.

3. Advise on the measures which should, in their opinion, be taken to protect the health of the troops, and report on the adequacy of the arrangements already made for that purpose.

4. Advise on the selection, from a sanitary point of view, of sites for camps and bivouacs, and on questions relating to the sanitary condition of towns, villages, or buildings about to be occupied. To this end they should accompany the Staff Officers charged with the selection of camps, billets, or bivouacs.

5. Advise regarding the purification and distribution of water for drinking purposes; also in respect of latrines and urinals, burial of the dead, and disposal of refuse and carcasses of animals, etc.

6. Impress on Commanders of units and on Medical Officers in charge of troops the imperative necessity of obtaining the highest possible standard in sanitation, both in camp and on the line of march, and bring to the notice of superior authority any neglect of sanitary measures possible under existing circumstances.

The Sanitary Officer thus acts as medical adviser in these matters to the Commander of the force to which he belongs, and supervises the carrying out of orders issued relating to the subjects under his control, throughout the area occupied by the force to which he belongs. His sanitary section provides him with the medium of establishing the necessary supervision.

The regimenta1 sanitary organisation consists of the Medica1 Officer of the unit, with certain details appointed to act as sanitary police under his control. There is also a water detail, to look after the water supply and its protection. The strength of these details varies with the size of the unit, but the duties which they carry out are the same in every case.

The Sanitary Police are responsible for--

1. The preparation and care of latrines and urinals, including the filling in of the same and marking of old sites.

2. The systematic collection, removal, and disposal of refuse by burning or other method.

3. The construction of ablution places and the disposal of waste water.

4. The sanitation of cooking places, horse and mule lines and slaughtering places, in the area occupied by the unit.

The Regimenta1 Sanitary Police are detailed from the strength of the unit, and are vested with the authority of military police for the better performance of their duties. They are under the Regimental Quartermaster for their employment, but the Medica1 Officer will direct their efforts from the sanitary point of view.

The Regimenta1 Water Detail is posted to the unit from the Medica1 Corps, the numbers varying according to the size of the unit. They are responsible for--

1. Daily supervision of water-supply and its purification for drinking purposes by boiling, filtration, or the addition of chemicals, as may be directed.

2. Charge of all apparatus and stores connected with the water-supply of the unit.

The Water Detail takes charge of the water-carts with the unit, and the issue of water to the troops. Where natural water-supplies are used, they are responsible for the care of the watering-places, and will regulate the use of same.

The most important factor in the chain of sanitary control is the responsibility placed on every individual for keeping the laws governing sanitation. This responsibility is definitely stated as regards every Officer and N.C.O., who is held responsible for the sanitary conditions in the area occupied by his command, and also for the care of the health of his men. By this regulation every Officer is made the responsible Sanitary Officer in his own area, and consequently he must understand what is expected of him. The matter is commonly supposed to be too technical for the average Officer, and to be the work of specialists; but this is not so, and the regulations are very positive in fixing the responsibility of the Officer and N.C.O.

For this reason it is necessary to go into the details of these duties very fully, since you are all charged with this important duty. It should be a matter of pride with every Commander that he has not lost a single man from a preventable disease, and there is no doubt that the day is coming when every Officer and N.C.O. will be compelled to offer an explanation of an outbreak within his command. Perhaps it will be as well to define a few of the diseases which are encountered in the army, explaining their causes briefly, and the steps to be taken to prevent their outbreak.

Cholera This disease is caused by a germ entering the body, usually in water, but also conveyed in milk. It commences with sudden diarrhoea and purging. The patient has severe cramps, the face is pinched, and the body becomes cold. Death follows rapidly, sometimes occurring in a few hours. On discovery, all suspects should be instantly isolated, and all articles which may be infected collected by the contacts, for the order of the Medical Officer as to disposal. To prevent outbreaks the troops should be warned against all unauthorised water and milk supplies, and from eating indigestible foods unripe fruit, or anything likely to upset the stomachs, and avoid excess of alcohol.

Dysentery. - This disease is very prevalent during war. It is caused by a germ conveyed in water, milk, or food, especially such foods as shell-fish. The symptoms are sudden in development, first a frequent desire to stool, severe straining, pain, and. passing of slime and blood. To prevent, control use of water, milk, and dangerous foods, and destroy flies, which are carriers. Collect all possibly infected articles and take care of the disposal of excreta and watch personal cleanliness.

Enteric Fever (Typhoid Fever). - Caused through germs entering the body from water, milk, or contaminated food, and by inhaling germs. This disease is very prevalent in war-time, and is exceedingly dangerous. It is identified by high fever, pain in the head and stomach, cramps and diarrhoea. Stools are pale yellow in colour, and watery. The germs are very active in all excreta, and the patient may excrete germs for years afterwards. Many mild cases occur which are apt to be overlooked. Therefore all cases of diarrhoea should be sent to the Medica1 Officer for examination. These cases are just as dangerous as the more severe cases. To prevent the outbreak of the disease, the first and most effective precaution is to inoculate the soldier. This precaution has resulted in a reduction of deaths among our troops in India from 5.83 in 1903 to 0·30 in 1911, these figures being the ratio per 1000 cases. The next step is to strictly control all water-supply which has not been passed by the medical authorities, milk, foodstuffs, etc. The destruction of flies is very important, and possible breeding-places of these pests must he removed. All cases of diarrhoea nest be immediately sent to hospital. Latrines used by suspected cases must be carefully treated lay disinfectants and filled in. All articles used by suspects must be collected and treated by the Medica1 Officer.. The protection of water supply, especially from animal contamination, is most important. All quarters must be examined closely as regards cleanliness, and frequent examinations made of the men's persons and clothing for the same purpose.

Heatstroke is caused from excessive heat or effort. The predisposing causes are excessive use of alcohol, overeating, and physical exhaustion. To avoid, the troops must be counselled to abstain from excesses in any form, to relate clothing and equipment on the line of march, and to wear effective covering on the head, shading the eyes and the back of the neck. It can be identified by the pain in the head, fever, flushed face, heavy snoring breathing, and very dry skin. Place the patient in shade with head slightly raised, and remove to hospital.

Malaria.

This disease is caused by germ-carrying mosquitoes which infect the blood by their bite. It is recognised by the alternative stages of cold and pallor, heat and flushing, and profuse perspiration. To prevent, destroy all possible breeding-places for the mosquitoes, use netting around sleeping quarters, destroy vegetation close to quarters, prevent troops getting in close proximity to natives of the district, and use paraffin on all water, especially stagnant pools, etc., in the vicinity of the camp. Protection may be obtained by giving quinine in closes of 5 grains daily, or 10 to 15 grains twice per week.

Mediterranean Fever.

This disease is caused by goat's milk in the areas in which the disease is prevalent. The symptoms are those of high fever, which comes in successive attacks, each lasting from three weeks to ~ month, with pains in the joints. To prevent, enforce the law that goat's milk must not be drunk. Take usual precautions as to contacts and suspects.

Plague.

This disease is very deadly amongst the natives in India. It is caused by a germ carried by rats from the area of infection, which are communicated to man. It is usually contracted through association with natives who are infected. The symptoms are high fever, swelling of the glands in the armpit and groin, or inflammation of the lungs. To prevent outbreak, control native quarters and forbid access of troops. Strict cleanliness. When detected, prompt action must be taken to prevent spread.

Scurvy.

This disease is generally caused by shortage of green vegetables, fruit, or fresh meat. It is not infectious or contagious. The symptoms are pains in the calf of the leg, general weakness, swelling of the gums later, and marks like bruises on the skin. To prevent, make up deficiencies of diet or issue ration of lime-juice.

Tuberculosis. -

This disease is highly infectious, and is caused by a germ found in milk or carried by the air. The disease is slow in its development. The sufferer is addicted to a hollow cough and much spitting. The sputum is highly dangerous, since it conveys the germ, and upon the sputum drying these are distributed in the air. To prevent, keep rooms well ventilated and remove suspects. Watch for and prevent spitting in all public places. Patients should use their own messing utensils, and should use rags to spit in, the rags being destroyed afterwards.

Yellow Fever.

This disease is caused by a mosquito which carries the germ. The same precautions as for malaria will effectually prevent the disease if strictly observed.

By far the most deadly of diseases as far as loss of efficiency to the army is concerned are the venereal diseases.

These can only be contracted by actua1 contact with other cases. The usual method of infection is by intercourse with a diseased woman. Cases frequently occur, however, of infection by the use of utensils belonging to a diseased person. The germ requires an inlet into the blood, and the slightest abrasion is sufficient to inoculate the person with the disease if contact is made with the germ. The far-reaching effect of these diseases needs to be explained to the troops and, for that matter, to the whole world. Education of the soldier in the risks run and strict control of possible places of infection are the best preventatives.

The most dangerous of these diseases is that of syphilis. This disease takes three weeks to develop from the date of contact and infection, and requires vigorous treatment to eradicate the disease. The difficulty of concealment confronts the authorities in regard to venereal diseases, but the soldier must be made to understand the danger of delaying effective treatment. The first symptom is an ulcer which appears upon the skin at some point. This ulcer is definite in its form, and cannot be confused with any other class of sore. The disease passes through three stages unless effectively treated, the first being that of the outbreak of the sore, the second being a rash on the skin, whilst the third stage evidences itself when the disease has been neglected, usually within the course of a few months, or even years, when nervous disorders, accompanied by swelling of the glands and other functional ailments, occur. The disease is most deadly from the fact that it may be communicated to others and pass through several generations.

The second disease is gonorrhoea, which although more common than syphilis, is not so disastrous in its effect if properly treated. The disease is conveyed by sexual intercourse, or by infection conveyed to the eyes by using a towel which has been used by an infected person. Serious complications may occur where the disease is neglected.

The third disease is that of a local trouble which can be promptly handled by a competent medica1 man, and produces no serious results when properly treated.

The prevention of these diseases can best be accomplished by lectures on the risks which are run by illicit intercourse, and by explaining the necessity of immediately reporting to the Medical Officer when infection is discovered, coupled with rigid control of all known loose characters.

The Regimenta1 Officer should pay strict attention to the cleanliness of all quarters of his command. Inspections should be made of all cupboards, corners, ledges, etc., and all possible breeding-places for germs or receptacles for filth. All foodstuff should be kept covered, and all refuse tins should be emptied daily and covers placed over them during the day.

Manure and stable refuse should be removed regularly. Scraps of food and refuse must be deposited in proper receptacles.

The floors of all rooms should be scrubbed twice a week and dry-scrubbed daily. Blankets aired daily or as frequently as circumstances permit Windows of rooms should be left open on the leeward side of the building at night.

The food of the men should be carefully watched to see that it is sufficient and properly cooked. The articles sold in canteens should be regulated to see that they are a wholesome quality. The use of liquor should be discouraged and the evils of excess explained to the men. Frequent lectures upon sanitation should be given by the Medical Officer, making them short and interesting, in order to hold the attention of the men.

Inspections of the men should be held, whereat they parade with bare arms, chests, and legs. This enables the Officer to inspect their skin to see that it is clean and their underclothing washed.

In the field, facilities should be devised to enable the men to wash their clothing and to bathe. Rest-days when on the march should be regulated, in order to occupy suitable quarters at this time. When marching, the men should be instructed to loosen their clothing at the neck, to avoid smoking on the march, and to rest at halts by removing packs and lying down.

When off parade the men should be encouraged to take part in prearranged sports, concerts, etc. thereby removing temptation to wander into doubtful areas. Interesting lectures may be given to vary the evening attractions.

The moral and physical condition of the men must be the constant care of the Commanders, and the more severe the conditions of service are, the closer must be the personal supervision of the Commanders to insure the maximum of efficiency.

The construction of adequate and proper sanitary conveniences when on the march, in camp, or bivouac, and the disposal of refuse, etc.; needs personal attention, otherwise the men, when tired, will be apt to neglect the necessary precautions.

The success of the whole system of sanitation in the field must depend upon the effective co-operation of every Officer and N.C.O.