MANUAL ■ : | OF THE I :i I MEDICAL DEPARTMENT : UNJTED STATES NAVY MS m2 41 MANUAL OF THE MEDICAL DEPARTMENT OP THE UNITED STATES NAVY PUBLISHED BY THE BUREAU OF MEDICINE AND SURGEPY Und** the authority of the CRETARY of the navy UNITED STATES GOVERNMENT PRINTING OFFICE* WASHINGTON: 1942 Bureau of Medicine and Surgery, Navy Department, Washington, D. C.} November 80, 1988. The accompanying Manual of the Medical Department supersedes prior editions. Orders or instructions contained in this publication shall have full force and effect for the guidance of all persons in the Naval Estab- lishment (art. 74 (4), N. R.). They shall in no way alter or amend any provision of the Navy Regulations or of any Navy Department General Order (art. 74 (3h), N. R.). P. S. Rossiter, Surgeon General of the Navy. Approved: Claude A. Swanson, Secretary of the Navy. II TABLE OF CONTENTS Chapter 1. The Bureau of Medicine and Surgery. paragraphs Establishment, Organization, and Duties of the Bureau 1-13 Chapter 2. The Medical Corps. Section I. Establishment and Organization 101-104 II. Appointments 111-121 III. Promotions 131-139 IV. Retirements 151 V. The Naval Reserve (Medical Corps) 171 Chapter 3. The Dental Corps. Section I. Appointments 201-208 II. Promotions 221-225 III. General Duties of Dental Officers 231-244 IV. Duties of Dental Officers Afloat.. 261-262 V. Duties of Dental Officers Ashore 271-275 VI. The Naval Reserve (Dental Corps) 281 Chapter 4. The Nurse Corps. Section I. Laws Relating to the Nurse Corps 301-309 II. The Superintendent of the Nurse Corps 311 III. Assistant Superintendents 321-322 IV. Chief Nurses 331-337 V. Nurses 341-347 VI. Reserve Nurses 351-352 VII. Assignment and Transfer 361-363 VIII. Leave of Absence 371-378 IX. Illness 391-394 X. Pay, Allowances, Subsistence, and Quarters 411-420 XI. Transportation and Traveling Allowances 431-435 XII. Uniform - 441 XIII. Discharge 451-454 XIV. Retirement 461-465 XV. Reports and Returns 471-477 Chapter 5. The Hospital Corps. Section I. General Information 601-621 II. Reports and Returns 631-639 Chapter 6. General Duties of Medical Officers. Section 1. Prevention of Disease 701-707 II. Care of Sick and Wounded 711-713 III. Miscellaneous Duties 729-742 IV. Professional Relations with Civilians 751-753 V. Junior Medical Officers 761-762 Chapter 7. Duties of Medical Officers Afloat. Section I. Fleet, Force, and Division Medical Officers 801-811 II. The Medical Officer of a Ship 821-837 III. Duties of the Medical Department in Emergencies. _ 861-888 III TABLE OF CONTENTS Paragraphs Chapter 8. Hospital Ships 1001-1011 Chapter 9. Doties of Medical Officers Ashore. Section I. Duties of District Medical Officers 1101-1102 II. The Medical Officer of a Shore Station 1121-1129 Chapter 10. Special Activities. Section I. Amphibious Operations 1201-1217 II. Field Service 1221-1232 III. Aviation Service 1261-1266 IV. Submarine and Diving Services 1276-1283 Chapter 11. Physical Examinations. Section I. Preliminary 1401-1407 II. General Instructions for Conducting the Examination. 1411-1416 III. General Provisions Governing Examinations 1417-1425 IV. The Eyes. 1426-1432 V. The Ears 1433-1437 VI. General Examination 1439-1448 VII. The Skin. 1446-1450 VIII. The Head 1451-1452 IX. The Face 1453 X. The Mouth, Nose, Pharynx, etc 1454-1455 XI. The Teeth. 1458-1462 XII. The Neck 1468-1464 XIII. The Spine 1467-1468 XIV. The Chest 1471-1472 XV. The Lungs 1475-1477 XVI. The Heart and Blood Vessels 1481-1492 XVII. The Abdomen 1493-1495 XVIII. The Pelvis 1498-1501 XIX. The Genito-urinary System 1502-1508 XX. The Extremities 1510-1511 XXI. The Nervous System 1514-1519 XXII. Annual and Special Examinations 1520-1537 XXIII. Aviation Examinations 1538-1564 XXIV. Records 1570-1578 XXV. Civil Employee Examinations 1594-1597 Chapter 12. Naval Hospitals. Section I. Establishment and Organization 1601-1606 II. Administration 1611-1625 III. Administrative Assistants and Adjuncts 1631-1653 IV. Clinical Administration and Facilities 1661-1680 Chapter 13. Special Hospitals. Section I. The Army and Navy General Hospital 2101-2111 II. Hospitals for Pulmonary Tuberculosis 2121-2122 III. The United States Naval Home 2142-2143 IV. Hospitals for the Insane 2151-2160 V. Other Government Hospitals 2170-2173 VI. Hospitals for Malignant Diseases 2176-2178 Chapter 14. Health Records. Section I. Opening, Custody, etc 2201-2217 II. The Name, Rank, Rate, etc 2251-2253 IV TABLE OF CONTENTS Chapter 14. Health Records—Continued. Paragraphs Section III. The Descriptive Sheet 2261-2263 IV. The Medical History Sheets 2281-2290 V. The Medical Abstract 2301 VI. The Dental Record 2311-2319 VII. Record of Refractions and Special Duty Abstracts 2331 VIII. The Syphilitic Abstract 2350 Chapter 15. Nomenclature of Diseases and Injuries. Section I. Instructions 2401-2420 II. Nomenclature of Diagnostic Titles See Appendix A III. Nomenclature of Surgical Operations See Appendix A IV. Nomenclature of Nature and Cause of Violence. See Appendix A Chapter 16. Misconduct Status 2501-2512 Chapter 17. Preventive Medicine and Sanitation. Section I. General Regulations and Instructions 2601-2623 II. Field and Camp Sanitation 2661-2680 III. Sanitary Reports 2691-2704 IV. Intelligence Reports 2711-2713 Chapter 18. Quarantine, Bills of Health, and Disinfection. Section I. Quarantine Laws 2801-2808 II. Quarantine Regulations 2811-2818 III. Quarantinable Diseases 2820-2827 IV. Navy Regulations Relating to Quarantine 2828-2834 V. Bills of Health 2835-2845 VI. Disinfection and Disinfectants. 2851-2864 VII. Fumigation of Vessels 2871-2874 VIII. Destruction of Vermin 2881-2888 Chapter 19. Deaths and Resulting Duties. Section I. Recording and Reporting of Deaths 2901-2911 II. Investigation of Deaths 2916-2918 III. Notification to Next of Kin 2921-2924 IV. Preparation of Remains 2931-2941 V. Transportation of Remains 2951-2961 VI. Funeral Escorts 2965-2973 VII. Funeral Expenses 2975-2993 VIII. Funerals and Funeral Flags 2998-2999 Chapter 20. Finance and Property. Section I. Annual Appropriations and Bureau Fund 3001-3005 II. Estimates of Expenditures 3011-3016 III. Allotments, Obligations, and Expenditures 3022-3024 IV. Procurement Methods 3030-3059 V. Property: Custody, Issue, and Disposition 3062-3081 VI. Accounting Records: Ships and Shore Stations 3086-3088 VII. Accounting Records, Naval Hospitals 3094-3117 VIII. Medical Stores, Naval Medical Supply Depots 3142-3155 Chapter 21. Medical and Dental Attendance. Section I. Medical attendance 3161-3168 II. Naval and Marine Corps Reserve Personnel. 3169-3180 III. Dental Treatment 3190-3199 Chapter 22. The Naval Medical Center 3301-3341 V TABLE OF CONTENTS Chapter 23. Reports and Returns. Paragraphs Section I. General Instructions 3401-3406 II. Lettered Forms 3411-3438 III. Numbered Forms 3442 IV. Hospital Forms 3451-3492 V. Miscellaneous 3501-3520 VI. Tabulation 3551-3555 Changes in Manual of the Medical Department. Index. VI CHAPTER 1 THE BUREAU OF MEDICINE AND SURGERY ESTABLISHMENT, ORGANIZATION, AND DUTIES OF THE BUREAU Paragraph Establishment 1 Organization 2-5 Duties 6 Bureau Orders 7 Material, Apparatus, etc. 8 Finances 9 Assignment of Personnel 10 Public Works and Protection of Public Property 11 Information to Persons Outside the Department 12 Publications under the Bureau 13 1. Establishment of the Bureau of Medicine and Surgery.—The Department of the Navy was created by the act of April 30, 1798. The bureau system of the Navy Department was established by the act of August 31, 1842, which provided that the business of the De- partment should be distributed among five bureaus, including a Bureau of Medicine and Surgery. The present laws relating to the Bureau are to be found in title 5, United States Code, section 430 of which provides that all of the duties of the Bureau shall be performed under the authority of the Secretary of the Navy, that its orders shall be considered as emanating from him, and shall have full force and effect as such. The Bureau of Medicine and Surgery of the Navy Department will be referred to henceforth in this manual as the Bureau. Other bureaus will be specifically designated. 2. The Chief of the Bureau.—The Chief of the Bureau is appointed by the President, by and with the advice and consent of the Senate, from the list of surgeons of the Navy, for a term of 4 years, and while so serving holds the title of Surgeon General of the Navy and the rank and title of rear admiral. He is to be addressed and designated by the title of his rank; in written communications the title of his office is to be stated next after his name. 3. The Assistant to the Bureau.—Statutory provision for an Assist- ant to the Bureau dates from the act of July 16, 1862, and is embodied in title 5, section 451, United States Code. Under this authority and that of section 5 of the same title, and in the actual absence of the Chief of Bureau, the Assistant to Bureau shall perform the duties of the Chief of Bureau. 4. The Chief Clerk.—In accordance with title 5, section 5, United States Code, the Chief Clerk of the Bureau, in the actual absence of 1 6-6 OH. 1.—THE BUREAU the Chief of Bureau and of the Assistant to Bureau shall perform the duties of the Chief of Bureau. 5. Organization.—(a) The activities of the Bureau are organized along functional lines to include the following divisions: (1) Division of Administration, (2) Division of Personnel (Medical Corps, Nurse Corps, Hospital Corps), (3) Division of Dentistry, (4) Division of Physical Qualifications, (5) Division of Preventive Medicine, (6) Divi- sion of Aviation Medicine, (7) Division of Materiel and Finance, (8) Division of Inspections, (9) Division of Planning, (10) Division of Publications, and (11) Division of Red Cross and Veterans’ Admin- istration. The Naval Medical Center and the Naval Dispensary, Navy Department, although not a part of the Bureau, function under its direct administrative control. (b) Maintenance of contact in the Medical Department.—The Chief of the Bureau maintains contact with Medical Department activities, afloat and ashore, through the fleet surgeons, the medical officers in command or the senior medical officers, via official channels; in matters of internal administration at naval hospitals and naval medical supply depots, direct. 6. Duties.—(a) General.—The Bureau, under the direction of the Secretary of the Navy, is charged with and responsible for the main- tenance of the health of the Navy, for the care of the sick and injured, for the custody and preservation of the records, accounts, and prop- erties under its cognizance and pertaining to its duties, and for the professional education and training of officers, nurses, and enlisted men of the Medical Department of the Navy. (b) Naval hospitals, medical supply depots, technical schools, etc. ; upkeep and operation.—The Bureau is charged with the upkeep and operation of naval hospitals, medical supply depots, medical laboratories, the Naval Medical Center and of all technical schools established for the education or training of Medical Department personnel, including repair of buildings, except as excluded in article 484, Navy Regulations; and has charge of the civilian force employed at naval hospitals, medical supply depots, medical laboratories, the Naval Medical Center, and at all technical schools for the education or training of Medical Department personnel. (c) Inspections, recommendations, care of the sick and wounded, hygiene and sanitation, etc.—The Bureau provides for inspection of the sanitary condition of the Navy, recommends with respect to all questions connected with hygiene and sanitation affect- ing the service and, to this end, has opportunity for necessary inspec- tion; it advises with other bureaus and offices in reference to the sanitary features of ships under construction and in commission, 2 establishment, organization, and duties 6 regarding berthing, ventilation, and location of quarters for the care and treatment of the sick and injured; of the provisions for the care of wounded in battle; and, in the case of shore stations, with regard to health conditions depending on location, the hygienic construction and care of public buildings, especially of barracks and other habita- tions, such as camps. It also advises concerning matters pertaining to clothing and food; to water supplies used for drinking, cooking, and bathing purposes; and to drainage and disposal of wastes, so far as these affect the health of the Navy. It safeguards the personnel by the employment of the best methods of hygiene and sanitation, both afloat and ashore, with a view to maintaining the highest possible percentage of the personnel ready for service at all times, and adopts for use all such devices or procedures as may be developed in the sciences of medicine and surgery as will in any way tend to an increase in military efficiency. (d) Physical fitness.—It is the duty of the Bureau to provide for the physical examination of officers, nurses, and enlisted men, with a view to the selection or retention of only those whose physical condi- tion is such as to maintain or improve the military efficiency of the service if admitted or retained therein. (e) Complements of Medical Department personnel; admin- istration of the Nurse Corps; professional standards for the Hospital Corps.—The Bureau recommends to the Bureau of Naviga- tion the complement of Medical Department personnel for hospitals and hospital ships, and recommends and has information as to the assignment and duties of medical officers, dental officers, and hospital corpsmen. It is charged with the administration of the Nurse Corps, and has the power to appoint and remove all nurses, subject to the approval of the Secretary of the Navy. It passes upon the com- petency, from a professional standpoint, of all hospital corpsmen for enlistment, enrollment, and promotion by means of examinations conducted under its supervision or by such forms as it may prescribe. (f) Medical Department supplies and equipment.—The Bureau requires for and has control of the preparation, inspection, reception, storage, care, custody, transfer, and issue of all supplies of every kind used in the Medical Department for its own purposes. (g) Hospital ships.—The design of hospital ships insofar as relates to their efficiency for the care of the sick and wounded is subject to the approval of the Bureau, which also provides for the organization and administration of the medical department of such vessels. (h) Care of the dead.—The arrangements for care, transporta- tion, and burial of the dead are under the jurisdiction and control of the Bureau, except as otherwise provided in article 1841, Navy Regulations. 3 7-13 CH. 1. THE BUREAU 7. Bureau Orders.—The chief of a bureau shall issue orders or directions only in connection with duties specifically prescribed by law, regulation, or general order (art. 393 (5), (6), and (7), N. R.). 8. Material, Apparatus, Etc.—(a) Each bureau shall determine upon and require for or have manufactured all material, apparatus, tools, stores, fuel, transportation, stationery, blank books, forms, and ap- pliances of every kind needed for its own use in carrying out its duties and shall be charged with the preservation of public property under its cognizance, including all that relates to the equipment of ships, and each bureau shall inspect all material for its use except where otherwise provided (art. 393 (8) and (9), N. R.). (b) Work done by one bureau for another bureau, including con- struction, alteration, and repair of public works and the inspection of material, shall be done by the former after approval by, and to the satisfaction of, the latter; and such work shall at all times be open to the inspection of the bureau for which it is done (art. 393 (10), N. R.). 9. Finances.—Each bureau shall estimate for and defray from its own funds the cost necessary to carry out its duties (art. 393 (11), N. R.). 10. Assignment of Personnel.—Each bureau shall make recom- mendations for assignment of officers to duty under its cognizance (art. 393 (12), N. R.). 11. Public Works and Protection of Public Property.—(a) At hos- pitals, medical supply depots, medical laboratories, the Naval Medical Center, and at technical schools for the education or training of Medical Department personnel, repairs to public works and utilities within the capacity of the force employed, as well as their upkeep and operation, shall be under the cognizance of the Bureau (art. 484 (3), N. R.). (b) The Bureau shall provide watchmen and labor for the protection and cleaning of public property under its cognizance (art. 492, N. R.). 12. Information to Persons Outside the Department.—No informa- tion is to be furnished from the records of the Navy Department to attorneys or agents concerning the naval service of officers or enlisted men of the Navy except as stated in article 397, Navy Regulations. 13. Publications Under the Bureau.—The Manual of the Medical Department, Drill Book for the Hospital Corps, Naval Medical Bul- letin, Hospital Corps Manual, and the Statistics of Diseases and Injuries in the United States Navy are published and distributed under the cognizance of the Bureau. Additional information is disseminated from time to time by Bureau circular letters and memoranda. 4 CHAPTER 2 THE MEDICAL CORPS Paragraphs Section I. ESTABLISHMENT AND ORGANIZATION 101-104 H. APPOINTMENTS 111-121 m. PROMOTIONS 131-139 IV. RETIREMENTS 151 V. THE NAVAL RESERVE (MEDICAL CORPS) 171 Paragraph Laws Concerning the Medical Corps. 101 Precedence and Authority 102 Title 103 Right to Communicate with Commanding Officers 104 SECTION I. ESTABLISHMENT AND ORGANIZATION 101. laws Concerning the Medical Corps.—(a) The appointment of assistant surgeon was first authorized by the act of May 24, 1828 (ch. 121) for the better organization of the Medical Department of the Navy of the United States. Laws passed subsequently have fixed the total number of officers, the number in each grade, promo- tion, rank, and other matters of similar concern to the personnel of the Medical Corps. The principal act now in force is that of August 29, 1916 (39 Stat. 576), which states that— * * * the total authorized number of commissioned officers of the Medical Corps shall be sixty-five one-hundredths of one per centum of the total authorized number of the officers and enlisted men of the Navy and Marine Corps, including midshipmen, Hospital Corps, prisoners undergoing sentence of discharge, enlisted men detailed for duty with the Naval Militia, and the Flying Corps. * * *. (b) In addition to the above, by the act of August 29, 1916, the authorized number of surgeons was increased by one for duty with the military relief division of the American National Red Cross. (c) The number of medical officers specified in the act of August 29, 1916, is known as the authorized strength That number is, however, reduced through limitations set by annual appropriation bills so that the number actually provided for usually is the percentage ratio applied to the appropriated strength of the Navy and Marine Corps instead of the authorized strength. The distribution of medical officers in the several grades, and the rules governing advancement in rank, follow the provisions of the act of June 10, 1926 (44 Stat. 717, equalization act, as amended by the act of August 5, 1935, 49 Stat. 530). 5 102-113 CH. 2.—THE MEDICAL CORPS 102. Precedence and Authority.—Consult articles 153 (1), 154, and 181 (c), Navy Regulations, and the annual Navy Register. 103. Title.—Medical officers are addressed in oral or written communications in accordance with article 148 (3), Navy Regulations. 104. Right to Communicate With Commanding Officer.—Consult articles 180, 182 (10), and 183, Navy Regulations. SECTION II. APPOINTMENTS Paragraph Regulations Governing Appointments 111 Qualifications for Appointment 112 Appointment by Competitive Examination 113 Form of application 114 Certificates 115 Permit for Examination 116 Physical Examination 117 Professional Examination 118 Withdrawal from Examination 119 No Allowance for Expenses 120 Failure in Professional Examination 121 111. Regulations Governing Appointments.—Appointments to office in the Navy are governed by article 1631, Navy Regulations. 112. Qualifications for Appointment.— (a) Appointees to the grade of assistant surgeon shall be between the ages of 21 and 32 at the time of appointment (act of August 29, 1916). Their physical, moral, mental, and professional qualifications shall be decided upon by a board of medical officers. (b) Acting assistant surgeons may be appointed for temporary service after such examination as the Secretary of the Navy may prescribe (art. 1638, N. R.). (c) Graduates of class A medical schools, who have had an interne- ship in a civilian hospital, may be commissioned in the permanent Medical Corps as assistant surgeons with the rank of lieutenant (junior grade), if found physically and professionally qualified. (d) Senior medical students of class A medical schools may receive temporary appointments as acting assistant surgeons and be assigned to one of the larger naval hospitals for a year’s intemeship. Upon completion of this year’s intemeship, the interne may appear for competitive examination for appointment in the permanent estab- lishment as an assistant surgeon with the rank of lieutenant (junior grade). 113. Appointment by Competitive Examination.—Competitive ex- aminations will be held during the months of May and November each year for graduates of class A medical schools, who have com- pleted an intemeship in a civilian hospital and for senior medical students of class A medical schools who are desirous of obtaining an intemeship in a naval hospital. 6 SEC. II.—APPOINTMENTS 114 Graduates of class A medical schools who have completed an in- terneship in a civilian hospital and who successfully pass the competi- tive examination will be commissioned as assistant surgeons with the rank of lieutenant (junior grade) and assigned to the Naval Medical School, Washington, D. C., for a post-graduate course of instruction prior to their assignment to sea or foreign shore duty. Senior medical students who qualify for an appointment to an interneship in the Medical Corps of the Navy will be appointed acting assistant surgeons with the rank of lieutenant (junior grade), for temporary service during the interne year. Upon the satisfactory completion of his interneship, the interne will be allowed to appear for competitive examination for appointment as assistant surgeon, rank of lieutenant (junior grade), in the Medical Corps of the Navy. Should the interne desire to return to the practice of medicine in civil life, his appointment as an acting assistant surgeon will be terminated and he will be honorably discharged from the naval service. The requirements for appointment in the Medical Corps of the United States Navy are the same for both the interne and the gradu- ate, which provide that the candidate be a citizen of the United States between 21 and 32 years of age at the time of appointment and a graduate of, or a senior student in, a medical school, listed as class A by the Council on Medical Education of the American Medical Association, and pass the required physical and professional ex- aminations. 114. Form of Application.—This form is to be copied on a separate sheet in the handwriting of the applicant, and submitted in duplicate. (Residence) " "(Date)" Sir: I request permission to be examined for appointment in the grade of assistant surgeon (acting assistant surgeon), rank of lieutenant (junior grade), in the Medical Corps of the United States Navy. I was bom at , and was years of age on the day of , 19 ; and am a citizen of the United States, and a legal resident of the State of My permanent address is I graduated (will graduate) from Medical School in 19__. I forward herewith letters testifying to my moral character, habits, citizen- ship, preliminary education, and professional qualifications. Very respectfully, (Name In full, written legibly) Chief of the Bureau of Medicine and Surgery, Navy Department, Washington, D. C. 7 115-116 CH. 2.—THE MEDICAL CORPS 115. Certificates.—The above application must be accompanied by the following certificates: (a) Letters or certificates from two or more persons of good repute, testifying from personal knowledge to good habits and moral character. (b) Satisfactory evidence as to citizenship: Any one of the following may be considered as satisfactory proof of citizenship: If native born.—(1) A duly verified copy of a public or church record of birth; (2) affidavit, under oath, of the physician, mid- wife, or other person present at the birth; (3) in cases where neither (1) nor (2) can be obtained by the candidate, the affidavit of either parent; (4) in cases where the candidate certifies that no one of the above is obtainable, the affidavits (under oath) of two reputable citizens acquainted with him. Each of these affidavits should state the facts within the knowledge of the deponent upon which he bases his statement as to the citizenship of the candidate; as for example, that he has known the candidate since birth, that he knew his parents, that he knew him to be a bona fide voter, as the case may be. If foreign born.—(1) Certificate of naturalization, under the seal of the court by which naturalized; (2) certificate of naturalization, under the seal of the court by which naturalized, of the parent during the minority of the candidate, together with the affidavit of a parent that the candidate is the child of the parent whose certificate of naturalization is submitted; (3) in special cases where the candidate certifies that neither (1) nor (2) is obtainable, the affidavits of two reputable citizens acquainted with him. As every naturalization is a matter of record in some court, these affidavits will be accepted only in very exceptional cases and on the understanding that the candidate shall later submit a proper certificate of naturalization. (c) Letter from the dean of the medical school certifying to the conduct and standing of the applicant, if a student. If the candidate is a graduate, he must submit a certificate of graduation in medicine and a certificate of intemeship from a civilian hospital (do not sub- mit diplomas). (d) A recent photograph (size preferably 5 by 7 inches). (e) If the candidate has had hospital service or special educational or professional advantages, certificates to this effect, signed by the proper authorities, should also be forwarded. The applicant wfill save unnecessary correspondence if he will make sure when submitting his application to meet the requirements enumerated above. 116. Permit for Examination.—After passing upon the credentials of the candidate, the Bureau will recommend that a permit be issued to the candidate to appear before a board of medical examiners and naval 8 SEC. III.—PROMOTIONS 117-131 examining board for physical and professional examination. An effort will be made to select a place for the examination as near as possible to the place of residence of the candidate. 117. Physical Examination.—(a) A thorough physical examination precedes the professional examination, and the candidate is required to certify that he is free from all mental, physical, and constitutional defects (ch. 11.). (b) If the candidate be found physically disqualified, his exam- ination is concluded. If found to be physically qualified, his examina- tion is continued. 118. Professional Examination.—(a) Assistant surgeon.—The professional examination embraces the subjects of (1) general medi- cine, (2) general surgery, (3) obstetrics and gynecology, and (4) pre- ventive medicine and medical jurisprudence; also an oral and practical examination. (b) Acting assistant surgeon.—The professional examination embraces the subjects of (1) general medicine, (2) general surgery; also an oral and practical examination. 119. Withdrawal From Examination.—With the consent of the naval examining board, a candidate may withdraw at any time from further examination upon written request to the board and may at a future time present himself for reexamination. 120. No Allowance for Expenses.—No allowance shall be made for the expense of persons undergoing examination for appointments, except as provided by law for midshipmen (art. 1838, N. R.). 121. Failure in Professional Examination.—A candidate failing in the professional examination may apply for a reexamination, but such reexamination will not be granted until after a period of 6 months has elapsed since the last examination. SECTION III. PROMOTIONS Paragraph Eligibility for Promotion 131 Examination Required 132 Failure to Pass Physical Examination 133 Failure to Pass Professional Examination 134 Examination for Advancement to the Rank of Lieutenant 135 Examination for Advancement to the Rank of Lieutenant Commander 136 Examination for Advancement to the Rank of Commander 137 Examination for Advancement to the Rank of Captain 138 Examination for Advancement to the Rank of Rear Admiral 139 131. Eligibility for Promotion.—Medical officers are eligible for selection for promotion up to and including the rank of rear admiral with the officer of the line with whom or next after whom they take precedence under existing law. 9 132-139 CH. 2.—THE MEDICAL CORPS 132. Examinations Required.—Examinations for promotion are governed by articles 1650 and 1661, Navy Regulations. 13S. Failure to Pass Physical Examination.—Any officer failing to pass the required physical examination for promotion to one of the selective grades, in the event of retirement by reason of the disability causing such failure, is not entitled to be retired with the rank of the next higher grade (art. 1670 (1) N. R.). 134. Failure to Pass Professional Examination.—All staff officers who have not been recommended for advancement and who, after the completion of the designated periods of service as prescribed for their respective ranks, become ineligible for consideration by a selec- tion board, or who, if recommended for advancement, undergo the required examinations for advancement and are found not pro- fessionally qualified, shall be transferred to the retired list of the Navy (act of August 5, 1935). 135. Examination for Advancement to the Rank of Lieutenant.—(a) The written professional examination will be in the subjects of (1) general medicine, including tropical diseases, (2) general and mili- tary surgery, (3) general and naval hygiene and sanitation, and (4) Navy Regulations and Manual of the Medical Department. (b) A practical examination will be held in medical diagnosis, surgical ability, and laboratory ability. (c) Candidates are not examined orally except in explanation of written and practical work. 136. Examination for Advancement to the Rank of lieutenant Commander.—This examination is similar in scope to that for lieu- tenant, except that the candidate is expected to have greater practical knowledge and ability in the subjects in which examined. 137. Examination for Advancement to the Rank of Commander.— This examination will be predominantly professional in character, comprehending the subjects of medicine, surgery, and preventive medicine, but including also questions pertaining to Medical Depart- ment organization and administration. 138. Examination for Advancement to the Rank of Captain.—In this examination questions will be asked in the subjects of Medical Department organization and administration, hospital plans and con- struction, hygiene and sanitation, Navy Regulations, and Manual of the Medical Department. 139. Examination for Advancement to the Rank of Rear Admiral.— The mental, moral, and professional examination of a candidate for the rank of rear admiral shall be such as the Secretary of the Navy may prescribe. 10 SEC. V. NAVAL RESERVE 151-171 SECTION IV. RETIREMENTS Paragraph Regulations 161 151. Regulations.—Voluntary retirement (art. 1665, N. R.); age of retirement (art. 1668, N. R.); retirement for physical disability (art. 1670, N. R.); chief of bureau, retired (art. 1792 (1), N. R.); officer wholly retired (art. 1793, N. R.); involuntary transfers to retired list (act of August 5,1935); retired officers on active duty (art. 177, N. R.). SECTION V. THE NAVAL RESERVE (MEDICAL CORPS) Paragraph Information Regarding the Naval Reserve 171 171. Information Regarding the Naval Reserve.—Regulations per- taining to naval medical reserves are incorporated in part H, Bureau of Navigation Manual. For current information and instructions relative to these reserves see Bureau Circular Letter M, appendix D, of this manual. CHAPTER 3 Paragraphs Section I. APPOINTMENTS 201-208 II. PROMOTIONS 221-225 m. GENERAL DUTIES OF DENTAL OFFICERS 231-244 IV. DUTIES OF DENTAL OFFICERS AFLOAT 261-262 V. DUTIES OF DENTAL OFFICERS ASHORE 271-275 VI. THE NAVAL RESERVE (DENTAL CORPS) 281 THE DENTAL CORPS SECTION I. APPOINTMENTS Paragraph General 201 Qualifications for Appointment 202 Form of Application 203 Certificates 204 Permit for Examination 205 Physical Examination 206 Professional Examination 207 Candidate may Withdraw 208 201. General.—The Dental Corps is a part of the Medical Depart- ment of the Navy, although separate and distinct from the Medical Corps. Dental officers are appointed and commissioned in the Navy in the ratio of 1 for each 500 of the total actual number of officers and enlisted men of the Navy and Marine Corps. Original appoint- ments in the Naval Dental Corps are made in the grade of assistant dental surgeon with the rank of lieutenant (junior grade). Examina- tions for appointment will be held from time to time, to fill vacancies as they may occur. 202. Qualifications for Appointment.—All appointees to the Naval Dental Corps shall be citizens of the United States between 21 and 32 years of age. They shall be graduates of acceptable dental colleges, and trained in the several branches of dentistry. Before appointment, they must satisfactorily pass mental, moral, physical, and professional examinations (act of July 1, 1918). 13 203-206 CH. 3.—THE DENTAL CORPS 203. Form of Application (in the handwriting of the candidate): (Residence) , 19- Sib: I request permission to be examined for appointment in the grade of assistant dental surgeon, rank of lieutenant (junior grade), in the Dental Corps of the United States Navy. I was born at on the day of , in the year I am a (native born or naturalized) citizen of the United States, residing in , county of , in the State of lam a graduate of Dental School. I forward herewith: (а) Letters testifying to moral character and habits. (б) Certificate of birth and citizenship. (c) Certificate of professional education. (d) Recent photograph, without hat. Very respectfully, (Signature in full) Chief of the Bureau of Medicine and Surgery, Navy Department, Washington, D. C. 204. Certificates.—The above application must be accompanied by the following: (a) Letters or certificates from two or more persons of good repute, testifying from personal knowledge as to applicant’s good habits and moral character. (b) Satisfactory evidence of citizenship (proof of citizenship shall be the same as is required of candidates for the Medical Corps). (c) Certificate of dental education. This certificate should give the name of the school and the date of graduation. (d) If the candidate has had institutional service or special educa- tional or professional advantages, certificates to this effect, signed by the proper authorities, also should be forwarded. (e) A recent photograph, without hat, approximately 5 by 7 inches, with candidate’s signature and date taken on the back. 206. Permit for Examination.—After having passed upon the cre- dentials of the candidate, and when all requirements have been met, the Bureau will recommend to the Bureau of Navigation that a permit be issued to the candidate to appear before a Board of Medical Examiners and a Naval Examining Board for his physical and professional examinations, at a time and place designated by the Bureau. No allowance can be made for the expenses of the candidate. 206. Physical Examination.—(a) The physical examination, which precedes the professional examination, is thorough, and the candidate is required to certify that he is free from all mental, physical, and constitutional defects. 14 SBO. H.—PROMOTIONS 207-223 (b) If the candidate be found physically disqualified, his examina- tion is concluded. 207. Professional Examination.—The requirements for this are— (a) A letter to the board describing in detail his general and profes- sional education and experience. (b) Written and oral examinations in the following subjects: Anatomy, physiology, histology, physics, chemistry, metallurgy, dental materia medica and therapeutics, dental pathology and bacteriology, roentgenology, oral surgery, operative dentistry, and prosthodontia. (c) Clinical examination in operative dentistry, oral surgery, and prosthodontia. (d) An oral examination may be conducted on subjects of prelimi- nary education. Applicants holding diplomas or certificates from reputable literary or scientific colleges or normal schools, may submit such diplomas or certificates for the consideration of the board in this connection. 208. Candidate may Withdraw.—Upon written request and with the consent of the board, a candidate may withdraw from further exami- nation. The board may conclude the examination (written, oral, and clinical) at any time, and may deviate from this general plan as may seem best for the interests of the naval service. SECTION n. PROMOTIONS Paragraph General.— 221 Examination for Advancement to the Rank of Lieutenant 222 Examination for Advancement to the Rank of Lieutenant Commander 223 Examination for Advancement to the Rank of Commander 224 Examination for Advancement to the Rank of Captain 225 221. Ceneral.—(a) Dental officers are eligible for advancement in rank with their running mates in the line, in accordance with existing legislation. (b) They shall pass such professional, moral, mental, and physical examination as may be required (art. 1650, N. R.). 222. Examination for Advancement to the Bank of Lieutenant.— (a) The candidate shall present a letter to the board reporting his general and professional duties since appointment. (b) The professional examination shall include the following sub- jects: Dental and oral surgery, dental materia medica and thera- peutics, dental bacteriology and pathology, Navy Regulations, and Manual of the Medical Department. 223. Examination for Advancement to the Bank of Lieutenant Commander.—This examination is similar in scope to that for lieu- tenant, except that the candidate is expected to have greater practical knowledge and ability in the subjects in which examined. 15 224-231 CH. 3.—THE DENTAL CORPS 224. Examination for Advancement to the Rank of Commander.— This examination will be predominantly professional in character, comprehending the subjects of dental and oral surgery, but including also questions pertaining to the organization and administration of dental activities in the Navy. 225. Examination for Advancement to the Rank of Captain.—In this examination questions will be asked on the organization and administration of dental activities in the Navy, Navy Regulations, and Manual of the Medical Department. SECTION m. GENERAL DUTIES OF DENTAL OFFICERS Paragraph Assignment and Professional Duties 231 Preventive and Restorative Treatment 232 Dental Examinations 233 Dental Property 234 Requisitions for Dental Property 235 Hospital Corpsman Assigned 236 Dental Operating-room Linen 237 Educational Measures 238 Official Documents and Correspondence 239 Prosthetic Dental Treatment 240 Alcoholic Solutions, Narcotics, and Poisons 241 Articles on Professional Subjects 242 Professional Relations with Civilians 243 Annual Report of Dental Activities 244 231. Assignment and Professional Duties.—(a) Dental officers are assigned to the medical department of the ship or station to which they may be attached (par. 275). (b) The professional duties of dental officers are limited to the care and treatment of the teeth and their surrounding structures. Except as noted in subparagraph (e), dental officers shall not be called upon to assume any of the professional duties or responsibilities of medical officers. Subject to the above restrictions as to their professional duties, dental officers have the same rights and privileges as other officers of the medical department. (c) The care and treatment of dental disabilities are direct respon- sibilities of the dental officer. The dental officer shall consult with the medical officer regarding matters of policy, management, or rou- tine, and shall inform the medical officer whenever a case requires medical attention. (d) The professional services of dental officers shall be available only for officers and men of the Navy and Marine Corps on the active and retired list (art. 1178, N. R.). (e) Dental officers may be assigned to a battle-dressing station, and shall familiarize themselves with the duties to be performed at such stations. 16 SEC. III. GENERAL DUTIES 232-238 232. Preventive and Restorative Treatment.—(a) The fundamental duty of all dental officers is to prevent dental disease and to promote oral health. Naval dental treatment should be systematized in order that every effort may be made to accomplish all necessary preventive and restorative dental treatment for the personnel of the Navy and Marine Corps. (b) The term preventive dental treatment is intended to refer to all measures which will prevent the development of pathological conditions of the teeth and surrounding structures. (c) The term restorative dental treatment is intended to in- clude only the reparative measures which may be accomplished by means of the materials listed in the supply table. (d) The Bureau does not intend that the restoration of teeth by materials other than those listed in the supply table shall be under- taken by dental officers, either for persons on the active list of the Navy and Marine Corps or for other persons, except that restorations by means of gold or prosthetic appliances may be furnished at certain activities where facilitities for special treatment have been established; then only upon the approval of the Bureau. 233. Dental Examinations.—Every officer and man shall be ex- amined by a dental officer as soon as practicable after appointment or enlistment, and an accurate description of the conditions noted and any treatment performed shall be entered on the dental record sheet prepared at the time. Preparation of dental record sheets and all entries upon dental record sheets shall be made in accordance with the instructions contained in chapter 14. For information relative to special dental examinations, dental treatment, and dental require- ments see chapters 11 and 21. 234. Dental Property.—The dental officer will comply with article 1182, Navy Regulations, in all matters pertaining to the receipt and custody of, and accounting for, dental property. , 235. Requisitions for Dental Property.—Requisitions for dental prop- erty will be made in accordance with article 1183, Navy Regulations. 236. Hospital Corpsman Assigned.—A hospital corpsman, pref- erably one trained as a dental technician, shall be assigned for duty with the dental officer. 237. Dental Operating-room linen.—An adequate supply of dental operating-room linen shall be furnished the dental officer by the medi- cal department of the ship or station to which he is attached. The laundry of dental linen shall be included in that of the medical depart- ment of the ship or station concerned. 238. Educational Measures.—Advantage shall be taken of every opportunity to educate the personnel in matters concerning oral 17 239-240 CH. 3.—THE DENTAL CORPS health. The value of oral hygiene in preventing dental disease and maintaining general health should be explained and emphasized. Hospital corpsmen shall be instructed in the precautions to be taken against the spread of infectious diseases of the mouth. 239. Official Documents and Correspondence.—The dental officer shall see that copies of official documents received and copies of official letters and indorsements sent, are filed and preserved. Circular letters and all other communications which relate to dental activities shall be kept on file (art. 2047, N. R.). 240. Prosthetic Dental Treatment.—(a) Prosthetic dental treat- ment at the expense of the Government will be allowed only when authorized in advance by the Bureau, except minor repairs, such as repair of clasps, broken dentures, or fractured porcelains. These may be done in advance of receipt of approved Form L—Dental. (b) Prosthetic dental treatment will be rendered by naval dental officers only where facilities for such treatment have been established and will be restricted to the most necessary measures. Priority shall be given to patients who have lost teeth as the result of injuries incurred in the line of duty. (c) Whenever prosthetic dental treatment is considered necessary a Form L—Dental shall be prepared by the dental officer and sub- mitted in triplicate, via official channels, to the Bureau. (d) Upon the receipt of approved Form L—Dental, appointment for patient should be requested from the proper authority. (e) The mouth of the patient shall be placed in condition to receive the appliance needed, prior to transfer, and every effort shall be made to reduce to the minimum the time during which patients must be separated from duty. (f) When transportation is involved, the Bureau will recommend to the Bureau of Navigation or to the Major General Commandant, Marine Corps, that the patient be transferred to the activity where treatment is to be rendered. (g) It is not contemplated that the expenditure of material in any case will be greater than is necessary to improve the dental condition to the degree of efficiency necessary to health, nor is it expected that the replacement of every missing tooth will be attempted. In brief, prosthetic dental treatment will be restricted to measures which will restore lost masticatory function most economically and promote physical fitness. (h) When prosthetic dental treatment has been completed, the activity furnishing same shall enter on the back of both copies of Form L—Dental, the type of treatment furnished, brief description, tooth form and shade, with the approximate weight and cost of 18 SEC. m.—GENERAL DUTIES 241-244 precious metals expended. The original Form L of completed cases shall be submitted monthly along with the letter report required by paragraph 274. Identical entry shall be made in the dental record of patient. (i) All activities equipped to furnish prosthetic dental treatment shall submit monthly a special letter report, as required of naval hos- pitals in paragraph 274, subparagraph (c). 241. Alcoholic Solutions, Narcotics, and Poisons.—Dental officers shall assure themselves that all alcoholic solutions, narcotics, and poisons under their charge are properly labeled, kept under lock and key, and prescribed in accordance with paragraphs 737 and 738. The key or keys shall always be in the custody of the dental officer. Anti- dotes for narcotics and poisons shall be kept on hand at all times (arts. 13, 118, 1145, and 1146, N. R.). 242. Articles on Professional Subjects.—Dental officers shall be guided in the preparation and publication of such articles by article 113 (2), Navy Regulations and by General Order No. 9. 243. Professional Relations with Civilians.—(a) It is anticipated that dental officers may, for humanitarian reasons, be required to use Government facilities or materials in the treatment of emergency cases among persons not in the naval service when other adequate professional facilities are not available. No charges shall be made for such services when Government facilities or materials are used. (b) Naval dental officers shall not undertake to operate upon or treat prospective applicants for enlistment or appointment in the Naval Reserve, the Marine Corps Reserve, the Navy, or the Marine Corps, with a view to correcting defects, disqualifications, and dis- abilities so as to enable them to be enlisted or appointed. 244. Annual Report of Dental Activities.—In addition to the annual sanitary report of the ship or station, the medical officer shall prepare and submit to the Bureau, via official channels, a report of dental activities according to the following form: Annual Dental Report op THE U. S All reports shall contain the following data, tabulated, as indicated below: Stock No. Number on hand Manufacturer Voltage and current Date received Book value Present condition Probable date of replacement 14-019 19-096-7 22-0011 i List each item of clads 22 on band on separate line, aB per above specimen. 19 261-262 CH. 3. THE DENTAL CORPS Class 24, book value $ estimated replacement cost for next fiscal year $ Class 26, book value $ estimated replacement cost for next fiscal year $ SUPPLIES Class 23—Expenditures during period covered by this report $ Class 25—Expenditures during period covered by this report $ Class 25A—Expenditures during period covered by this report $ Class 27—Expenditures during period covered by this report $ Estimated requirements for next fiscal year, class 23 $ Estimated requirements for next fiscal year, class 25 $ Estimated requirements for next fiscal year, class 25A $ Estimated requirements for next fiscal year, class 27 $ Approximate number of persons dependent upon the activity for dental treatment Number of dental officers attached Number of dental officers doing prosthetic work Number of dental technician assistants Number of other enlisted assistants This report should set forth the facts and observations of general or special interest, and should discuss the adequacy of supplies and equipment. Well con- sidered ideas relative to improvement of the dental service should be presented in this report. A special letter report, in duplicate, shall be made to the Bureau, of any defective or unsatisfactory material (when received) with all identifying marks possible. Paragraph Fitting Out 261 Transfer of Dental Property 262 SECTION IV. DUTIES OF DENTAL OFFICERS AFLOAT 261. Fitting Out.—(a) When fitting out, and as soon as possible after reporting for duty, the dental officer shall examine the dental operating room and its equipment and the other accommodations for dental facilities. Should he discover any defects or deficiencies therein, he shall make a detailed written report of the facts to the proper authority. (b) As soon as practicable after going into commission, the dental officer shall examine the crew in order to verify the dental records and to ascertain if any dental diseases or deficiencies exist, which probably would render members physically unfit to perform their duties. If any such diseases or deficiencies are found, he shall report the facts to the medical officer with the proper recommendations. 262. Transfer of Dental Property.—Prior to detachment from a ship, if time will permit, the dental officer shall take an inventory of dental property and shall transfer custody of such property, through the medical officer, to his relief (art. 1182, N. R.). 20 SEC. V.—DUTIES ASHORE 271-274 Paragraph General 271 Training Stations and Recruit Depots 272 Navy Yards 273 Naval Hospitals 274 Additional Instructions 275 SECTION V. DUTIES OF DENTAL OFFICERS ASHORE 271. General.—(a) The dental officer of a shore station shall make a study of local conditions with the view of establishing a system by which dental service may be made available to the greatest pos- sible number of the personnel dependent on the activity for treat- ment. In addition to the establishment of a system of treatment, an effort shall be made to standardize the arrangement and equip- ment of dental operating rooms, dental storerooms, and other facilities. (b) Provision shall be made for the continuation of the instruction of hospital corpsmen assigned to duty in the dental dispensary or dental operating room. 272. Training Stations and Recruit Depots.—(a) Every recruit shall be examined as soon as possible after enlistment, and notation of every condition found shall be made on the dental record. In order to arrest dental disease in its incipiency and to prevent the develop- ment of more extensive systemic disorders, an effort shall be made to complete the dental treatment which is found to be necessary before the recruit is transferred to other duty. (b) All recruits shall be instructed, by lecture and demonstration, in oral hygiene. They should be taught to use the toothbrush efficiently and should be warned of the dangers of dental neglect. (c) The dental officer shall bring to the attention of the medical officer all recruits whose dental defects make them undesirable for retention in the naval service. 273. Navy Yards.—(a) The dental officer of a navy yard shall adopt such measures as will enable him best to carry on the dental exami- nation and treatment of the personnel dependent upon the facilities of the navy yard for such service and the personnel of vessels to which dental officers are not attached. (b) The cooperation of the commanding officers and medical offi- cers of vessels should be obtained in order that the dental examina- tion and treatment of the crews may be facilitated. Appointments for dental treatment shall be so arranged that members of the crews will be separated from ships’ duties when they can be spared most conveniently. 274. Naval Hospitals.—(a) The dental officer of a naval hospital is the chief of the dental service. He shall direct his efforts toward the accomplishment of measures which will be of the greatest value 21 275-281 OH. 8.—THE DENTAL CORPS in expediting the return of patients to duty status. He shall en- deavor to cooperate in every possible way in the diagnosis and treat- ment of cases which are referred to him, and should consult fre- quently with the medical officers under whose care the patients may be. (b) Whenever practicable, the dental officer shall attend the staff meetings for the discussion of administrative efficiency, economy, and professional subjects. (c) Whenever the equipment of a naval hospital or other activity includes facilities for prosthetic dental treatment, the dental officer shall submit monthly to the Bureau a letter report stating (1) the num- ber of patients in the naval hospital awaiting prosthetic dental treat- ment which has been authorized to be rendered at the naval hospital; (2) the number of patients at other stations awaiting treatment which has been authorized to be rendered at the naval hospital; (3) the num- ber of patients for whom prosthetic dental treatment was completed during the preceding month; (4) the number of patients undergoing prosthetic dental treatment on the date of the report; (5) approximate weights and cost of precious metals expended during month on cases completed. 275. Additional Instructions.—(a) The instructions set forth in this chapter of the Manual of the Medical Department are but a portion of the general instructions with which dental officers should become conversant. All dental officers shall read and become familiar with the instructions included in other chapters of this manual in so far as they may relate to dental officers or to the activities of the Dental Corps. (b) Certain duties and responsibilities, additional to those which are incidental to the practice of dental surgery, may be assigned officers of the Dental Corps by virtue of their commissions as officers of the Navy. Dental officers shall familiarize themselves with the various duties which a staff officer may be called upon to perform, and become conversant with the Navy Regulations, the Uniform Regulations, Naval Courts and Boards, General Orders, the Bureau of Navigation Manual, and such other regulations, orders, and instructions as may be issued from time to time for the guidance of all officers of the Navy (par. 231). Paragraph Information Regarding the Naval Reserve 281 SECTION VI. THE NAVAL RESERVE (DENTAL CORPS) 281. Information Regarding the Naval Reserve.—Regulations per- taining to naval dental reserves are incorporated in part H, Bureau of Navigation Manual. For current information and instructions relative to these reserves see Bureau Circular Letter D, appendix D, of this manual. 22 CHAPTER 4 Paragraphs Section I. LAWS RELATING TO THE NURSE CORPS 301-809 H. THE SUPERINTENDENT OF THE NURSE CORPS 311 m. ASSISTANT SUPERINTENDENTS 321-322 IV. CHIEF NURSES 331-337 V. NURSES 341-347 VI. RESERVE NURSES. 851-352 VH. ASSIGNMENT AND TRANSFER 361-363 Vm. LEAVE OF ABSENCE 371-378 IX. ILLNESS 391-394 X. PAY, ALLOWANCES, SUBSISTENCE, AND QUARTERS 411-420 XI. TRANSPORTATION AND TRAVELING ALLOWANCES 431-435 XH. UNIFORM 441 Xffl. DISCHARGE 451-454 XIV. RETIREMENT 461-465 XV. REPORTS AND RETURNS 471-477 THE NURSE CORPS SECTION I. LAWS RELATING TO THE NURSE CORPS Paragraph Establishment of the Nurse Corps 301 Acceptance of Presents 302 Leave, Transportation, Travel Expenses, Medical Care, and Quarters 303 Death Gratuity 305 Pay 306 Subsistence 307 Transportation of Household Effects 308 Retirement 309 301. Establishment of the Nurse Corps (act of May 13, 1908, 35 Stat. 146).— The Nurse Corps (female) of the United States Navy is hereby established, and shall consist of one superintendent, to be appointed by the Secretary of the Navy, who shall be a graduate of a hospital training school having a course of instruction of not less than two years, whose term of office may be terminated at his discretion, and of as many chief nurses, nurses, and reserve nurses as may be needed: Pro- vided, That all nurses in the Nurse Corps shall be appointed or removed by the Surgeon General with the approval of the Secretary of the Navy, and that they shall be graduates of hospital training schools having a course of instruction of not less than two years. The appointment of superintendent, chief nurses, nurses, and reserve nurses shall be subject to an examination as to their professional, moral, mental, and physical fitness, and they shall be eligible for duty at naval hospitals and on board of hospital and ambulance ships and for such special duty as may be deemed necessary by the Surgeon General of the Navy. Reserve nurses 302-307 CH. 4.—THE NURSE CORPS may be assigned to active duty when the necessities of the service demand, and when on such duty shall receive the pay and allowances of nurses: Provided, That they shall receive no compensation except when on active duty. The superin- tendent, chief nurses, and nurses shall, respectively, receive the same pay, allow- ances, emoluments, and privileges as are now or may hereafter be provided by or in pursuance of law for the Nurse Corps (female) of the Army. 302. Acceptance of Presents.—Nurses are forbidden to receive presents from patients or from relatives or friends of patients for services rendered when on duty (act of May 13, 1908) (art. 1649 (4), N. R.). 303. Leave, Transportation, Travel Expenses, Medical Care, and quarters.—The act of July 9, 1918, making appropriation for the support of the Army for the fiscal year ending June 30, 1919, provides that— Members of said Nurse Corps shall be entitled to cumulative leave of absence with pay at the rate of 30 days for each calendar year of service in said corps, not exceeding, however, 120 days at one time, and in addition thereto sick leave not exceeding 30 days in any ODe calendar year in cases of illness or injury incurred in the line of duty. That members of said Nurse Corps shall receive transportation and necessary expenses when traveling under orders, and, during illness, such medical care as may be prescribed in regulations by the Secretary of War; and when at places where no public quarters are available, commutation in lieu thereof. 305. Death Gratuity.—The Navy act of June 4, 1920 (41 Stat. 824), provides that an amount equal to 6 months’ pay at the rate received by the nurse at the date of her death shall be paid to any dependent relative of the nurse previously designated by her; said amount to be paid from funds appropriated for the pay of the Navy; provided that the nurse was a member of the regular Navy on active duty. 306. Pay.—An act of June 10, 1922, provides in part as follows: Sec. 13. That, commencing July 1, 1922, the annual pay of female nurses of the Army and Navy shall be as follows: During the first three years of service, $840; from the beginning of the fourth year of service until the completion of the sixth year of service, $1,080; from the beginning of the seventh year of service until the completion of the ninth year of service, $1,380; from the beginning of the tenth year of service, $1,560. Superintendents of the Nurse Corps shall receive a money allowance at the rate of $2,500 a year; assistant superintendents, direc- tors, and assistant directors at the rate of $1,500 a year; and chief nurses at the rate of $600 a year, in addition to their pay as nurses. Nurses shall be entitled to the same allowance for subsistence as is authorized in section 5 of this act for officers receiving the pay of the first period, and to the same allowance for rental of quarters as is authorized in section 6 of this act for officers receiving the pay of the first period. 307. Subsistence.—An act making appropriations for the naval service for the fiscal year ending June 30, 1923, and for other pur- poses, approved July 1, 1922, provides under section Provisions, Navy, “* * * for subsistence in kind in hospitals and on board ship in lieu of subsistence allowance of female nurses.” 24 SEC. I.—LAWS 308-309 308. Transportation of Household Effects.—Members of the Nurse Corps are entitled to packing, crating, and transportation of the following weights of household effects, subject to all conditions of General Order No. 166: Superintendent Temporary change of station, 400 pounds. Permanent change of station, 8,000 pounds. Assistant superintendent Temporary change of station, 300 pounds. Permanent change of station, 7,000 pounds. Chief nurse Temporary change of station, 200 pounds. Permanent change of station, 6,000 pounds. Nurse Temporary change of station, 200 pounds. Permanent change of station, 5,000 pounds. 309. Retirement.—(a) An act of May 13, 1926, provides as follows: That when a member of the Army Nurse Corps or the Navy Nurse Corps shall have served thirty years or shall have reached the age of fifty years, having served twenty years, she may, in the discretion of the Secretary of War or the Secretary of the Navy, respectively, be retired from active service and placed on a list, hereby created in each of the aforementioned services and designated the “Nurse Corps Retired List” in the grade to which she belonged at the time of her retirement. That the annual pay of a retired member of the Army Nurse Corps or the Navy Nurse Corps shall be 3 per centum of the annual active base pay which she is receiving at the time of retirement multiplied by the number of complete years of service rendered prior to retirement, but not exceeding 75 per centum of such annual active base pay, and in addition, supplemental annual retired pay for each complete year of active service rendered prior to retirement in each of the grades hereafter named, as follows: Chief nurse, $18; assistant superintendent, $45; director, $45; assistant director, $45; superintendent, $75: Provided, That in computing the period of service in any grade for such supple- mental retired pay any period less than a year served in any higher grade may be included. That for the purpose of computing eligibility for retirement and re- tired pay, there shall be credited active service in the Army Nurse Corps and in the Navy Nurse Corps, active service as contract nurse prior to February 2, 1901, and service as a reserve nurse on active duty since February 2, 1901. That retired nurses shall be authorized to bear the title and may, under such regulations as may be prescribed by the Secretary of War or the Secretary of the Navy, wear the uniform of the grade held at the time of retirement, and in time of war or national emergency, may be employed on active duty, in the discretion of the Secretary of War or the Secretary of the Navy, and when so employed shall receive the full active pay and allowances of their respective grades. (b) An act of June 20, 1930, provides as follows: That pursuant to the regulations to be prescribed by the Secretary of War or the Secretary of the Navy, as the case may be, when a member of the Army Nurse Corps or of the Navy Nurse Corps shall be found by a board of medical officers to have become disabled in line of duty from performing the duties of a nurse, and such findings are approved by the head of the department concerned, she shall be retired from active service and placed upon the Nurse Corps retired list of the appropriate department in the grade to which she belonged at the time of her retirement and with retired pay at the rate of 75 per cent of the active service pay received by her at the time of her transfer to the retired list. 25 311-322 CH. 4.—THE NURSE CORPS SECTION II. THE SUPERINTENDENT OF THE NURSE CORPS Paragraph Duties 311 311. Duties.—(a) The superintendent of the Nurse Corps, under the direction of the Surgeon General, shall have general supervision of the corps, and her duties and the duties of chief nurses and nurses shall be as prescribed by the Surgeon General (art. 1649 (2) N. R.). (b) By authorized inspections and from information contained in reports and returns, the superintendent shall keep herself informed of the condition, number, distribution, and competency of the mem- bers of the corps. She shall conduct correspondence with schools of nursing and nurses’ associations with the idea of obtaining accept- able and qualified nurses for the naval service. Sha shall be a mem- ber of the examining board for nurses. She shall have charge of all records pertaining to the corps, and shall be responsible for the filing, indexing, and care of the individual records of nurses. Reports and returns relating to the Nurse Corps shall be referred to her for her information, comment, or recommendation. She shall indorse all recommendations for promotion and prepare the questions for the examination of nurses preliminary to promotion, recommending those qualified as their services are required. She will make recom- mendation regarding matters of discipline, leave, resignation, and the acceptance, assignment, transfer, discharge, and reduction of members of the Nurse Corps. She will endeavor to maintain the usefulness of the corps as a part of the Medical Department, and will recommend to the Surgeon General measures for the promotion of morale and efficiency. (c) The superintendent is eligible for such other duties not herein noted as may be assigned her by the Surgeon General (act of May 13, 1908, 35 Stat. 146). SECTION III. ASSISTANT SUPERINTENDENTS Paragraph Appointment 321 Duties 322 321. Appointment.—Assistant superintendents shall be appointed from the grade of chief nurse by the Surgeon General, upon the recommendation of the superintendent of the Nurse Corps. Their term of office shall be terminated at his discretion. 322. Duties.—The assistant superintendents shall perform, under supervision of the superintendent of the Nurse Corps, such duties as will be prescribed by the Surgeon General. 26 SEC. IV.—CHIEF NURSES 331-334 SECTION IV. CHIEF NURSES Paragraph Appointment 331 Recommendations for Appointment 332 Examination for Promotion 333 Precedence in Assignment 334 Absence of The Chief Nurse of a Station 335 Revocation of Appointment and Reappointment 336 Duties 337 331. Appointment.—Chief nurses will not be appointed from civil life, but vacancies will be filled by promotion from the grade of nurse. Permanent appointments as chief nurse are made by the Surgeon General of the Navy. A nurse permanently appointed as chief nurse shall not have her appointment revoked except by direction of the Surgeon General. 332. Recommendations for Appointment.—Recommendations for appointment as chief nurse are based on the official fitness reports and recommendations from the chief nurse and commanding officer of the hospitals to which the nurse has been attached. When vacan- cies are to be filled in the grade of chief nurse the Surgeon General will appoint a board to examine the records of the staff members of the Nurse Corps to make recommendations for promotion. 333. Examination for Promotion.—(a) When directed by the Bureau a nurse recommended for promotion to the grade of chief nurse shall prepare herself for a written examination which will include the Navy Regulations and the Manual of the Medical Department. Prior to the written examination a physical examination shall be held by a board of medical officers to determine the physical fitness of a nurse for promotion. A candidate who fails to pass the physical examination shall not be given the written examination. (b) The examination of a nurse for promotion will be conducted in the Bureau under the direction of the superintendent of the Nurse Corps, or at the station to which the nurse is assigned, under the direction of the commanding officer, questions having been submitted from the Bureau. (c) Precautions shall be taken to safeguard the premature dis- closure of the examination questions and the candidate shall certify that she has received no assistance during the examination. Upon completion of the examination the papers, including both questions and answers, shall be forwarded without assigning marks to the Bureau for final action. 334. Precedence in Assignment.—When two or more chief nurses are serving at the same station, one will be assigned to duty as the chief nurse and the others will serve as her assistants. The question of precedence is decided by length of service as chief nurse. 27 335-342 CH. 4.—THE NURSE CORPS 335. Absence of The Chief Nurse of a Station.—See paragraph 1671. 336. Revocation of Appointment and Reappointment.—(a) A nurse permanently appointed as chief nurse will not have her appointment revoked except by direction of the Surgeon General and with the approval of the Secretary of the Navy. (b) A nurse holding a permanent appointment, whose services are no longer required as chief nurse, may be discharged or assigned to regular duty as a nurse, as she may elect. If discharged, she may, upon her own request, have her name placed upon a list of those nurses who will accept service in time of war or emergency. Under these circumstances she shall report by letter to the Surgeon General her residence on January 1 and July 1 of each year. She may be recalled to active duty without examination, except physical. {c) Service as chief nurse will not necessarily entitle a nurse to a subsequent assignment as chief nurse or to be reappointed in the service. An appointment as chief nurse without examination may follow a reappointment in the Nurse Corps at the discretion of the Surgeon General. 337. Duties.—The duties of the chief nurse of a hospital are given in detail in paragraph 1671. SECTION V. NURSES Paragraph Application for Appointment 341 General Requirements for Appointment 342 Physical Requirements for Appointment 343 Eligible List 344 Probationary Period 345 Duties 346 Reserve List 347 341. Application for Appointment.—Application for appointment in the Navy Nurse Corps should be made to the Surgeon General of the Navy, who will furnish the necessary blanks therefor. 342. General Requirements for Appointment.—(a) An applicant for appointment in the Navy Nurse Corps must be single and a citizen of the United States. She must be a registered nurse. She must have been graduated from a school of nursing, the educational and professional standards of which are approved by the Surgeon General of the Navy. (b) An applicant for appointment as nurse, United States Navy, must be between the ages of 22 and 28. An applicant for appoint- ment as reserve nurse, United States Navy, must be between the ages of 22 and 45. (c) The qualifications of the applicant shall be ascertained by means of a certificate submitted by the superintendent of the school 28 SEC. V. NURSES 343-345 of nursing from which the applicant was graduated, showing the date of graduation, moral and professional qualifications during her train- ing, at the time of graduation, and (so far as known) at the time of application. Other evidences of fitness as may be deemed necessary will be required. (d) The professional and mental examination shall be in writing and shall be conducted by a board of examiners appointed for the purpose. 343. Physical Requirements for Appointment.—The physical fitness of the applicant shall be determined in accordance with instructions outlined in paragraph 1527. 344. Eligible List.—The names of applicants who have fulfilled the prescribed conditions will be placed on the eligible list for appoint- ment at such time as their services are required. No applicant shall be eligible who will not agree to serve for 3 years as nurse, United States Navy, or whenever needed as reserve nurse, United States Navy. A candidate for the Nurse Corps may be given an appoint- ment as reserve nurse, United States Navy, if, in the opinion of the examining board, this form of appointment is deemed advisable. 345. Probationary Period.—(a) The first 6 months of active duty subsequent to appointment will be regarded as a probationary period to determine the professional, moral, mental, and physical fitness of a nurse, United States Navy, or of a reserve nurse, United States Navy, for duty in the naval service, and her adaptability to com- munity environment peculiar to the Navy. During this period she shall be instructed in regulations governing the Navy Nurse Corps and upon completion of the period of probation she shall be given a written examination on this subject, the results of which shall be forwarded to the Bureau. (b) At the expiration of the probationary period the chief nurse of the station shall submit a special fitness report relative to the general fitness and aptitude of the nurse with special notation of the professional, moral, and mental qualifications, and shall make such recommendations as may be indicated by the report. The command- ing officer shall state by indorsement whether or not he concurs in the opinions expressed and shall also submit a report of physical examination on the prescribed form. If this report is favorable, a request for uniforms shall also be forwarded to the Bureau. (c) Failure to meet the physical qualifications for duty in any climate and inaptitude for the service will determine recommendations for release from the service. (d) The Bureau will inform the probationer concerning the require- ments noted in (a), (b), and (c) of this paragraph prior to her assign- ment to duty. 29 346-352 CH. 4.—THE NURSE CORPS 346. Duties.—The duties of nurses are given in detail in chapter 12. 347. Reserve list.—Consult paragraphs 336 (b) and 351. Paragraph Reserve Nurses, United States Navy 351 Naval Reserve Nurse Corps (Volunteer) 352 SECTION VI. RESERVE NURSES 351. Reserve Nurses, United States Navy.—(a) Rules and regu- lations.—(1) When called into active service a reserve nurse is subject to all established rules and regulations and is entitled to the same pay and allowances as a nurse, United States Navy of equal length of service, from the date she proceeds to duty in obedience to official orders. A reserve nurse who, having served continuously for a period of 3 years, requests release from active duty for good and sufficient reasons and whose services can be spared will be given orders and Government transportation to her home, which is inter- preted to be the place from which she was ordered to duty. A reserve nurse who has been honorably discharged from the service may, upon her own request, have her name placed upon a list of those nurses who will accept service in time of war or emergency. She may be recalled to active duty without examination, except physical. (2) A reserve nurse on the reserve list shall conform to the pro- vision noted in paragraph 330 (b). (b) Selection in emergencies.—In time of war or other emer- gency requiring the services of additional nurses, they may be selected from those enrolled in the American Red Cross nursing service. Those so selected will be given appointments as reserve nurses, United States Navy. (c) Inactive status.—(1) A reserve nurse may be placed in in- active status at her own request or by the action of the Bureau, provided her services are no longer required. (2) A reserve nurse in inactive status shall conform to the provision noted in paragraph 336 (b). (3) A reserve nurse in inactive status will be discharged from the Navy Nurse Corps upon reaching the age of 50 years; or if she becomes permanently incapacitated by ill health; or if she fails, without satisfactory reason, to respond promptly to a call into active service; or if she fails to notify the Surgeon General of any change in her permanent address; or for other good and sufficient reasons; but a nurse, shall not be discharged from inactive status without due notice of the cause for such action and an opportunity to reply to any charges which may be made against her. 352. Naval Reserve Nurse Corps (Volunteer).—Regulations per- taining to the Naval Reserve Nurse Corps (Volunteer) are incorpo- SEC. VII.—ASSIGNMENT AND TRANSFER 361-363 rated in part H, Bureau of Navigation Manual. For current infor- mation and instructions relative to these reserves see Bureau Circular Letter M, appendix D, of this manual. Paragraph Assignment and Professional Duties 361 Care of Families 362 Transfer 363 SECTION VII. ASSIGNMENT AND TRANSFER 361. Assignment and Professional Duties.—Nurses will be assigned to duty by direction of the Surgeon General, and will be required to serve at home or abroad. Their services are available for sick, wounded, and disabled officers, enlisted men, and other patients in naval hospitals, and for such other duty as may be prescribed by the Surgeon General. When traveling under orders by land or sea, they shall assist in the care of sick officers and enlisted men who may be present on the same conveyance, such service being rendered under the direction of a medical officer if one be present. A report of such service shall be sent to the Surgeon General. 362. Care of Families.—Members of the families of officers and en- listed men are not entitled to the services of Navy nurses. When, in the opinion of the commanding officer of the hospital or the medical officer of the station, such services are required for great emergencies and in the manifest interest of humanity, he may re- quire that they be performed, and he shall report the circumstances to the Surgeon General. If this service emergency is other than of a temporary character, or should the situation render the services of civilian nurses impossible, a Navy nurse, if she so desires and if her services can be spared, may, with the approval of the command- ing officer of the hospital or the medical officer of the station, be granted special leave without pay and allowances in order to take the case, such leave not to exceed 30 days in the calendar year for an individual nurse. 363. Transfer.—(a) Nurses will not be transferred without the authority of the Surgeon General, except at stations beyond the con- tinental limits of the United States where a surplus of nurses may exist or where, upon the recommendation of the medical officer, transfers may be directed by the commander in chief. Nurses, when so transferred, shall report immediately upon arrival in the United States to the commanding officer of the naval hospital nearest to the port of arrival, where they will be placed on temporary duty awaiting instructions from the Surgeon General. Such transfer of nurses shall be reported at once to the Surgeon General, with a state- ment of the circumstances. 31 371 CH. 4.—THE NURSE CORPS (b) Nurses shall not absent themselves from their stations and duties except by proper authority. (c) Upon receipt of orders fixing no date and not expressing haste, nurses shall be guided by article 132, Navy Regulations. Paragraph Leave to Which Entitled 371 Sick Leave 372 Absence over Leave 373 Authority to Grant Leave 374 Request for Leave 375 Return to the United States on Leave 376 Permission to Leave the United States 377 Leave Prior to Discharge 378 SECTION VIII. LEAVE OF ABSENCE 371. leave to Which Entitled.—(a) Members of the Navy Nurse Corps are entitled to cumulative leave of absence, with pay, at the rate of 30 days for each calendar year of service in the corps, to be counted, in the case of nurses, United States Navy, from the date the oath is taken when followed by entrance on active duty, and, in the case of reserve nurses, United States Navy, from the date of proceeding to duty under orders. (b) Leave may be accumulated at the rate of 2% days for each cal- endar month of completed service, and the accrued amount may be granted whenever the exigencies of the service permit, not to exceed 120 days in one period. Leave credit is not allowed for periods of absence without pay. (c) Leave accruing but unused under one appointment will not be credited under a subsequent appointment. This ruling does not apply to a continuation of service beyond the 3-y.ear term, nor, in the case of nurses, discharged as reserve nurses, United States Navy, for the purpose of appointment as nurses, United States Navy. In such cases the duty is considered continuous. (d) A nurse traveling in a leave status is not entitled to Govern- ment transportation nor to reimbursement for traveling expenses. (e) When accumulated leave of absence with pay is granted to a nurse on duty in Alaska or beyond the continental limits of the United States for the purpose of coming to and returning from the United States, such leave shall be calculated between the date she reached or might have reached the United States and the date she left or should have left the United States by the usually traveled routes. (f) In the case of a nurse coming to the United States from a foreign station or going from the United States to a foreign station who desires to make the journey by a route other than the customary 32 372-375 SEC. VIII.—LEAVE OF ABSENCE one in order to visit foreign countries on leave of absence while en- route, an allowance of 30 days may be made, as in status of duty, without right to reimbursement for incidental traveling expenses. Such allowance is made to cover the average amount of time neces- sary to perform the journey from her station to the usual port of arrival in the United States or from said port to her station, and in calculating her leave this period of 30 days for travel shall, in each instance, be excluded. (g) When leave with pay is granted a nurse on duty in the Philip- pine Islands to be absent therefrom, other than to come to the United States, such leave shall be calculated between the date of reaching Manila from her station and the date of leaving Manila in return- ing to her station. (h) Leave of absence without pay and allowances may be granted under the circumstances indicated in paragraph 362, and in other cases if the reasons are sufficient and the requirements of the service permit. 372. Sick Leave.—Nurses are also entitled to sick leave, not to ex- ceed 30 days in each calendar year, for illness or injury in line of duty, said leave in excess of 10 days to be granted by the Surgeon General upon recommendation of a board of medical survey. In cases re- quiring immediate action, approval by the Surgeon General may be requested by telegram. 373. Absence Over Leave.—Nurses absent over leave shall be auto- matically in the status of leave without pay and shall be reported to the Surgeon General with such explanations as may be submitted for definite action. 374. Authority to Grant Leave.—(a) Authority to grant leave of ab- sence in excess of 10 days rests only with the Surgeon General, subject to modification by section (b) of this paragraph. (b) In the case of nurses on duty at hospitals or on hospital ships beyond the continental limits of the United States, the commanding officer may grant leave of absence in accordance with paragraph 371 (h), subject to the reservations noted in paragraph 371 (d). 375. Request for Leave.—(a) Requests for leave of absence or ex- tension thereof shall be submitted by the nurse in writing, using tho prescribed form, and shall not be embodied in other requests. Suffi- cient time shall be allowed for delay and transmission by mail. (b) Nurses requesting leave of absence from the commanding officer, not to exceed 10 days, shall submit the request in writing. The original order granting this leave shall be returned to the nurse and a copy shall be forwarded to the Surgeon General. 33 376-393 CH. 4. THE NURSE CORPS 376. Return to the United States on Leave.—A nurse who has re- turned to the United States on leave of absence shall report in writing to the Surgeon General the date of arrival in the United States, giving address while on leave. 377. Permission to Leave the United States.—Permission to leave the United States on leave of absence must be obtained from the Secre- tary of the Navy, and such request should be submitted with due regard for the time required for this official procedure. 378. Leave Prior to Discharge.—(a) Final leave to the amount accu- mulated and unused, not to exceed 120 days, will be granted prior to honorable discharge. (b) A nurse who has been ordered from her station to her home for final leave prior to release from active duty shall, upon arrival home, report in writing to the Surgeon General, giving date and hour of arrival. Final leave of absence prior to discharge will be computed by the Bureau and a statement of the amount of such leave will be forwarded to the nurse via the senior medical officer for the information of the supply officer carrying the accounts of the nurse. The nurse shall report change of address, if such occurs, while in status of final leave. Paragraph Medical Attendance 391 Illness of Confidential Nature 392 Health Records 393 Discharge for Disability 394 SECTION IX. ILLNESS 391. Medical Attendance.—(a) A nurse on duty is entitled to receive medical attendance and treatment. A full report in all cases shall be entered on the prescribed.forms (health record, Form F, etc.). (b) Medical attendance and treatment will usually be provided at the hospital where the nurse is serving, but when it is reported as desirable the Surgeon General may effect her transfer to another naval hospital or to a civil hospital for treatment. (c) Nurses will be governed by the general information and instruc- tions contained in chapter 21 concerning medical and hospital treat- ment of officers. 392. Illness of Confidential Nature.—Illness considered to be of a confidential nature shall, when occurring, be the subject of a special report made privately to the commanding officer and forwarded by him to the Surgeon General. 393. Health Records.—Health records and medical history sheets described in chapter 14, shall be made out in accordance with in- structions. SEC. X.—PAY AND ALLOWANCES 394-414 394. Discharge for Disability.—A nurse will not be discharged for disability contracted in line of duty until after reasonable time has been allowed for treatment. SECTION X. PAY, ALLOWANCES, SUBSISTENCE, AND QUARTERS Appropriations for 411 Accounts 412 Longevity Pay 413 Laundering of Uniforms 414 Purchase Privilege 415 Checkage for Hospital Fund 416 Subsistence 417 Mess Gear and Linen 418 Quarters. 419 Allowance for Rental of Quarters 420 Paragraph 411. Appropriations for.—The pay of the Nurse Corps, rent of quarters for the use of its members, the cost of their subsistence, and their traveling expenses are paid from the appropriation pay, sub- sistence AND TRANSPORTATION OF NAVAL PERSONNEL. 412. Accounts.—(a) When a nurse is appointed a member of the Navy Nurse Corps, the supply officer shall take up her accounts on presentation of two certified copies of her original appointment, on which is noted the date the oath was accomplished, together with two certified copies of her orders and all indorsements thereon. (b) Two certified copies of an appointment as superintendent, assistant superintendent, director, or chief nurse shall be presented to the supply officer concerned. (c) When a nurse is transferred to another hospital or station, the supply officer will furnish her with a transfer account as in the case of officers, showing the rate of pay and date, inclusive, to which paid. Presentation of such transfer pay account, together with two certified copies of orders authorizing travel, will be sufficient author- ity for the supply officer to place her name on the pay roll at the station to which she is transferred. 413. Longevity Pay.—In calculating longevity pay for nurses, credit for previous service in the Nurse Corps of the Army, including service as contract nurse, shall be allowed. 414. Laundering of Uniforms.—Nurses’ uniforms will be laundered in the hospital laundry, and at hospitals, stations, and on- naval ves- sels, where a laundry is not provided, will be included with other medical department laundry, under contract or by requisition. On hospital ships, which are construed to be floating hospitals, the arrangements for laundry will be the same. 35 415-420 CH. 4.—THE NURSE CORPS 415. Purchase Privilege.—Members of the Navy Nurse Corps are entitled to the purchase privileges which are customarily enjoyed by commissioned officers. (General Order No. 49, War Department, approved August 14, 1920.) 416. Checkage for Hospital Fund.—Members of the Nurse Corps will be checked 20 cents per month to be credited to the naval hospital fund as in the case of officers and enlisted men. 417. Subsistence.—(a) Under an act of June 10, 1922, members of the Nurse Corps in the Navy are entitled to the same allowance for subsistence as is authorized for officers receiving the pay of the first period. (b) An act of July 1, 1922, provides for subsistence in kind at hospitals and on board ship in lieu of subsistence allowance of nurses. (c) For information regarding subsistence of guests, see paragraph 1636. 418. Mess Gear and Linen.—To maintain a proper and adequate mess for the nurses, such articles of mess gear, dishes, silver, and linens as may be required are a proper charge against the Government. 419. Quarters.—(a) When on duty in hospitals, or where nurses’ buildings have been provided, such quarters as may be available will be provided for the use of members of the Nurse Corps, in which case heat and light will be supplied as may be necessary; to be regu- lated by the commanding officer. (b) When practicable the allowance of quarters for nurses on duty at a naval hospital will include one dining room, one kitchen, one sitting room, and the necessary toilets and bathrooms for the use in common of all the nurses, with a separate bedroom for each nurse and for the chief nurse. At hospitals where more than five nurses are stationed, an office and a separate bathroom and sitting room should, when practicable, be provided for the chief nurse. (c) The Bureau will supply the necessary linen and furniture for public quarters for nurses. Such linen will be laundered with the laundry of the hospital or station, as provided for uniforms in para- graph 414. 420. Allowance for Rental of Quarters.—Members of the Navy Nurse Corps, when not occupying Government quarters, will receive the same allowance for rental of quarters as is authorized for officers receiving pay of the first period. This amount will be credited on the pay roll upon the certification by the commanding officer of the hospital or the medical officer of the station that application and no assignment of quarters has been made and that Government quarters are not available. 36 SEC. XI. TRANSPORTATION AND ALLOWANCES 431-441 SECTION XI. TRANSPORTATION AND TRAVELING ALLOWANCES Paragraph Comptroller’s Decisions 431 Unused Transportation 432 When no Transportation Furnished 433 Expense Account 434 Transportation Overseas 435 431. Comptroller’s Decisions.—Members of the Navy Nurse Corps, when traveling under orders, are entitled, at public expense, to their own transportation and to the same travel allowances as members of the Nurse Corps of the Army (Comptroller’s decision, July 9, 1913); also to receive such additional allowances for transportation of them- selves and baggage as in cases where this service is performed by the Government for Army nurses (Comptroller’s decision of March 28, 1914). 432. Unused Transportation.—Transportation requests issued but not used shall be returned to the Bureau of Navigation. If transpor- tation requests are exchanged for tickets which, as a whole or in part, remain unused, said tickets or portions thereof shall also be returned. 433. When no Transportation Furnished.—When transportation in kind is not furnished and transportation requests can not be pro- cured, a member of the Nurse Corps may pay her own travel fare (which must not exceed the cost of first-class limited ticket between her starting point and her destination), and ask for reimbursement in her expense account, submitted in accordance with the schedule in article 1817, Navy Regulations. 434. Expense Account.—A member of the Nurse Corps incurring ex- penses for which she is entitled to reimbursement upon completion of the travel shall prepare her expense account, of the same, in quad- ruplicate on the prescribed Bureau of Supplies and Accounts form to be submitted with her orders (original) and three certified copies, with all indorsements. 435. Transportation Overseas.—Transportation overseas will be by Government conveyance when practicable. SECTION XII. UNIFORM Paragraph Uniform Regulations 441 441. Uniform Regulations.—(a) The uniform regulations for the Navy Nurse Corps are approved by the Secretary of th6 Navy and are found in Uniform Regulations, United States Navy. (b) No other than regulation uniform or uniform wrap shall be worn while in the performance of duty. 37 451-453 CH. 4.—THE NURSE CORPS Paragraph Regulations 451 Physical Examination Prior to Discharge 452 Orders 453 Indorsements 454 SECTION XIII. DISCHARGE 451. Regulations.—(a) Nurses and reserve nurses may be given honorable discharge after a 3-year period of active service, if they have completed the required tour of duty at a station involving extensive travel to which they have been transferred at their own request. Nurses and reserve nurses under orders to proceed home to await honorable discharge will not be discharged until arrival home, or until they shall have had time to arrive home by following the usual route of travel with ordinary diligence or as provided for in paragraph 371 (f). (b) A nurse may be discharged at any time by the Surgeon Gen- eral with the approval of the Secretary of the Navy: (1) For unsuit- ability during her probationary period (see par. 345 (c)); (2) should her services no longer be needed; (3) on account of physical dis- ability interfering with active service, as reported by a board of medical survey; (4) for inefficiency, inaptitude, or violation of Navy Regulations (as determined by a properly constituted board or court, appointed by the Surgeon General); (5) under certain con- ditions upon her own request. (c) A nurse ordered home for honorable discharge will be entitled to transportation and reimbursement for traveling expenses as here- inafter provided. She will be allowed travel time to enable her to reach her home before the beginning of her final leave of absence, unless she shall prefer to take her final leave before proceeding home, in which event travel orders will be arranged accordingly. (d) A nurse ordered home for discharge shall at once report by letter to the Surgeon General the date and hour of her arrival home in order that her leave credit may be correctly adjusted. (e) A nurse renders herself ineligible for retention in the Navy Nurse Corps when she marries. 452. Physical Examination Prior to Discharge.—A physical examina- tion prior to release from active duty shall be conducted in accord- ance with paragraph 1527. 453. Orders.—(a) Orders to proceed home may be issued to a nurse: (1) For honorable discharge; (2) should her services no longer be needed; (3) on account of physical disability interfering with active service; (4) upon her own request because of reduction from the grade of chief nurse. 38 SEC. Xm.—DISCHARGE 454 (b) Home will be defined as that place from which the nurse was furnished Government transportation to the first station of duty, or to another point of no greater distance, if requested. (c) Orders to proceed home will not be given to a nurse under the following conditions: (1) Prior to expiration of 3-year period of duty; (2) prior to completion of required tour of duty at a station involving extensive travel, to which a nurse has been transferred at her own request; (3) for insubordination or other misconduct, subject to the provisions noted in paragraph 454 (c). 454. Indorsements.—(a) When honorably discharged the following indorsement will be placed on the letter of appointment: (Date) By direction of the Secretary of the Navy, the honorable discharge of the herein-named nurse, (or reserve nurse), United States Navy (or United States Navy Reserve) , is effective , 19__. Period of active duty from , 19 , to , 19 Surgeon General, United States Navy. (b) An application for discharge prior to the expiration of a 3-year period of active duty may be made by letter forwarded through official channels to the Surgeon General, stating the reasons. If the discharge be authorized, the following indorsement is placed on the letter of appointment: (Date) By direction of the Secretary of the Navy, the resignation of the herein-named nurse, (or reserve nurse), United States Navy (or United States Navy Reserve) __ , is accepted, effective 19 Period of active duty from , 19 , to , 19 Surgeon General, United States Navy. This indorsement is also placed on the letter of appointment of a nurse who applies for and is given a discharge prior to the com- pletion of continuous service following transfer at her own request involving extensive travel. Orders to proceed home will not be given to nurses securing dis- charge under the conditions noted in this paragraph, except that a nurse stationed beyond the continental limits of the United States who has been recommended for discharge will, whenever practicable, be transferred to the port in the United States nearest the station. 461 CH. 4.—THE NURSE CORPS (c) In the case of a nurse discharged for insubordination or other misconduct (as determined by a properly constituted board or court appointed by the Surgeon General), orders and transportation home will not be recommended, except that a nurse stationed beyond the continental limits of the United States, who has been recommended for such discharge, will be given transportation and allowed neces- sary expenses to the port in the United States nearest the station. The letter of appointment of a nurse discharged for such cause will be indorsed: (Date) By direction of the Secretary of the Navy, the herein-named nurse, (or reserve nurse), United States Navy, (or United States Navy Reserve), , is discharged by reason of failure to comply with Navy Regulations. Period of active duty from , 19 , to 18 Surgeon General, United States Navy. (d) For revocation of appointment, the following indorsement is placed on the letter of appointment: (Date) By direction of the Secretary of the Navy, the appointment of the herein named nurse (or reserve nurse), United States Navy (or United States Navy Reserve) , is revoked, effective - , 19- Period of active dutv from , 19__, to , 19— Surgeon General, United States Navy SECTION XIV. RETIREMENT Paragraph Application and Recommendation 461 Orders 462 Regulations 463 Accounts 464 Hospitalization 465 461. Application and Recommendation.—(a) By individual con- cerned.—A nurse who desires to retire by reason of age or service or physical disability and who believes herself eligible shall submit to her chief nurse an application for retirement, addressed to the Sur- geon General, for transmission through official channels. This request must be accompanied by her letter of appointment and two certified copies of all her other appointments (Army Nurse Corps; contract service, United States Army; nurse, United States Naval Reserve; reserve nurse, United States Navy; former service as nurse, SEC. XIV.—RETIREMENT 462 United States Navy; chief nurse, etc.). The applicant shall specifi- cally cite the reason why she does not desire to remain on the active list. In forwarding the application the chief nurse and commanding officer shall indorse their views and recommendations thereon. (b) By commanding officer.—Whenever the commanding officer of any nurse eligible for retirement by reason of age or service or physical disability believes that her retention on the active list would, in his judgment, no longer be to the best interests of the service, he may forward through official channels a recommendation to that effect, embodying therein a full statement of his reasons. In such event, before forwarding his recommendation to higher authority for action, he shall refer it to the nurse concerned for any comment by indorsement thereon that she may care to make, but which must include a specific statement on her part as to whether or not she desires retirement or is indifferent as to the action taken. (c) By the Surgeon General.—Whenever the Surgeon General believes that any nurse eligible for retirement by reason of age or service or physical disability should be retired, he may initiate a recommendation similar to that required of the commanding officer, as outlined above, and will refer the recommendation to the nurse concerned, through official channels, for a personal indorsement thereon, as to her desires. (d) When a nurse on being ordered to perform the duties appro- priate to her appointment reports herself unable to comply with such order, or, whenever in the judgment of the commanding officer or the Surgeon General, a nurse is incapacitated to perform her duties, she will immediately be ordered to appear before a board of medical survey to determine her physical fitness for further naval service. (e) When any nurse on the active list becomes physically incapaci- tated to perform her duties, and the probable future duration of such incapacity is permanent or indefinite, her case will immediately be referred to a board of medical officers appointed by the Surgeon General of the Navy, and, pending final action on the question of her retirement, according to the act of June 20,1930, will not be promoted. Should a nurse so desire, she may appear in person before the board. 462. Orders.—Upon approval of an application or recommendation for retirement in the case of a nurse who is eligible therefor the Navy Department will issue orders directing her to proceed to her home to be placed on the Nurse Corps retired list after the expiration of such accrued leave as may be due her. The date of her actual transfer to the Nurse Corps retired list will be the date following the last date of her accrued leave. 41 463-465 CH. 4. THE NURSE CORPS 463. Regulations.—(a) A nurse ordered home for retirement shall report by letter to the Surgeon General the date and time of pro- ceeding to and arrival home. (b) A nurse on the Nurse Corps retired list not assigned to active duty by Navy Department orders shall report by letter her address to the Surgeon General on January 1 of each year and shall also report promptly any change of address. (c) A retired nurse recalled to active duty shall wear the uniform, including insignia, prescribed for nurses on the active list. (d) When attending social functions or ceremonies of an official character, or on any other occasion deemed appropriate a retired nurse, not on active duty, may wear the uniform, including insignia, either the pattern in effect on the date of her retirement or that in current use by nurses on the active list, except that parts of two uniforms, if of a different pattern shall not be combined. (e) When a nurse is retired the following indorsement will be placed on the letter of appointment: (Date) By direction of the Secretary of the Navy, the herein-named nurse, , is placed on the Nurse Corps retired list on Period of active duty from to » Surgeon General, United States Navy. 464. Accounts.—The accounts of all retired nurses of the Navy will be carried in the Bureau of Supplies and Accounts, Navy Depart- ment. When a nurse is placed on the retired list, the Bureau will transmit in duplicate to the Bureau of Supplies and Accounts a certified record of her naval service, with specific reference to inclusive dates of service in any grade above that of nurse, and two certified copies of all original appointments and two certified copies of her orders home, and two certified copies of her report stating the date and time of proceeding to and arrival home. The accounts of retired nurses will be kept and payments made under the same regulations as are now in effect for retired officers of the Navy. 465. Hospitalization.—A retired nurse is entitled to receive medical attendance and treatment in a naval hospital. For information regarding health record see chapter 14. 42 SEC. XV.—REPORTS AND RETURNS 471-474 SECTION XV. REPORTS AND RETURNS Official Communications 471 Monthly Return to Surgeon General 472 Monthly Return to Disbursing Officer 473 Fitness Reports 474 Change in Status 475 Beneficiary Slip 476 Annual Physical Examination 477 Paragraph 471. Official Communications.—(a) All communications relating to official matters shall be forwarded through official channels. (b) The chief nurse shall be responsible to the commanding officer for the preparation of the reports, returns, information slips, and all official papers concerning the nurses, requiring indorsement by the commanding officer. Requests for transfer or release from serv- ice, submitted by nurses, shall be indorsed by the chief nurse and the commanding officer, with expression of opinion concerning the request, based upon consideration of the needs of the service. 472. Monthly Return to Surgeon General.—On the last day of each month, or as soon thereafter as may be practicable, a return of nurses shall be submitted to the Surgeon General by the senior medical officer of every hospital or station to which nurses are attached. 473. Monthly Return to Disbursing Officer.—On the last day of each month the senior medical officer under whom nurses are serving shall advise the disbursing officer concerned, on the form prescribed for that purpose, of the number of nurses on duty during the month, noting the number of days each nurse (1) subsisted herself, (2) was subsisted by the Government, (3) was on leave with or without pay. The disbursing officer will also be notified regarding the assignment of chief nurses. 474. Fitness Reports.—(a) Reports on fitness of members of the Nurse Corps, other than nurses in the first pay period, shall be made on prescribed forms on the last days of March and September of each year, and whenever nurses are ordered to appear for examination, detached from the service, or transferred, or whenever the reporting senior is detached. Reports on fitness of nurses in the first pay period shall be made on prescribed forms on the last days of March, June, September, and December of each year, and at the end of the probationary period, or when they are detached from the service or transferred, or whenever the reporting senior is detached. All reports of fitness shall be considered as strictly confidential communications. In the event of their being referred for comment or other purpose, they shall be sent confidentially and shall be similarly 474 CH. 4.—THE NURSE CORPS returned direct unless they call in question the action of any higher authority, in which case they shall be forwarded in the same confiden- tial manner via such higher authority. To avoid the submission of reports for very brief intervals of time, separate reports for periods of not over 1 month before or after the last days of March or Septem- ber, such as those due to change of duty of an officer or the reporting senior, are not required, provided these periods are included in the current semiannual report with an appropriate modification of the dates covered thereby. Special fitness reports may be submitted at any time it is deemed advisable by the commanding officer. (b) Fitness reports shall be prepared by the chief nurse. The senior medical officer shall state by indorsement thereon whether or not he concurs in the opir:ons expressed and the marks assigned. (c) Nurses shall be marked in paragraph 6 of fitness report, on scale of 0-4 as follows: 4. Excellent. 3.5. Very good. 3. Good. 2.5. Fair (passing). Below 2.5 for those who are not professionally satisfactory, those who are not adapted to Navy work and those who are physically dis- qualified. Zero (0) for those who are recommended for immediate discharge on account of insubordination and other violations of Navy Regulations. (d) A nurse marked below 2.5 shall be informed of this grading, and the statement that she has been informed shall be noted on the report. The nurse may make a statement in writing concerning such adverse report if she so desires. Should sufficient improvement be noted to indicate a higher grade, a special fitness report shall be sent to the Surgeon General. Two reports marking a nurse below 2.5 without noting improvement, will be considered sufficient, as a general rule, to indicate general inaptitude for the service and sub- sequent action by the Bureau. (e) A nurse marked 0 shall be so informed and a full report shall be submitted after careful investigation of the charges. The nurse shall be given an opportunity to be heard in her own defense, and any written statement shall be forwarded with the report. (f) The senior medical officer shall report on the fitness of the chief nurse and upon other chief nurses (after consultation with the chief nurse). In making these reports, the various details filled by chief nurses shall be noted. 44 SEC. XV.—REPORTS AND RETURNS 475-477 (g) Fitness reports shall be regarded as confidential, open only to the chief nurse, executive surgeon, and higher authorities. These reports shall be properly safeguarded and transmitted to the Bureau, direct, in sealed envelopes marked in the lower left-hand corner nurse corps. 475. Change in Status.—Changes in the status of nurses, such as arrival, departure, leave of absence, transfer to or from another sta- tion, or from the grade of reserve nurse to nurse, or from nurse to chief nurse, physical disability, or death, shall be reported immedi- ately to the Surgeon General by means of information slips, giving, in each instance, the name as appointed, accurate dates, and addi- tional data as indicated. 476. Beneficiary Slip.—Upon the initial reporting for duty of a nurse, United States Navy, or upon the transfer of a reserve nurse to the grade of nurse, the beneficiary slip shall be prepared and for- warded to the Bureau. In filling out this slip, the nurse shall state wherein the dependency, if any, exists. 477. Annual Physical Examination.—During the month of January of each year, or as soon thereafter as practicable, the report of annual physical examination shall be forwarded to the Bureau (par. 1522). 45 CHAPTER 5 Paragraphs Section I. GENERAL INFORMATION 601-621 II. REPORTS AND RETURNS 631-639 THE HOSPITAL CORPS SECTION I. GENERAL INFORMATION Paragraph Instructions Governing Enlistments, Etc 601 Transfer to the Hospital Corps From Other Ratings 603 Transfer to Hospital Corps Training Schools 605 Advancements 607 Courses of Instruction 609 Duty Upon Completion of Course 611 Training of Hospital Corpsmen 613 Discharges 615 Retirements 617 Naval Reserve 619 Promotion to Pharmacist and Chief Pharmacist 621 601. Instructions Governing Enlistments, Etc.—(a) Enlistments, reenlistments, and extensions of enlistments for Hospital Corps per- sonnel are governed by instructions issued from time to time by the Bureau of Navigation (art. 1713, N. R.). (See Circular Letter M, appendix D, of this manual.) (b) When enlistments are made directly for the Hospital Corps, physical and professional examination by one or more medical officers shall be required in each case. The records of such enlistments and all other papers relating thereto are referred by the Bureau of Navi- gation to the Bureau for information, and to afford an opportunity for recommendation (art. 1713, N. R.). 603. Transfer to the Hospital Corps From Other Ratings.—Com- manding officers are authorized to change the rating of a man to a rating of same pay grade in the Hospital Corps for which he has been found qualified by the required examination, in accordance with instructions governing changes in rating contained in the Bureau of Navigation Manual. 605. Transfer to Hospital Corps Training Schools.—Transfers of hospital apprentices, first and second class, to Hospital Corps training schools, upon enlistment or change of rating to that of hospital apprentice, will be governed by instructions contained in the Bureau of Navigation Manual. 47 607 CH. 5.—THE HOSPITAL CORPS 607. Advancements.—(a) All candidates for advancement to higher ratings in the Hospital Corps must qualify by professional examina- tion in accordance with instructions contained in the Bureau of Navi- gation Manual. (b) Members of the Hospital Corps who are candidates for ad- vancement in rating, besides showing a knowledge of the duties required of their special rating, must demonstrate a thorough knowl- edge of general naval activities as outlined in Chapter 5, Bureau of Navigation Manual. (c) Questions for examination for each rating should broaden in scope and thoroughness with each higher rating. For this purpose the Hospital Corps Manual should be used as a general guide in the examination, bearing in mind that men should have acquired a prac- tical knowledge of the service requirements in their ratings. Different questions for each rating allow the candidates to demonstrate in a definite manner their qualification for the rating they seek and the increased knowledge they possess. (d) The technician examination prescribed in the Bureau of Navi- gation Manual applies for the purpose of determining technical qualification only, and examining boards are reminded that the exi- gencies of the service are such that at any time a man may be assigned to duty for an indefinite period where he will have little opportunity to use his special technical knowledge. Therefore, an officially designated technician should not be recommended for advancement in rating, unless he is thoroughly qualified to perform the general duties of the higher rating in addition to the duties of his technical specialty. (e) Men possessing no other qualifications than those of long service shall not be advanced in rating. Only those who are quali- fied in all respects and have a satisfactory knowledge of the duties of the rating to which they seek advancement shall be advanced. (f) Examining officers should use discretion and careful judgment in recommending men for advancement to higher ratings. Especially is it necessary that discretion be exercised in recommending men for advancement to pharmacist’s mate, first class, and chief pharmacist’s mate. Men holding these ratings are the only ones for whom the Bureau holds itself responsible when they are serving on duty inde- pendent of a medical officer. A high standard of efficiency in these ratings must be maintained, and while chief pharmacist’s mates, and pharmacist’s mate, first class, are not offered as substitutes for qualified medical officers, it is expected that they will be men of such training, judgment, and experience that commanding officers of vessels having no attached medical officer may rely on them for 48 SEC. I. GENERAL INFORMATION 609-613 valuable assistance in first-aid work and for the detailed management and care of the sick or injured. The Bureau necessarily depends upon the discretion and judgment of medical officers in the field for the selection and recommendation of men possessing the attainments required for independent duty. 609. Courses of Instruction.—See Circular Letter M, appendix D, of this manual for courses of instruction currently provided for Hos- pital Corps personnel. 611. Duty Upon Completion of Course.—Service school graduates are not a separate class of men, or have they a right to special con- sideration. They may be assigned any duty or any detail in the discretion of their commanding officers, but it is assumed that these officers will take cognizance of and give full consideration to the val- uable training that has been given. 613. Training of Hospital Corpsmen.—(a) The systematic train- ing of hospital corpsmen is of great importance. At all activities where one or more medical officers are attached, instruction in both practical and theoretical work of the Hospital Corps shall be routine, in accordance with instructions contained in the Bureau of Navigation Manual. (b) Not less than 1 hour daily, 4 days per week, shall be devoted to classroom instruction of the Hospital Corps, for all rates below that of chief pharmacist’s mate at medical department activities ashore and afloat; with the exception that pharmacist’s mates, first class and second class, may be excused at the discretion of the medical officer, provided their service records show that they have satisfactorily completed the instruction schedule on some other ship or station. (c) Courses shall be continuous and progressive, and shall cover the following subjects: Clerical forms and procedures. Dosage of ordinary drugs; dosage and restrictions of dangerous drugs. Management of common diseases and injuries. First-aid treatment in emergencies. Preventive-medicine measures: Vaccination, antityphoid, and vene- real prophylaxis. Practical work in nursing, pharmacy, urinalysis, and microscopic technique, where activities are equipped with microscopical outfits. (d) On activities where medical officers are not available as in- structors for the complete schedule of instruction, pharmacists, chief pharmacist’s mates, nurses, and qualified technicians may be detailed as instructors for not more than half the total work given. 49 615-631 CH. 5.—THE HOSPITAL CORPS (e) On completion of the schedule of instruction, a notation should be attached to the service record of every hospital corpsman who has completed the course, with marks assigned on the various sub* jects covered, to provide a permanent record of instruction received. (f) The Bureau of Navigation Manual directs the attention of all commanding officers to the urgent need of trained hospital corps- men for vessels to which no medical officer is attached; therefore all chief pharmacist’s mates, and pharmacist’s mates, first class, will be considered sufficiently trained and shall be considered qualified for this type of duty. 615. Discharges.—Discharges from the naval service, other than those resulting from medical survey, are governed by instructions contained in the Bureau of Navigation Manual. 617. Retirements.—Enlisted men who have completed a total of 30 years’ service in the Army, Navy, and Marine Corps are entitled to retirement in accordance with instructions contained in Navy Regulations. 619. Fleet Reserve.—For instructions governing transfer to the Fleet Reserve and the benefits derived therefrom, see part H, Bureau of Navigation Manual. 621. Promotion to Pharmacist and Chief Pharmacist.—(a) Pro- motion to warrant grade, and to commissioned warrant rank in the Navy, is governed by instructions contained in the Bureau of Navi- gation Manual and in Navy Regulations. (b) Candidates for appointment to pharmacist and promotion to chief pharmacist shall meet the physical qualifications prescribed in chapter 11, of this manual. Paragraph Form N. Nav. 524, Report of Examination 631 Form NMS—HC-3, Transfer and Disposition Card 635 Form NMS—HC-4, Roster Report 637 Form N. Nav. 1, Service Record and Continuous-service Certificate 639 SECTION II.—REPORTS AND RETURNS 631. Form N. Nav. 524, Report of Examination.—(a) In all cases of examination for original enlistment, advancement in rating, or for transfer from another branch to a rating of the Hospital Corps, this form, properly filled out, shall be prepared in triplicate. The original shall be forwarded to the Bureau, one copy to the Bureau of Naviga- tion, and one copy to the officer having charge of the man’s service record. In all examinations, marks shall be assigned in all the subjects required. (b) All spaces on this report must be filled in. The report in all cases shall be dated, and the grade attained in each subject shall be 50 SEC. II.—REPORTS AND RETURNS 635-639 assigned by the examining board and the proper space filled in. In those cases where advancement may be made by the commanding officer without reference to the Bureau the report should show the date from which the advancement is effective, and be signed by the commanding officer before forwarding. In assigning a mark for aptitude, the candidate’s aptitude for the higher rating, and not for his present rating, should be given. 635. Form NMS—HC-3.—Transfer and Disposition Card.—For de- tailed instructions regarding the preparation of this form see Appendix D, Manual of the Medical Department, Bureau Circular Letter M-6 of January 1, 1941. 637. Form NMS—HC-4.—Roster Report.—For detailed instructions regarding the preparation of this form see Appendix D, Manual of the Medical Department, U. S. Navy, 1939, Bureau Circular Letter M-7 of January 1, 1941. 639. Form N. Nav. 1, Service Record and Continuous-service Cer- tificate.—In addition to marks in proficiency in rating, ability as leader of men, and conduct, hospital corpsmen possessing technical qualifications in x-ray, laboratory, physiotherapy, embalming, etc., will be given marks for the same on their service record, and con- tinuous-service certificate, under the heading of Special qualifica- tions OR SPECIAL DETAILS. 51 53 CHAPTER 6 GENERAL DUTIES OF MEDICAL OFFICERS Paragraphs Section I. PREVENTION OF DISEASE 701-707 H. CASE OF THE SICK AND WOUNDED 711-713 m. MISCELLANEOUS DUTIES____ 720-742 IV. PROFESSIONAL RELATIONS WITH CIVILIANS 751-753 V. JUNIOR MEDICAL OFFICERS 761-762 SECTION I. PREVENTION OF DISEASE Paragraph General 701 Physical Fitness of the Personnel 702 Examination before Transfer 703 Educational Measures 704 Use of Immunizing Agents, Vaccination 705 Communicable Diseases 706 Cooperation with Other Agencies 707 701. General.—All medical officers are charged with responsibility for the prevention and control of disease and promotion of health in the Navy, as well as for the treatment of disabled individuals. Every medical officer must, therefore, keep himself informed in matters per- taining to hygiene, sanitation, and epidemiology. 702. Physical Fitness of the Personnel.—(a) No matter how well planned or efficiently executed are the efforts to prevent physical disa- bility and maintain the highest percentage of the personnel ready for service at all times, the morbidity rates of the Navy can not be kept within reasonable limits unless men of inferior mental or physi- cal quality are rejected in the recruiting office or eliminated as soon after enlistment as practicable. Medical officers must constantly bear in mind the necessity for discharging men who are permanently incapacitated for the proper performance of their duties by reason of mental or physical disabilities, where neither medical nor surgical treatment is indicated in the best interests of the Government. (b) Medical officers shall make such recommendations to the proper authority regarding physical exercises, athletics, recreational measures, or other matters, from the hygienic standpoint, as will tend to improve or maintain physical fitness of the personnel. (c) Whenever, in the opinion of the medical officer, there is reason to believe that diseases are being concealed by any member of the crew or personnel of the command, he shall, with the approval of the commanding officer, conduct such examinations as may be neces- 55 703-707 CH. 6. GENERAL DUTIES OF MEDICAL OFFICERS sary for the detection of concealed cases. During such examina- tions the physical condition and cleanliness of the men should be carefully observed. The results of such inspections shall be reported in writing to the commanding officer. 703. Examination Before Transfer.—(Art. 1142 (3) N. R.) Every man about to be transferred from one ship or station to another shall be subjected to a careful physical examination conducted by the medical officer, who shall make the requisite entries on the man’s health record. Except in an emer- gency, no man who is known to have been exposed to an infectious or contagious disease, or who is found to be suffering from such disease or from active venereal infection, which may be a menace to others, shall be recommended for transfer except for treatment in hospital or passage thereto. When an emergency re- quires the transfer of men with these diseases, a full report shall be forwarded through official channels to the medical officer of the ship or station to which transfer is made. If any cases of these diseases are found and retained, they shall be promptly admitted for treatment and a report of the facts made to the com- manding officer. 704. Educational Measures.—(a) General.—Advantage shall be taken of every opportunity to educate the personnel in matters concerning health. Useful and authoritative information shall be disseminated from time to time with regard to the prevention of communicable diseases, other preventable diseases, and accidents, as well as upon subjects pertaining to personal hygiene and sanitation. (b) Venereal Diseases.—Medical officers are charged with in- structing the entire personnel regarding the nature of venereal diseases, and warning them of the dangers therefrom. Any information or educational material which may be distributed by the Bureau relative to social hygiene should be utilized. Measures for the prevention and control of venereal diseases are prescribed in General Order 14. (c) Instruction of Hospital Corpsmen.—An outline for the in- struction of hospital corpsmen is given in chapter 5. 705. Use of Immunizing Agents, Vaccination.—Instructions appear in chapter 17. (See also arts. 1152 and 1457 (1), N. R.) 706. Communicable Diseases.—Instructions in regard to communi- cable diseases are contained in chapters 17 and 18. 707. Cooperation with Other Agencies.—Medical officers of the Navy are instructed to cooperate, in such ways as may be practicable, with the United States Public Health Service and other Federal and local agencies for the prevention of disease. SECTION II. CARE OF THE SICK AND WOUNDED Paragraph Care of the Sick 711 Consultation 712 Transfer to Other Than a Naval Hospital 713 SEC. III. MISCELLANEOUS DUTIES 711-731 711. Care of the Sick.—Each medical officer shall bestow the most careful professional attention possible upon the patients under his care and be attentive to their comfort and the cleanliness of their clothing, bedding, and persons. 712. Consultation.—In difficult cases the medical officer shall con- sult with other medical officers of the Navy present concerning diagnosis and treatment. (See also art. 1189 (4) N. R.) 713. Transfer to Other Than a Naval Hospital.—See articles 1143 and 1831, Navy Regulations. SECTION III. MISCELLANEOUS DUTIES Paragraph Rough Log 729 Organization and Standing Order Book 730 Reports by Medical Officer to the Officer of the Deck, Etc 731 Official Documents and Correspondence 732 Health Records 733 Dental Treatment 734 Physical Examinations 735 Prescription of Narcotic Drugs 736 Prescription of Poisonous Drugs 737 Custody of Alcoholic Solutions, Narcotics, and Poisons 738 Articles on Professional Subjects 739 Unofficial Certificates 740 Transcripts of Medical Records 741 Examination for Evidence of Intoxication.. 742 729. Rough log.—The medical officer of each ship, station, or other place of duty shall keep, or caused to be kept, a journal or rough log, which shall be a complete, succinct record of affairs coming within the province of the medical department, other than medical histories of individuals which are recorded in the health records. This rough journal shall be retained in the files of the activity. 730. Organization and Standing Order Book.—Each hospital or other medical department activity on shore (other than expeditionary forces), is required to publish for use and instruction an organization and standing order book, designed to inform the duty personnel of matters of local interest, policy, and routine. Should it be deemed advisable, an organization book and a standing order book may be issued separately. 731. Reports by Medical Officer to Officer of the Deck, Etc.— Injuries or deaths of personnel, damage or destruction of medical department property, and any important occurrence coming under the observation of the medical officer of a ship or station shall be reported to the officer of the deck or other proper official for entry in 57 732-736 CH. 6.—GENERAL DUTIES OF MEDICAL OFFICERS the log or journal of the ship or station (arts. 1078, 1511, 1517 (6), N. R.). 732. Official Documents and Correspondence.—Detailed instruc- tions in regard to preparation and routing of official correspondence are contained in chapter 52, Navy Regulations. All medical officers shall keep suitable files of all official correspondence (art. 2047 (1) and (2) N. R.). 733. Health Becords.—Instructions in regard to health records are given in chapters 14 and 15. 734. Dental Treatment.—(a) Treatment by appointment.—Ex- cept in an emergency, medical officers shall make appointments in advance when it becomes necessary to send patients to dental officers of ships or stations. (b) Dental record to accompany patient.—When a patient is sent to another ship or station for dental treatment, his dental record shall be sent to the dental officer with, or in advance of, the patient. If there is no dental record in the health record, a statement to that effect shall be forwarded. After he has made the necessary entries the dental officer shall return the dental record to the medical officer having custody of the health record. (c) Patients with syphilis.—Medical officers shall notify the dental officer whenever a man suffering from syphilis or other communicable disease is sent to him for dental treatment (par. 1531). (d) When ordered to stations without dental facilities.— Whenever practicable, officers and men ordered to ships or stations, where the services of a naval dental officer will not be available, shall be referred to a naval dental officer for examination and necessary treatment before proceeding to such ship or station for duty. 735. Physical Examinations.—(a) No person other than the medi- cal officer shall be permitted to conduct any part of a physical exami- nation or to sign an original entry on any medical record of enlistment. Every such examination shall be completed according to the official forms (art. 1200, N. R.). (b) It is desired that, whenever practicable, dental examinations be made by dental officers who shall submit a signed report to the medical officer or board of medical examiners. 736. Prescription of Narcotic Drugs.—(a) Any official of the Federal Government, or of a State, county, or municipal government requir- ing the use of, or prescribing in his official capacity, any of the narcotic drugs coming within the scope of the act of December 17, 1914, is exempt from registration and payment of special tax under the pro- visions of this act, but his right to exemption shall be evidenced as provided in the regulations of the Treasury Department. In the case 58 SEC. III.—MISCELLANEOUS DUTIES 737-738 of officers of the Medical Department, the right to exemption will be evidenced by lists furnished by the Surgeon General to the Com- missioner of Narcotics, Treasury Department, of all officers authorized to purchase narcotic drugs in the course of their official duties. (b) When an exempt official prescribes, in his official capacity, any narcotic drugs covered by the law, his prescription shall be written on an official prescription blank, or otherwise on official stationery. (c) In order to facilitate the strict enforcement of the law, exempt officials in charge of narcotic drugs shall keep accurate records of the amounts of such drugs purchased and dispensed and have such records available for inspection by internal revenue officers. (d) In order to comply with the above paragraph all prescriptions for narcotics shall be given a separate file number preceded by the letter N and filed separately from other prescriptions. (e) Where the exempt official, if a medical officer, is also engaged in private practice outside of his official duties, the exemption herein specified does not apply to this portion of his practice, and he is required to register, and in all other respects comply with the provi- sions of the law and regulations governing such practice. 737. Prescription of Poisonous Drugs.—(a) Poisonous drugs shall be dispensed only on prescriptions written and signed by medical officers or by pharmacists or pharmacists’ mates on duty where there is no medical officer. Prescriptions for such drugs to be used in dental treatments shall be written and signed by the dental officer. All prescriptions for poisonous drugs shall be numbered and filed by the dispenser. (b) Bichloride tablets shall be issued only in the forms furnished by the supply depot. 738. Custody of Alcoholic Solutions, Narcotics, and Poisons.—(a) No medical officer of the Navy shall take or receive into his custody on board ship or in any Naval or Marine Corps establishment any alcoholic liquors or Intoxicating or narcotic substances except as authorized for medical purposes or for retention as evidence in dis- ciplinary cases; nor shall the medical officer permit alcoholic liquors or narcotic substances under his custody to be placed in the possession of any enlisted or appointed man, except in small quantities for imme- diate consumption by patients. Alcoholic liquors other than those obtained through Medical Department sources shall not be accepted for medical purposes except upon approval of the Bureau. If accepted, these liquors shall be taken up on inventory, used for medicinal pur- poses only, and accounted for accordingly (arts. 13, 118, and 1146, N. R.). 59 738 CH. 6. GENERAL DUTIES OF MEDICAL OFFICERS (b) Narcotics, alkaloidal poisons, alcoholic beverages, and poisonous chemicals not in constant use shall be kept under lock and key, and the keys shall always be in the custody of an officer. Poisons in constant use shall be safeguarded by proper labels, containers, dis- tinctive coloring, and such other safeguards as the medical officer may consider advisable. Small quantities of alkaloids and narcotics for dispensing purposes may be issued from time to time to the officer or enlisted man in charge of the pharmacy and shall be properly recorded when expended and kept under lock and key when not in use. (c) Medical officers shall assure themselves that all drugs and chemicals under their charge are properly labeled, and shall see that all poisons, chemical or alkaloidal, are indicated as such by appropriate poison labels. (d) Drugs of a powerful or dangerous nature which may be mis- taken for other drugs because of their appearance shall be kept in bottles of different sizes or shapes and in separate positions. (e) All solutions of phenol shall be tinted pink (fuchsin), and all solutions of bichloride of mercury shall be tinted blue (methylene blue). (f) All persons in the medical department shall be duly warned regarding the dangers of accidental poisoning and instructed in the proper handling of poisons. (g) When drugs are prescribed or issued in poisonous amounts the last person removing the drug from a distinctive, or distinc- tively marked, container is responsible for the proper disposition of such drug. Medicine glasses shall not be used for any other pur- pose than the administration of internal medicines. (h) Prior action by the Bureau is required on all requisitions or requests for intoxicating liquor, including alcohol, irrespective of source of supply, originating with all medical department activities ashore within the continental limits of the United States. The requisition or request shall be forwarded to the Bureau and will be returned with the Bureau’s action appearing thereon. (i) Medical department activities located without the continental limits of the United States, including hospital ships, need not submit for Bureau’s prior action requisitions for alcohol to be obtained from the supply depot at Canacao or the local supply department, and, in the case of the medical department of Marine Corps activities, requisitions upon the Marine Corps quartermaster. These medical department activities shall, however, report quarterly by letter to the Bureau the amount of alcohol so obtained and also the date received. 60 SEC. HI. MISCELLANEOUS DUTIES 739-741 (j) The medical departments of ships, except hospital ships, shall requisition and receipt for alcohol and narcotics in similar manner as for other supplies. Special requisitions and receipts for these items are not necessary in as much as the requisition form provides the Bureau with adequate control and information. (k) Intoxicating liquors, including alcohol, shall be used only in connection with the treatment of the sick or to meet the essential requirements of medical department activities. For inspection pur- poses the files of all medical department activities must show for what purposes all intoxicating liquors, including alcohol, charged thereto were expended. 739. Articles on Professional Subjects.—Medical officers shall be guided in the preparation and publication of such articles by article 113 (2), Navy Regulations, and General Order No. 9. 740. Unofficial Certificates.—(a) The medical officer shall not give an unofficial certificate of ill health or of inability to perform any duty (art. 1139, N. R.). (b) The Judge Advocate General has held (file No. 28697-93 of July 1922) that the above regulation merely defines the relation of a naval medical officer to other individuals in the naval service and does not apply to the relation of a naval medical officer to civilians employed in navy yards or naval stations under the jurisdiction of the Navy Department. In this opinion it was further held “that requests for certificates from the civilian employees of navy yards or stations to enable them to receive compensation from lodges, benevolent societies, and the yard refief associations may be properly unofficially granted.” (See art. 103, N. R., re: Letters to employees and former enlisted men.) 741. Transcripts of Medical Records.—(a) Blank forms not to be completed.—It is not the policy of the Bureau to complete the blank forms submitted from insurance companies, beneficial organizations, and societies, but in lieu thereof to furnish transcripts of medical records or copies of official death reports, as the case may be, upon receipt of proper authority as outlined below. (b) Medical histories.—Since it has been held that an individual is entitled to a copy of his medical record, medical officers may prop- erly furnish a copy of the current medical record to an individual in the naval service upon his signed request. Copies of medical records on file in the Bureau may be furnished to the individual upon his signed request. Since the medical records are held to be strictly con- fidential they can be furnished to other persons only upon the written authority of the individual, except for official purposes. (See art. 1195, N. R.) 61 742 CH. 6. GENERAL DUTIES OF MEDICAL OFFICERS (c) Medical records for courts.—In cases where the medical record is required for use in a civil court application should be made in writing, under the seal of the court, to the Secretary of the Navy, by the judge or the clerk of the court before whom the case is to be tried. (d) Request for death reports.—Medical officers shall forward all requests for copies of death reports to the Bureau. In cases where blank forms have been received from insurance companies the cor- respondence shall be forwarded to the Bureau, including, if possible, the request of the next of kin. Medical officers should notify the writers of the action taken. A copy of the official report of death from the Bureau is accepted by insurance companies and beneficial organizations in the adjudication of claims. 742. Examination for Evidence of Intoxication.—(a) Medical officers will make a sufficiently comprehensive examination to determine: (1) Is the condition and behavior of the individual normal or abnormal? (2) Is he suffering mentally or physically from the results of sickness or injury? (3) Is his condition or behavior due wholly or in part to the use of a drug or alchol? (4) Is the intoxication “sufficient sensibly to impair the rational and full exercise of the mental and physical faculties”? (5) Is there evidence that the individual has used alco- holic liquor for drinking purposes? (6) Is he fit to perform duty? (b) As the medical officer’s opinions will probably be accepted as those of an expert, he should be prepared to cite facts to support them. In view of the probability that he will be called as a witness before a court-martial it is important that at the time he take notes recording the time of examination and the detailed history of the case. (c) Definition of legal drunkenness (par. 55 naval courts AND BOARDS, 1937): Any intoxication from alcoholic liquor which is sufficient sensibly to impair the rational and full exercise of the mental and physical faculties to a degree that will incapacitate for the proper performance of any duty which a person of the rank or rate of the accused could properly be called upon to perform, consti- tutes drunkenness. (d) Medical officers are reminded that under the stimulus of an official examination an individual may assume such self-control that it may be difficult to diagnose his condition. Sufficient time, there- fore, should be given to the examination. Disturbances of motor coordination, speech, gait, balance, etc., as well as abnormalities of ideas, have special significance. 62 SEC. IV.— RELATIONS WITH CIVILIANS 751-753 Paragraph Professional Aid to Civilians 751 Use of Public Supplies and Facilities 752 Not To Operate upon Prospective Applicants 753 SECTION IV. PROFESSIONAL RELATIONS WITH CIVILIANS 751. Professional Aid to Civilians.—(a) The commander in chief may require the medical department officers of his command to render professional aid to persons not in the naval service, when such aid is necessary and demanded by the laws of humanity or the principles of international courtesy (art. 685, N. R.). (b) The following references also appear in the Navy Regulations: Officers’ families and injured employees (art. 1185, N. R.); applicants for pensions (art. 1540 (3), N. R.); civilian employees (art. 1575, N. R.). 752. Use of Public Supplies and Facilities.—(a) For persons not in distress.—No article of public supplies is ever to be appropriated to the private use of any person not in distress without the consent of the Secretary of the Navy or the order of the senior officer present, who shall give the Secretary of the Navy information of every case that may occur, together with the attending circumstances, and he shall be careful to take the best security for indemnity to the Govern- ment (art. 1385, N. R.). Issues of medicines or medical stores to persons not in the Navy shall be noted in a prescription book kept for that purpose. (b) Emergency cases.—Medical department officers are authorized to use Government facilities or materials in the treatment of emergency cases among persons not in the naval service when other adequate professional facilities are not available. No charges shall be made for such services when Government facilities or materials are used, and persons so treated shall not be retained in naval hospitals or dispensaries without permission of the Bureau, after such time as they may be moved without serious danger to life and health. 753. Not To Operate Upon Prospective Applicants.—Naval medical department officers shall not undertake to operate upon or treat prospective applicants for the regular or reserve Navy or Marine Corps, with a view to correcting defects, disqualifications, and disa- bilities so as to enable them to be enlisted or appointed. 63 761-762 CH. 6. GENERAL DUTIES OF MEDICAL OFFICERS Paragraph Duties 761 Permission To Be Absent from Duties 762 SECTION V. JUNIOR MEDICAL OFFICERS 761. Duties.—(a) Junior medical officers shall at all times conform to the directions of the medical officer of the ship or station in regard to the professional treatment, care, and comfort of the sick and wounded, to whom they shall be unremitting in their attention. They shall exact from those under their direction a rigid performance of their duties. (b) They shall assure themselves that the medicines are properly dispensed and administered by members of the Nurse Corps and Hospital Corps, who shall record in writing all drugs so administered. (c) Junior medical officers shall, subject to the direction of the medical officer, keep the health records and supervise the preparation of the regular reports and returns, unless the medical officer prefers to perform this duty himself. (d) Junior medical officers shall keep the medical officer fully informed as to the condition of all patients and shall frequently consult with him in regard to their professional treatment. 762. Permission To Be Absent from Duties.—They shall, before applying for leave to be absent from their duties, obtain the permis- sion of the medical officer. 64 CHAPTER 7 DUTIES OF MEDICAL OFFICERS AFLOAT Paragraphs Section I. FLEET, FORCE, AND DIVISION MEDICAL OFFICERS 801-811 II. THE MEDICAL OFFICER OF A SHIP 821-837 III. MEDICAL DEPARTMENT DUTIES IN EMERGENCIES 861-888 SECTION I. FLEET, FORCE, AND DIVISION MEDICAL OFFICERS Paragraph Reference Revised Statutes 801 Inspections, When Made 802 Scope of Inspection 803 Detailed Outline of Inspection 804 Special Inspections 805 Written Report Required 806 Battle Plans 807 Annual Sanitary Report 808 Information Concerning Epidemic Diseases, Etc 809 Medical Meetings 810 Force and Division Medical Officers 811 801. Reference Revised Statutes.—The law dealing with the appoint- ment and duties of the fleet medical officer will be found in sections 1373 and 1374, Revised Statutes. 802. Inspections, When Made.—The fleet or force medical officer shall inspect ships of the fleet when directed to do so by the fleet or force commander, and at such other times as may be indicated in his judgment, subject to the approval of his commander. 803. Scope of Inspection.—This medical officer on his inspec- tion shall carefully inspect the medical department of the ship in all details. He shall also carefully examine the entire ship in regard to its sanitary condition, hygienic regulations, and its efficiency from a professional point of view; noting particularly its ability to cope with a contagious or other controllable disease and the adequacy of the arrangements for action in battle. 804. Detailed Outline of Inspection.—The following are enumerated as an outline of the conditions into which inquiry should be made: (a) Personnel of the medical department.—Number of medical officers, pharmacists, and hospital corpsmen. Efficiency of the organization and of official and professional administration. Num- ber of other ratings detailed for duty in the medical department during battle action and their duties. Instruction of hospital corps- 65 805 CH. 7.—DUTIES OF MEDICAL OFFICERS AFLOAT men, stretcher bearers, and other personnel of the ship in the duties required of them under the medical department. Condition of medical department books and forms. (b) Materiel of the medical department.—Location, arrange- ment, equipment, cleanliness, and suitability of the dispensary, sick bay, operating room, isolation ward, examining room, genito-urinary and prophylaxis room, baths, medical storerooms, dental office, and battle-dressing stations. Provisions made for use of medical depart- ment material in emergencies. Any defects or insanitary conditions in supplies and equipment. (c) Sanitary condition of the ship.—Cleanliness of the ship as a whole. Ventilation; heating; lighting; inspection, preparation, and serving of food, including proper food balance, to the crew and the sick; precautions observed against accidents; bathing facilities; edu- cational measures for prevention of venereal and other diseases; supply and protection of drinking water; ratio of urinals and water- closets to personnel; the cleanliness and order of the clothing of the crew; sanitary precautions used in the barber shop; measures taken to prevent rats and vermin from gaining entrance to the ship and measures to destroy them when present; facilities for sterilization of bedding, etc.; sanitary condition of the laundry; records of vaccina- tion and typhoid prophylaxis; evidence of overcrowding of personnel. (d) Miscellaneous.—First-aid supplies to battle stations; station bills for general quarters, fire quarters, collision, abandon ship, and landing parties; provisions for removal of dead and wounded from various parts of the ship; protective measures against chemicals and gases; identification tags (war time only); care of the violently insane; statement of health conditions for preceding 12 months; instructions relative to poisons and distilled spirits; instructions in first aid to divisional officers and crew; property accountability (art. 1380 N. R.). (e) Recommendations.—When defects in any of the conditions are found, the inspecting officer should make suitable recommendations for their correction. He shall make recommendations to the Bureau of desirable changes in medical department equipment and supplies and particularly in re- gard to those items in which the prescribed minimum stock is out of proportion to the general current rate of use, and elimination of items which have fallen into general disuse. The fleet surgeon may authorize the transfer of medical department supplies from a ship carrying an excess stock to a vessel requiring such supplies. 805. Special Inspections.—When so directed, the fleet or force medical officer shall investigate the sanitary condition of any ship of 66 SEC. I.—FLEET, FORCE, AND DIVISION MEDICAL OFFICERS 806~811 the fleet, where epidemics and much sickness exist, and in so doing he shall examine the different parts of the ship where diseases may be acquired because of insanitary conditions. He shall make any other inspection necessary to ascertain the causes of disease and recommend such steps as may be necessary to prevent its spread. 806. Written Report Required.—(a) In the case of each inspection the medical officer shall make a written report in detail to his com- mander, indicating in such report the condition of the medical depart- ment of the ship. (b) Whenever he deems it necessary he shall make to his com- mander recommendations or reports, in writing, concerning sanitary conditions of the fleet or force, the prevention of disease or means for checking its spread, and the promotion of the care of the sick and wounded. 807. Battle Plans.—(a) The fleet medical officer shall submit to the commander in chief a concrete plan for the care and transportation of the sick and wounded of the fleet during and after an action and shall keep himself informed of the facilities available for this pur- pose in the ships of the fleet. When requested, he shall prepare medical department contributory plans for the commander in chief’s basic operating plans. (b) He shall, after an action and from the reports of the medical officers of the ships of the fleet, make to the commander in chief, for transmission to the Navy Department, a tabulated report of all the killed and wounded. 808. Annual Sanitary Report.—At the end of each calendar year the fleet medical officer shall forward to the Navy Department, through the commander in chief, a general sanitary report of the command. 809. Information Concerning Epidemic Diseases, Etc.—The fleet medical officer shall from time to time issue to the medical officers of the fleet such information concerning epidemic diseases, sanitary measures, health conditions of ports, etc., as might otherwise not come to their attention. 810. Medical Meetings.—The fleet medical officer should endeavor to stimulate interest in professional subjects by holding meetings of medical and dental officers, for the discussion of professional subjects. Medical and dental officers should be encouraged to avail themselves of clinical facilities in the ports visited and on board hospital ships. 811. Force and Division Medical Officers.—(a) The duties of force and division medical officers shall be similar to those of the fleet medical officer insofar as relates to the ships of the organization to which they are assigned (art. 788, N. R.). 67 821-822 CH. 7.—DUTIES OF MEDICAL OFFICERS AFLOAT (b) Force and division medical officers shall endeavor to see that expenditures of the medical departments of ships of the organization are made with due regard to efficiency and economy and shall note in their reports to the force or division commander instances of waste- fulness or unauthorized expenditures. Paragraph General 821 Fitting Out.__ 822 Medical Stores and Supplies 823 Medical Storerooms 824 Inspections 825 Daily Report of Sick 826 Health Records. 827 Medical Surveys 828 Transfer of Patients 829 Deaths 830 Bill of Health 831 Health of Port 832 Sanitary Reports 833 Instruction of Hospital Corps 834 Watch, Quarter, and Station Bills 835 First-aid Instruction 836 Transport Duty 837 SECTION II. THE MEDICAL OFFICER OF A SHIP 821. General, (a) Head of medical department.—The medical officer is the head of the medical department of the ship. He shall have charge of all medical material and stores aboard and shall be in direct care and charge of the treatment and care of the sick and wounded (art. 1132, N. R.). (b) In charge of surgeon’s division.—He shall take charge of the surgeon’s division and of the men on the sick list and shall be stationed in the sick bay at quarters (arts. 1175, 1176, 1177, N. R.). (c) Absence or disability.—(1) In the absence, or during the disability, of the medical officer of the ship the medical officer next in rank on board shall perform his duties (art. 1149, N. R.). (2) When two or more medical officers are attached to the ship, at least one shall always be on board and ready for duty, unless otherwise authorized, under special circumstances, by previous per- mission from the commanding officer (art. 1729 (6) N. R.). Article 810, Navy Regulations, provides for a medical guard. 822. Fitting Out.— (a) Prior to going into commission.—As soon as possible after reporting, the medical officer of the ship shall examine the sick bay, battle stations, dispensary, medical storerooms, and other accommodations for sick and wounded, and report any defects or deficiencies to the commanding officer in writing, forwarding a copy 68 823-825 SEC. II.—MEDICAL OFFICER OF A SHIP of the report to the Bureau via official channels (arts. 826, 1151, N. R.) (b) After going into commission.—He shall examine the crew and their health records, and at the same time arrange to vaccinate and give antityphoid prophylactic as necessary and required (arts. 826, 1151, 1152 (1), N. R.; see also ch. 17). 823. Medical Stores and Supplies.—Full instructions are contained in chapter 20. Medical officers aboard ship are also referred to Navy Regulations: Invoices and receipts of medical stores and supplies (art. 1164, N. R.); ships on detached service (art. 1165, N. R.); medical stores and supplies (art. 1166, N. R.); laundry and extra provisions (art. 1167, N. R.); surgical instruments (art. 1168, N. R.); loss of medical stores (art. 1169, N. R.); medical outfit when going out of commission (art. 1170, N. R.); transfer of stores (art. 1171, N. R.); supplies for ship departments (art. 1223, N. R.); inflammable medical stores; acids to be kept in lead-lined boxes (art. 1347 (5), N. R.); supplies to be checked on delivery; care in packing (art. 1381, N. R.); no article to be sent out of ship (art. 1386, N. R.). 824. Medical Storerooms.—The medical officer shall take charge of the medical storeroom and keep the key in his custody. Medical storerooms shall not be used as sleeping compartments and only medical stores and supplies shall be kept therein. Narcotics, alka- loidal poisons, alcoholic beverages, and poisonous chemicals shall be kept in separate lockers in the storeroom and dispensary, and the keys to these lockers shall always be in the custody of an officer. The storerooms shall be kept clean, dry, and in good order and ready for inspection at the same time as other parts of the ship (arts. 1048 (2) (3), 1145, 1434, N. R.). 825. Inspections.—(a) Personnel.—Subject to the approval of the commanding officer, inspection of the crew shall be held whenever the presence of contagious, controllable, or concealed disease is sus- pected. Cases of malingering shall be reported to the commanding officer (art. 1136, N. R.). (b) Food and water.—Instructions in regard to the inspection of food and water appear in chapter 17. The following references appear in Navy Regulations: Food for the sick (art. 1140, N. R.); to inspect the provisions for the crew (art. 1156, N. R.); preparation of food (art. 1157, N. R.); testing water (art. 1158, N. R.); fresh provisions, and examine contents of bumboats (art. 1159, N. R.); inspections and use of fresh food, etc. (art. 1320 (2), N. R.); food and water (art. 1320 (2) (5), N. R.); bumboats and traffic (art. 1323 (3), N. R.); harbor water (art. 1324, N. R.). 69 826-829 CH. 7.—DUTIES OF MEDICAL OFFICERS AFLOAT (c) Compartments, cells, bedding.—To inspect cells and prisoners (art. 1160, N. R.); inspection of holds, etc. (art. 1161, N. R.); cleanli- ness (art. 1319 (1), N. R.); bedding (art. 1319 (4), N. R.); inspection of compartments (art. 1360 (2), N. R.). 826. Daily Report of Sick.—(a) Sick list.—A list of all sick, with name, diagnosis, and condition, shall be submitted by the medical officer to the commanding officer daily by 10 a. m. It is considered desirable, insofar as possible, to avoid the use of technical medical terms in these reports (art. 1153, N. R.). (b) Binnacle list.—The medical officer shall submit daily to the commanding officer by 9:30 a. m. a list containing the names of all those he recommends excused from duty. The binnacle list shall be approved by the commanding officer and no additional names may be added without his permission (arts. 1154, 1322 (1), N. R.). (c) Sick list and binnacle list to correspond.—The names on the morning report of sick and the binnacle list should correspond each morning. The primary object of the binnacle list is to supply to the officer of the deck and other persons concerned the names of men excused from duty. When permission for a man to be excused from duty is obtained after the morning report of sick has been submitted, his name should be added to the binnacle list. If he is still unfit for duty when the next morning report of sick is submitted, his name shall be added thereto as admitted to the sick list on the date on which his name was added to the binnacle list. Names shall not be omitted from the morning report of sick because a satisfactory diagnosis has not been made. Such cases shall be noted as under observation or with the name of the chief complaint. Repeated and continuous admissions to the binnacle list without admission to the sick list mis- represent the facts, lead to omission of important information from the health records, and vitiate the statistics of the Medical Department. 827. Health Records.—Instructions in regard to health records are contained in chapter 14. 828. Medical Surveys.—Instructions in regard to medical surveys are contained in chapter 23. (See also arts. 1141,1197,1198, and 1199, N. R.) 829. Transfer of Patients.—Subject to approval by the command- ing officer, patients may be transferred to a hospital at any time upon recommendation of the medical officer or of a board of medical survey. Patients should be accompanied by their health record and a hospital ticket with their personal effects accurately inventoried and properly prepared for transfer, and in serious cases should be accompanied by 70 SEC. II. MEDICAL OFFICER OF A SHIP 830-836 a medical officer. Medical officers are referred to the following articles in Navy Regulations: Removal of sick to hospitals (art. 1141 (2), N. R.); tuberculosis cases (art. 1141 (3), N. R.); transfers (art. 1142 (1), (2), N. R.); patients in other than a United States naval hospital (art. 1143, N. R.); accounts of men sent to hospital (art. 1203 (1), (2), N. R.); orders upon recovery when not in naval hospital (art. 1203 (3), N. R.); notice sent to hospital where accounts have been transferred (art. 1873, N. R.). 830. Deaths.—See chapter 19, Form N, and the following articles in Navy Regulations: Deaths to be entered in log (art. 908 (1), N. R.); report of deaths (art. 908 (2), (3), N. R.); effects of deceased persons (art. 908 (4), (5), N. R.); disposition of effects of deceased persons (art. 908 (6), (7), (8), N. R.); certificate of death (arts. 900, 1144, and 1843, N. R.). 831. Bill of Health.—See chapter 18; also articles 860 and 1172, Navy Regulations. 832. Health of Port.—See chapter 17; also articles 1134 and 1147, Navy Regulations. 833. Sanitary Reports.—Detailed instructions in regard to sanitary reports are given in chapter 17. Medical officers are also referred to articles 1133, 1135, and 1173, Navy Regulations. 834. Instruction of Hospital Corps.—See chapter 5, paragraph 655. 835. Watch, Quarter, and Station Bills.—(Art. 1287 (13), N. R.); assignment of men (art. 1287 (15), N. R.); living and battle stations (art. 1287 (16), N. R.); keep bills corrected to date (art. 1287 (13), (20), N. R.). 836. First-aid Instruction.—(a) The medical department teaches first aid to the officers and crew in order that they may administer to the needs of the wounded under battle conditions, when no medical personnel are available. Minimum requirements for this teaching are— (1) Division officers.—Knowledge of the degree of proficiency of their men in first aid, and knowledge of the location and use of avail- able first-aid material. (2) Hospital corpsmen.—Knowledge that will fit them to become assistant instructors. (3) Stretcher bearers.—Knowledge of handling, lifting and trans- portation with stretchers. (4) Crew.—A practical knowledge of simple first-aid treatment of wounds and fractures and of resuscitation. 71 837-862 CH. 7.—DUTIES OF MEDICAL OFFICERS AFLOAT (b) See Circular Letter P in appendix D for more detailed informa- tion on instruction. 837. Transport Duty.—Medical officers on duty on transports carry- ing troops shall be guided by article 1457 N. R. and paragraph 1213. SECTION III. MEDICAL DEPARTMENT DUTIES IN EMERGENCIES Paragraph To Be Prepared for Emergencies 861 Drills and Emergencies... 862 Condition of the Ship in Relation to Drills and Bills 863 General Quarters—Condition 1 864 Readiness for Action—Condition 2 865 Readiness for Action—Condition 3 866 Damage Control 867 Chemical Warfare and Gas Defense 868 Landing and Recovery of Airplanes 869 Fire Quarters 870 Collision Drill 871 Fire and Rescue Party 872 Abandon Ship 873 Landing Force 874 Battle-Dressing Stations—Location 875 First-Aid Boxes and Other Containers at Battle Stations 876 Equipment at Battle-Dressing Stations 877 Water Supply of Battle-Dressing Stations 878 Light for Battle-Dressing Stations 879 Sterilizers at Battle-Dressing Stations 880 Routes To Be Marked 881 Final Preparations for Battle 882 Chaplain To Assist. 883 Dental Officer To Assist 884 Duty in Battle 885 Removal of Killed and Wounded 886 Transfer of Wounded to Hospital Ship... 887 Reports of Killed and Wounded 888 861. To Be Prepared for Emergencies.—The medical division shall be at all times prepared for emergencies, especially during drills, fueling ship, and other evolutions. It is important that personnel of the medical department be immediately available for aseptic work. 862. Drills and Emergencies.—(a) Medical officers will be guided by fleet regulations and orders as to special drills and emergencies and by ship’s regulations for routine drills. The internal administration of ships varies somewhat in detail. Ships vary greatly in structure; however, a general pattern of administration is evident and there is a tendency to develop type uniformity for ship administration. Among 72 SEC. III.—DUTIES IN EMERGENCIES 863 drills and routine ship activities of interest to the medical department are: (1) Strip ship and clear ship for action. (2) General quarters. (3) Damage control, materiel and personnel. (4) Gas defense and chemical warfare defense. (5) Launching and recovery of airplanes. (6) Fire quarters. (7) Collision drill. (8) Fire and rescue party. (9) Abandon ship and man overboard. (10) Landing force and Navy emergency relief force. (b) Drills are provided for in advance in ship’s organization— Watch, quarter, station, and other bills. The sections of these bills which apply to medical department personnel shall not only be posted in the sick bay, but the complement of the medical department shall be thoroughly instructed so that each man knows his station, exactly what he is to supply, and what to do when he arrives at his station. It is most important that these bills be kept up to date and strictly obeyed during drill periods. 863. Condition of the Ship in Relation to Drills and Bills.—(a) Strip ship and clear ship for action bills prepare the ship for battle. The medical department having arranged for distribution of the medical supplies and equipment to battle-dressing stations, and first- aid supplies to battle stations, takes over and equips space adjacent to each battle station cleared of peacetime usage and assigned to the medical department for the receipt of a considerable number of battle- personnel casualties, for example, 10 percent of the crew at each battle- dressing station. (b) Plans for preparation of the ship for battle must take cognizance of the materiel and personnel conditions. One personnel condition places the entire crew at their battle stations, another less restrictive, places the crew in watch and watch, approximately one-half of the crew at their battle stations, another still less restrictive permits of 4-hour watches with approximately one-third of the crew at their bat- tle stations. Letters are used to designate materiel conditions. One letter closes hatches, doors, etc., to produce the maximum of watertight integrity and defense against gas and chemicals. This materiel condition in a major engagement, is synchronous with the most restrictive personnel condition, both being set with general quarters in actual battle. A modification of the most restrictive materiel condition by opening certain doors, hatches, blowers, etc., 73 864-867 CH. 7.—DUTIES OF MEDICAL OFFICERS AFLOAT will permit enough air conditioning through artificial and natural ventilation to make battle stations more habitable. A further relaxa- tion of materiel closures will permit better ventilation and more improvement of the habitability of battle stations and is used during war cruising, especially in tropical temperatures. 864. General Quarters, Condition 1.—General Quarters with the most restrictive personnel and materiel condition set is a prepara- tion for a major engagement with enemy forces; under water, surface, and in the air. Officers and men of the medical department assigned to the battle-dressing stations shall proceed to their stations, taking with them all patients from the sick bay and such apparatus and material as are listed for that purpose and may be required. Other men of the medical department shall proceed to stations assigned. It is not neces- sary or expedient to remove the sick at each drill, but it should be practiced often enough to insure rapid and comfortable transportation for the sick. Crew personnel trained as stretcher bearers during general quarters are assigned to damage-control repair parties and other stations and when the opening of hatches and doors is directed by central station, they become available for transportation of the wounded. 865. Readiness for Action, Condition 2.—Maintained when enemy forces may be encountered but no reports of their immediate proximity have been received. Medical department personnel at dressing sta- tions maintain communication watches and reduce personnel to watch and watch. 866. Readiness for Action, Condition 3.—Maintained when contact with surface ship is not imminent, but submarines and airplanes may be present. Medical department maintains communication watches and carries on routine care of the sick. 867. Damage control.—A battleship is built, equipped, and manned for the purpose of inflicting damage upon the enemy. As the enemy has the same purpose, it is probable that both sides in a battle will receive damage. Damage control is that subdivision of the ship’s organization which plans and acts to minimize the effect of enemy damage upon the ship. Mobility and floatability of the ship being essential to the maintenance of effective fire power, damage control devotes much attention to the water- and gas-tight doors and hatches which bring about compartmentalization within the ship. This battle function is directed from central station. The majority of the medical department personnel is locked up at battle-dressing stations by damage-control closures. Damage to materiel, however, will seldom occur without concurrent damage to personnel. The medical department is responsible for the care of the wounded. The 74 SEC. III.—DUTIES IN EMERGENCIES 868 materiel condition of the ship interferes with mobility of medical department personnel. The wounded must therefore remain where they are, dependent for their care temporarily upon the degree of first-aid knowledge among their companions in the compartment where the damage has taken place. When central station is able to modify the tightly closed condition of the ship, repair parties move to make such materiel repairs as are possible and accompanying stretcher bearers begin to move the injured to or toward battle- dressing stations. This bottling up of the medical department by the necessities of damage control make the knowledge of first aid in the crew and among the stretcher bearers an essential of medical depart- ment preparation for battle. Ability of nonmedical personnel to administer first aid; ability of stretcher bearers to transport the wounded; and medical treatment facilities available at battle-dressing stations are three parts of preparation of the medical department for battle which must synchronize. Each must receive attention from inspecting officers. Hospital corpsmen will be assigned to accompany repair parties to direct and assist in first aid and transportation of casualties. The expectancy that large numbers of seriously wounded will collect requires an adequate number of hospital corpsmen to remain with the medical and dental officers at battle-dressing stations until that stage of battle is reached when doors and hatches can be opened to permit mobility of medical personnel to be restored. 868. Chemical Warfare and Gas Defense.—(a) Decontamination stations for personnel and methods for ship decontamination are assigned in the ship’s organization and set up for drills and prior to battle. The Bureau issues a pamphlet, available on requisition from the naval medical supply depot, for indoctrination of medical per- sonnel in the known therapy and first aid of these injuries. Medical officers must coordinate their defense against these agents with avail- able knowledge of their probable effect. (b) First-aid instruction.—The scope of training for first-aid and stretcher parties shall be extended to include the handling of gas casualties. These measures should also be included in the first- aid instruction to be given to the entire ship’s complement. (c) The first-aid packages distributed to turrets, handling rooms, gun stations, torpedo, fire and engine rooms, fire control, and other stations not readily accessible shall include supplies for the handling of chemical and gas casualties. Each stretcher shall be equipped with two head injury gas masks. (d) Gas masks.—The medical officer shall carry out adequate drills in the fitting and wearing of gas masks with hospital corpsmen 75 869-871 CH. 7.—DUTIES OF MEDICAL OFFICERS AFLOAT and ambulance parties in order that their duties under the conditions of a gas attack may be carried out efficiently. (e) Battle-dressing stations.—It is probable that all gassed cases will not be handled at decontamination stations. Some will be handled with the wounded at battle-dressing stations. Supplies for the various types of gas casualties will be added to these stations for the application of first-aid measures, such as carbon tetrachloride and Dakin’s solution for the treatment of mustard burns, a large supply of gauze or cotton sponges for use with the carbon tetra- chloride, 5 percent sodium hydroxide solution and ferric hydroxide glycerine paste for Lewisite bums, venesection outfits, intravenous apparatus with gum glucose solution, etc. (f) Degassing the ship.—The medical officer will hold himself in readiness to consult with the gas officer of the ship in reference to measures for degassing of personnel and materiel subsequent to a gas attack. He should assure himself that the sanitary integrity of the ship has returned to normal after degassing operations have been completed. A rigid inspection of scuttle butts, cooking utensils, mess gear, wash rooms, heads, and the food and water supply should be carried out to avoid possibility of residual contamination with gas. (g) Degassing of personnel will be accomplished by bathing and issuing of clean clothing. It may be necessary to degas or destroy all clothing and footgear worn during a gas attack. The medical officer should include all such measures in the scope of his inspection of degassing operations. 869. landing and Recovery of Airplanes.—Medical attendance to provide for emergencies during flight are provided for in ship’s organ- ization in accord with aviation doctrine. 870. Fire Quarters.—(a) The medical division shall assemble at the sick bay and make preliminary provision for the removal of the sick—have stretchers and life preservers ready. (b) Send one stretcher party, with a medical officer or hospital corpsman in charge, to report at the scene of the fire. (c) Inflammable liquids under the surgeon's charge will be re- moved to a place of safety, or, if necessary, thrown overboard. 871. Collision Drill.—(a) The medical division shall assemble at the sick bay and make preliminary preparations for saving the sick and salvaging valuable records. (b) Have stretchers and life preservers ready by the beds of patients. Prepare patients and transport them to proper stations on upper deck in case of actual collision. 76 SEC. III.—DUTIES IN EMERGENCIES 872-876 (c) Make this an active drill period. Drill the ambulance parties in the transportation of their own members to the upper deck and to the ship’s boats. (d) During such drill the medical officers and the sick will as- semble at their proper stations, leaving bed patients and necessary attendants in the sick bay with all doors and air ports closed. 872. Fire and Rescue Party.—(a) A junior medical officer and a hos- pital corpsman shall be detailed for duty with the fire and rescue party. They shall have necessary medical outfits and shall accom- pany the party whenever it is called away. Stretcher men will be provided when considered necessary. (b) Where training in the use of the rescue breathing apparatus is given, this shall, in all cases, be undertaken in the presence of a medical officer. 873. Abandon Ship.—The medical officer shall see that men of his division are detailed by name for the following duties: (1) Passing out boat boxes from the storeroom. (2) Transporting the sick, with life preservers on, to their proper boats. (3) Salvaging valuable records. 874. Landing Force.—(a) The organization of the medical divisions for duty with the landing force will depend entirely upon the size and character of the expedition. Medical officers should read carefully chapter 10 in this manual and the Landing Force Manual. (b) Fleet orders provide organization for landing naval forces to meet the emergency of disaster in civil communities. 875. Battle-Dressing Stations—Location.—(a) There should be two battle-dressing stations equipped behind armor—when possible one forward and one aft. Some ships have more than two. (b) Hospital corpsmen shall not be stationed in exposed positions. If present in sufficient strength, they shall be assigned to damage control repair parties as first-aid leaders. (c) The battle-dressing station offering the best facilities for sur- gical operating after battle shall be equipped with this purpose in view. The best surgical outfit and the best sterilizing outfit shall be placed at this station. 876. First-Aid Boxes and Other Containers at Battle Stations.— (a) These containers, first-aid boxes, gun bags, etc., are located on recommendation of the medical department where the commanding officer directs, with the purpose of placing within reach of the person- nel at each battle station first-aid supplies to permit first-aid care when access of the medical department personnel is denied by materiel condition. The supplies for these containers are medical, 77 877-880 ch. 7.—DUTIES OF MEDICAL OFFICERS AFLOAT as is the responsibility for teaching the crew their location and use. First aid is directed by the senior in charge of the battle station, no medical department personnel being present. (b) Turrets, masts, handling rooms, on deck-gun stations; torpedo, fire, and engine rooms; fire control, and other stations not readily accessible, in which officers and enlisted men are stationed in battle, shall be provided with first-aid packages, shell-wound dressings, tourniquets, dressings for burns, and such defensive gas appliances as may seem advisable. They should be plainly labeled and readily available for the emergencies of battle. 877. Equipment at Battle-Dressing Stations.—(a) The storeroom or locker at each battle-dressing station shall contain sufficient shell- wound dressings, bandages, muslin for making up large bandages, cotton, gauze, rubber gloves, buckets, pans, solutions of all kinds, hypodermics, irrigators, wipes, compresses, restoratives, etc. (b) The contents of the storeroom or locker shall be made a matter of record and carried as reserve stock. On the inside of the storeroom or locker door two itemized lists shall be posted, one of the contents, the other of articles to be supplied (par. 3069). (c) The contents of these lockers shall not be depleted under any circumstance other than actual battle or actual emergency. 878. Water Supply of Battle-Dressing Stations.—(a) Tanks of drinking water to be provided.—The forward and after battle- dressing stations should each be equipped with a fresh-water tank of capacity in gallons equal to the ship’s complement divided by 5. On ships having an amidships battle-dressing station, this station should be equipped with a tank of one-half the capacity of the above stated amount. (b) Washing water and lavatories.—Each battle-dressing sta- tion should be connected with the water system for purposes other than drinking. Prior to action, buckets, tubs, and bathtubs, if convenient should be filled, as the connections with gravity tanks may be shot away. 879. Light for Battle-Dressing Stations.—(a) There should be a suitable light installed over the operating table at each battle-dress- ing station. This light should be connected with both the day and battle lighting circuits. (b) Flashlights or dry-cell battery lights shall be provided for each station for use in case the electric lighting circuits suffer inter- ruption. 880. Sterilizers at Battle-Dressing Stations.—(a) Sterilizers should be installed at all stations and the proper connections made. 78 SEC. m.—DUTIES IN EMERGENCIES 881-886 (b) All surgical dressings, rubber gloves, etc., shall, if practicable, be sterilized before they are placed in the metal lockers. 881. Routes To Be Marked.—Routes leading to battle-dressing sta- tions should be plainly indicated by an arrow and a red cross, and hatchways leading up from the stations should be marked access in red letters. 882. Final Preparations for Battle.—(a) In addition to the usual equipment transferred from the sick bay and operating room and dis- tributed in the battle-dressing stations, the following articles should be provided for battle lockers: electric fans, with proper connections; half tubs; water buckets; sand; closed stools; swabs and brooms; washing stands; tables for apparatus; bedding and mattresses for the wounded in berthing spaces; and operating cabinet for the main station. (b) The supply of dressings at each station should be divided prior to an engagement in order to guard against total loss in case of accident. (c) All officers and enlisted men should wear their identification tags as a means of identification in case of death. (d) Space cleared for receipt of wounded up to 10 percent of com- plement at each battle-dressing station. 883. Chaplain To Assist.—The chaplain shall— (a) Visit the sick daily or oftener unless their condition renders these visits inadvisable. (b) At general quarters, report to his battle-dressing station as directed by the commanding officer (art. 1245, N. R.). 884. Dental Officer To Assist.—The dental officer shall be assigned to a battle-dressing station. 885. Duty in Battle.—(a) In battle it shall be the first duty of the medical officer to give such attention to the wounded as will permit those who are able to return promptly to their stations at the guns or elsewhere, and to render such aid along humanitarian lines as condi- tions will permit (art. 1174, N. R.). (b) Modem naval warfare presupposes a high casualty rate and a rapid accumulation of wounded, and every vessel should be self-sus- taining to the maximum extent practicable in caring for such wounded. This will require thorough instruction of the entire ship’s comple- ment in first-aid measures that may be promptly and effectively taken without unnecessary interference with the ship’s work. 886. Removal of Killed and Wounded.—When opportunity presents, in a suspension or lull in the battle or after the engagement, the ambu- lance parties should locate and remove the seriously injured to the battle-dressing stations and a list of the dead and wounded should be 79 887-888 CH. 7.—DUTIES OF MEDICAL OFFICERS AFLOAT prepared. A suitable place should be assigned for the disposition of the dead. 887. Transfer of Wounded to Hospital Ship.—When the medical transport or hospital ship is at hand, the seriously wounded should be transferred as promptly as is consistent with their welfare. A fight- ing ship should be cleared of such cases as soon as possible after an action, in order that she may be ready to reengage in battle. On the other hand, patients who will probably soon be fit for duty should be retained on board. These may constitute a large proportion of all cases. 888. Reports of Killed and Wounded.—As soon as possible after a battle the medical officer shall make out careful duplicate reports of the killed and wounded, sending one copy to the commanding officer and the other through him to the commander in chief (art. 1138, N. R. and par. 3520). 80 CHAPTER 8 HOSPITAL SHIPS Paragraph Regulations 1001 Medical Department 1010 The Medical Officer 1011 1001. Regulations.—Command, employment, etc., of hospital ships are defined by articles 665-668, Navy Regulations. 1010. Medical Department.—The medical department of a hospital ship includes all members of the Medical Corps, Dental Corps, Nurse Corps, and Hospital Corps attached thereto; all patients on the sick list of the hospital ship, and those parts of the ship devoted to the care and treatment of the sick and the storage of medical supplies and equipment. 1011. The Medical Officer.—(a) The medical officer of a hospital ship is the senior medical officer attached thereto. Subject to the orders of the commanding officer, he shall have charge of the medi- cal department of the ship and of all materiel and stores aboard under the cognizance of the Bureau. (b) He shall be responsible for the efficient management of the medical department of the hospital ship. (c) He shall comply with all orders issued by the commanding officer and shall keep the commanding officer informed of all matters of importance occurring in the medical department of the hospital ship. (d) He shall be guided by the instructions for the administration of a naval hospital insofar as they may be applicable (ch. 12, Manual for the Medical Department). (e) Article 1149, Navy Regulations, provides for a successor in case of absence or disability of the medical officer of a ship. 81 CHAPTER 9 DUTIES OF MEDICAL OFFICERS ASHORE Paragraphs Section I. DUTIES OF DISTRICT MEDICAL OFFICER 1101-1102 H. THE MEDICAL OFFICER OF A SHORE STATION 1121-1129 SECTION I. DISTRICT MEDICAL OFFICER Paragraph District Medical Officer 1101 Duties of District Medical Officer 1102 1101. District Medical Officer.—The senior medical officer assigned to serve on the staff of the commandant of a naval district will be designated district medical officer. 1102. Duties of District Medical Officer.—(a) He should have knowledge of and advise the commandant of the district concerning communications pertaining to medical activities forwarded to or through the commandant in accordance with article 1482 (4e), N. R. (b) He should have knowledge of and advise the commandant of the district concerning sanitary conditions and the prevalence of disease in and around the naval stations in the district. (c) He should advise the commandant concerning the coordina- tion of the naval medical activities in the district with each other and with Federal and local activities. (d) He shall formulate plans for the organization of medical relief work and prepare the medical department contributory plans in accordance with the commandant’s plans for the expansion of the district in times of emergency. (e) He shall supervise the preparation, custody, and transfer of the health records and maintain an index list of all the medical reserve personnel constituting the medical department of the Naval Reserve in the district, including base and station hospital groups. (f) He should advise the commandant of the district concerning the physical examination of the medical activities of the Naval Reserve in the district. (g) He should endeavor to advance knowledge concerning the medical department of the Navy among local organizations and the cooperation by such organizations with naval medical activities. (h) He shall consult with the medical officers of all the naval medical activities of the district in the formulation of projects covering 83 1121-1128 CH. 9.—DUTIES OF MEDICAL OFFICERS ASHORE alterations or additions to be considered by the local development board. (i) He shall, by periodic inspections of all the medical department activities of the district, including the Naval Reserve, keep advised of the condition and operation of each activity, and shall make reports of these inspections to the Bureau via the commandant. SECTION II. THE MEDICAL OFFICER OF A SHORE STATION Paragraph The Medical Officer of a Navy Yard - 1121 Regulations 1123 Annual Sanitary Report 1126 Physical Examination of Civil Employees 1127 Treatment of Civil Employees 1128 The Drug Room 1129 1121. The Medical Officer of a Navy Yard.—The officer in charge of the medical department of a navy yard shall have the following title: the medical officer; and shall be the officer of the Medical Corps detailed for this duty (art. 1518 (1), N. R.). 1123. Regulations.—The medical officer of a shore station should be familiar with the provisions of the following Navy Regulations: Reports on subordinates, article 137 (5); reports of death, article 1513; muster and discipline of enlisted men, article 1514 (1); suggestions to the commandant, article 1529; inspections ships, article 1530; reports of sick, article 1540; inspections of medical supplies, article 1616; supervision of hygiene and sanitation, including safety practices, environmental and occupational hygiene of all industrial activities, article 1184; attention to families, article 1185; responsible for property, article 1194; medical service to civil employees, article 1575; health records, article 1195; misconduct entries, article 1196. 1126. Annual Sanitary Report.—A sanitary report shall be sub- mitted to the Bureau on the 1st day of January each year, which shall contain the data required by paragraph 2700 of this manual. 1127. Physical Examination of Civil Employees.—Civil employees shall be examined in accordance with the instructions issued by the Civil Service Commission. 1128. Treatment of Civil Employees.—The first-aid department of a navy yard dispensary is for the treatment of injured employees. The medical officer shall supply whatever may be necessary in render- ing professional assistance and shall require considerate and prompt attention on the part of the personnel of the dispensary. If the injured employee requires hospital attention his relatives shall immediately be notified by telephone or telegram (par. 1653). 84 SEC. n.—AT SHORE STATION 1129 All serious cases shall be recorded and indexed in a book provided for that purpose, and, if the injury was received in the line of duty, the case shall be reported to the commandant (art. 1185 (9), N. R.). In all cases reporting for treatment the following information shall be obtained: The name, rate, and place of attachment of the person ill or injured; the nature of the case; and the name, address, and telephone number of the person making the request for treatment. See Circular Letter C of appendix D for abstracts of the Em- ployee’s Compensation Act and comment on provisions of this act for information governing treatment of civil employees. 1129. The Drug Room.—No drugs of any kind shall be issued except on the order of a medical officer. Alcohol, narcotics, and poisons shall be received, stored, and issued only in accordance with para- graphs 736, 737, and 738 of this manual. CHAPTER 10 Paragraphs Section I. AMPHIBIOUS OPERATIONS 1201-1217 n. FIELD SERVICE.. 1221-1232 m. AVIATION SERVICE 1261-1266 IV. SUBMARINE AND DIVING SERVICES. 1276-1283 SPECIAL ACTIVITIES SECTION I. AMPHIBIOUS OPERATIONS Paragraph References 1201 Composition of Forces 1202 Purpose of Landing Troops 1203 Military Phases of a Typical Operation 1204 Medical Phases of a Typical Operation 1205 Essentials for Success of Medical Function 1206 Medical Responsibility. 1207 Medical Department Plans 1208 Duties of the Fleet Medical Officer 1209 Duties of the Force Medical Officer of a Base Force 1210 Duties of the Medical Officer of a Transport Force 1211 Duties of the Medical Officer, Staff of an Attacking Force 1212 Duties of the Medical Officer of a Transport 1213 Force Surgeon with Troops 1214 Embarkation at Base Ports 1215 Debarkation for a Landing Operation 1216 Evacuation of Casualties 1217 1201. References.—Medical officers should familiarize themselves with instructions contained in references cited in current Circular Letter P in appendix (D) of this manual. Details of medical supply, equipment of personnel, and treatment of casualties are omitted. Such information is incorporated in the reference circular letter. 1202. Composition of Forces.—(a) In an amphibious expedition there is a combined activity of sea forces and land forces. (b) The sea forces include naval vessels and vessels attached under naval command to augment the fleet. (c) The land forces are organized as battalions, regiments, or brigades, each provided with its own medical service, and may be com- posed of troops from (1) normal complement of naval vessels, (2) addi- tional units of the United States Marine Corps such as the fleet marine force, (3) units of the United States Army, (4) any combination of the above. (d) Terminology.—When the landing force is composed of officers, men, and equipment drawn from the normal complements and materiel 1203-1205 CH. 10.—SPECIAL ACTIVITIES of naval vessels the term naval landing force may be used. When it is composed of personnel and materiel embarked upon a designated mission of protection, occupation, or enemy attack outside the con- tinental limits of the United States the term expeditionary force may be used. The term fleet marine force is a designation for a specific organization trained for assignment to the fleet to augment the size and power of the fleet landing force. (See G. O. No. 56.) This force may be a component of an expeditionary force. The term combined operation usually refers to joint action of the Army and the Navy. (e) However, on any amphibious military undertaking, the prin- ciples of evacuation, and the relationship between the medical organi- zations ashore and afloat are essentially the same, irrespective of the composition of the land forces. 1203. Purpose of landing Troops.—Troops may be landed for drill, ceremonies, parades, civilian disaster relief, or to guard embassies or United States citizens in foreign ports. In war they may be landed to seize, occupy, and defend military objectives. 1204. Military Phases of a Typical Operation.—(a) Mobilization in naval districts. (b) Embarkation for debarkation, last-in, first-out storage. (c) Overseas transit. (See ch. 17, sanitary standards for transports.) (d) Naval attack on shore defenses when indicated. (e) Debarkation, small boats, etc. (f) Advance from the beach. (See sec. II, field service.) (g) Occupation. (See ch. 17, field and camp sanitation.) 1205. Medical Phases of a Typical Operation.—(a) The scope of the medical problem depends upon the size of the force and the character of its mission. Planning should include provision of adequate space in naval vessels to accommodate accumulations of sick and injured in troop transports during the overseas transit, and the accumulation produced by the landing operations in the face of enemy resistance. In the accumulation of sick and injured it may be anticipated that one-third of casualties may be returnable to duty within 1 month, one-third within 1 to 3 months, one-third will be permanently lost as a military or naval asset. (b) Medical preparation for an extensive amphibious operation requires coordinate planning by the Bureau, district and fleet medical officers; and force, brigade, regimental, and battalion surgeons. Cooperation is considered in paragraph 1206. (c) Fleet medical participation requires provision of— (1) Adequate space in vessels for personnel casualties which accu- mulate during overseas transport. 88 SEC. I.—AMPHIBIOUS OPERATIONS 1206-1208 (2) Adequate space in vessels present in the zone of attack for re- ception on board of the large numbers of sick and wounded produced by the operation. (3) Space in vessels returning to base for accommodation of per- sonnel casualties requiring evacuation along sea lanes to base hospitals. (4) Ambulance ships, hospital ships. (5) Hospital companies and supporting hospitals. (6) Designation of medical officers in the attacking force to fol- lowing staff duties: Staff medical officer of the attacking force. Staff medical officer of the transport force. Beach party medical officer. 1206. Essentials for Success of Medical Function.—(a) Cooperation and coordination between medical facilities of all involved activities, afloat and ashore, and especially unity of medical control over the land and sea medical services are prime requisites (b) Staff participation is essential if medical service to the com- mand is to be employed to best advantage. Only through repre- sentation on staffs can medical advice to commanders be based upon a correct appreciation of the situation. Staff participation may be provided by the Navy Department. If not it should be provided by fleet and force commanders. When administrative units of the Marine Corps or Army are landed they generally function as one of the units of the naval command and are usually provided with their own medical service. (c) Adequacy of planned and supplied medical facilities. (d) Indoctrination and practice in landing operations by medical personnel. 1207. Medical Responsibility.—Medical responsibility extends in- land from the shor.! line for the forces landed and from the shore line seawards for the forces afloat. It includes: (1) Recommendations and advice to the naval and marine commanders; (2) collection, care, and evacuation of sick and wounded; (3) provision of medical supplies and equipment. 1208. Medical Department Plans.—The Bureau and subordinate units will prepare plans for the mobilization and replacement of medical department personnel and materiel for forces afloat and for naval and Marine Corps organizations to be landed overseas, for the care and evacuation of the sick and wounded and their disposition on arrival in the United States. The designated medical officers and 89 1209-1213 CH. 10.—SPECIAL ACTIVITIES activities in the United States shall, under the responsible military authority, be charged with the execution of these plans to the point of actual embarkation of personnel and loading of materiel and of the disposition of returning casualties and materiel from the point of debarkation or unloading. 1209. Duties of the Fleet Medical Officer.—He keeps the com- mander in chief informed of medical facilities afloat, indoctrinates fleet medical activities in accord with naval plans for the campaign, arranges for continuity of medical activity from front line ashore to beach, to ships, to fleet line of communications, to base, to the United States. He recommends disposition of medical facilities and medical personnel in the light of the medical plan handed down from higher authority. In case the need develops for a staff medical officer for duty with any subordinate command, he shall, when practicable, make such recommendations to the proper authority. 1210. Duties of the Force Medical Officer of a Base Force.—He supervises medical preparation of base force vessels including trans- ports, ambulance ships, and hospital ships prior to departure and keeps the fleet informed of space available for sick and wounded in base force vessels including transports. He advises the command in regard to assignment and utilization of ambulance and hospital ships, except the fleet hospital ship. In case the need develops for a staff medical officer for duty with any subordinate command, he shall, when practicable, make such recommendations to the proper authority. 1211. Duties of the Medical Officer of a Transport Force.—He advises in the matter of preparation of medical facilities of transports of the force for care of troops in transit. He recommends preparation of space for reception of sick and battle casulaties in transports and prepares to receive casualties from the zone of military activity. 1212. Duties of the Medical Officer, Staff of an Attacking Force.— He arranges for evacuation of battle casualties from high-tide level seaward to ships present. He recommends designation of a beach party medical officer to assist the naval beach master and keeps the beach master informed of available space for casuals in ships present. 1213. Duties of the Medical Officer of a Transport.—(a) After embarkation the responsibility for the care and treatment of all troop personnel rests with the medical officer of the ship. He should draft medical department regulations for approval by the commanding officer governing the health and treatment of troops. He may make official request for such assistance by the medical department person- nel with troops on board as may be required to meet medical needs. 90 1214-1216 SEC. I.—AMPHIBIOUS OPERATIONS As a general rule sick call for each troop organization is held by its attached medical personnel (art. 1457 N. R.). (b) He shall advise the commanding officer regarding the sanitary condition of the ship and shall formulate and submit for approval necessary regulations for the maintenance of the ship’s sanitation. (See ch. 17.) 1214. Force Surgeon with Troops.—The senior medical officer attached to the landing force is responsible for the medical service to the troops and functions as a member of the staff of the troop force commander. This detail may be by order of the Navy Depart- ment or it may be in addition to his duty as medical officer to the command with which he is serving. (See par. 1224 for the duties of this officer.) 1215. Embarkation at Base Ports.—(a) Medical field equipment should be loaded in ships with the medical unit to which its pertains, and should be placed on board in reverse order to that required at the theater of operation. This system, called the last in and first out, insures the immediate availability of equipment for forward stations of medical assistance. (b) All men physically unfit for amphibious duty should be trans- ferred ashore. The embarking troops must be carefully inspected for communicable diseases. 1216. Debarkation for a Landing Operation.—(a) Personnel.— The company-aid men should debark with their respective companies. The remainder of the battalion medical personnel may debark in an ambulance boat if the landing is unopposed. If a forced landing is anticipated it may be advisable to distribute a battalion’s aid-station personnel and materiel among several boats of its last subwave. Military experience indicates first-aid measures constitute about the only treatment practicable during the early stages of landing opera- tions. Consequently, as a general policy, in order to insure available medical service, it is advisable to delay landing of certain medical personnel, particularly if strong resistance is present ashore. The deferred landing of some medical units automatically creates medical assistance in reserve until progress has been made inland, and thus provides medical attention when its services are most needed. If there are two medical officers attached to each battalion, and no sup- porting hospital or collecting station is provided, it may be advisable to delay the landing of one battalion surgeon in order to enable him to join the regimental or brigade surgeon in forming a beach evacua- tion station. 91 1217 CH. 10.—SPECIAL ACTIVITIES (b) Ambulance boats will carry only medical department personnel and materiel. An ambulance boat cannot expect immunity from attack if it accompanies or is near boats carrying combatant personnel or materiel. The ambulance boat shall carry no arms whatever, except when operating against an uncivilized enemy, and shall fly a Red Cross flag on a staff at the bow. (c) Troop boats will be furnished first-aid materiel and personnel if advisable by the forces afloat for the purpose of treating casualties that occur enroute to the beach, and for treating returning wounded. Experience has demonstrated that during the initial phases of a land- ing, the shore to ship evacuation of wounded is frequently forced upon returning troop boats. 1217. Evacuation of Casualties.—(a) Evacuation medical offi- cer.—In amphibious operations when the forces are large the senior medical officer afloat should detail a medical officer to serve as medical evacuation officer on his staff. He will compile and have ready in advance a detailed availability list showing patient capacity and kind of patients to be accommodated on each ship. He will maintain this current tally of all bunks available afloat and will thus be able to inform the authorities on the beach to which ships to send the various types of wounded. The medical officer of the transport force may be assigned this task of shore to ship evacuation as additional duty. (b) Sorting begins at the battalion-aid station and continues to the rear. When casulaties are evacuated by returning boats in the early stages of landing the degree of sorting ashore should not be permitted to delay prompt evacuation. (c) Shore to ship evacuation.—(1) Medical station at beach.— The special situation determines the type of medical station required at the beach. It should not be located near sensitive points. This echelon of medical assistance may be a collecting station for rapid evacuation to vessels afloat, or some type of supporting hospital may be needed if the forces ashore are operating partially independent of the forces afloat. (2) A beach party medical officer should be attached to the staff of the beachmaster to supervise the sorting and evacuation of wounded from the beach to ships afloat. The actual loading of stretcher patients into the boats will be performed by medical detail of beach party. 92 SEC. II.—FIELD SERVICE 1221-1222 Paragraph Task 1221 Organization 1222 Functions of a Staff Surgeon 1223 The Force Surgeon 1224 The Regimental Surgeon,.. 1225 The Battalion Surgeon 1226 Company Hospital Corpsmen 1227 Litter Squad 1228 Preparation for Field Service 1229 Plans and Orders... 1230 Deployment and Function of Medical Units. 1231 Echelons of Medical Assistance 1232 SECTION II. FIELD SERVICE 1221. Task.—The task of the medical department in the field is the conservation of man power by the accomplishment of the following measures: (1) Instruction in first aid and sanitation, which should be given as thoroughly as practicable before taking to the field; (2) pre- vention of disease; (3) collection and treatment of the sick and wounded; (4) procurement and distribution of medical supplies and equipment. 1222. Organization.—(a) The responsibility for the medical service of any force is vested in the senior medical officer attached to the largest tactical unit of that force. The basic large unit of the United States Marine Corps is the brigade. The normal chain of medical responsibility in descending order is: Force surgeon, brigade surgeon, regimental surgeon, and battalion surgeon. (b) Each tactical organization larger than a company has a staff to assist the unit commander. Staff service is rendered by a team composed of executive staff officers and special staff officers. The surgeon belongs to the latter group. The function of the executive staff is that of direction and the function of the special staff is that of operation. (c) Expeditionary force.—The medical personnel attached to an expeditionary force, United States Marine Corps, is divided into— (1) Attached medical troops, namely, medical units which are in- tegral parts of combatant organizations—company, battalion, and regimental medical detachments. (2) Medical department organizations and supporting hospitals. In time of peace if a force landed be of such size that the attached medical troops are insufficient to meet the needs of the organization, a supporting hospital of suitable type should be landed unless definitive treatment is provided aboard a hospital ship or other designated naval vessel. 93 1223 CH. 10. SPECIAL ACTIVITIES When an expeditionary force is landed in time of war, the support- ing medical department organization for a brigade will be four medical companies. The functions, distribution, and coordination of these companies will be the duty of the brigade surgeon under the brigade commander. If the force be medically independent of sea forces and the hospital organization of the medical companies is insufficient, a'dditional supporting hospitals may be required. (d) The medical company.—Each medical company consists of four sections: headquarters, collecting, hospital, and service sections. (See Tables of Organization, U. S. Marine Corps, 1938. Table No. 6.) The company is designed to maintain evacuation from the unit in advance, establish a 72-bed hospital or two 36-bed hospitals, further evacuate cases in accordance with a prescribed plan, and to form a link in the chain of medical supply to the front. It is shown dia- gramatically as: Medical Company 0-6 WO-1 E-6C Hq. Sec. 0-1 WO-1 E-6 Coll. Sec. E-22 Hosp. Sec. 0-5 E-21 Serv. Sec. E-17 1223. Functions of a Staff Surgeon.—There is normally a staff medical officer for each command larger than a company. The pur- pose of the staff is to assist the commander to accomplish his mission. Teamwork is essential to efficient staff functioning. Cooperation not only works downward, it works upward, and laterally as well. A brigade surgeon, a regimental surgeon, or a battalion surgeon serves as his title indicates. In general, a staff surgeon: (1) Exercises supervision over all medical department activities of the command including instruction of medical department personnel. (2) Is charged, under the direction of the commanding officer, with the command of such personnel as are attached to or serving under the medical department of the command. (3) Furnishes his commanding officer with information and advice on all questions affecting the medical department. (4) Submits to his commanding officer such recommendations and requests as he may deem advisable as to training, instruction, and 94 SEC. II. FIELD SERVICE 1224-1225 utilization of personnel other than medical department to promote the medical welfare of the command. (5) Initiates and supervises measures for the care, treatment, and evacuation of the sick and wounded of the command. (6) Takes measures to insure that the required records are kept and required reports are made by the medical department personnel of the command. (7) Supervises the dental services of the command. (8) Recommends to his commanding officer measures for the pre- vention and control of disease in the command. (9) In territorial commands, recommends to his commanding officer, visits of inspection by himself or his assistants to such places, within the territorial limits of the command, as may be necessary for the purpose of inspecting medical department personnel, equipment, and administration, and of investigating conditions affecting the health of military personnel. (10) Performs such other duties as may be properly prescribed by superior authority. 1224. The Force Surgeon.—(a) The senior medical officer attached to the force shall serve as force surgeon on the staff of the force commander. (b) In addition to the general duties of a staff surgeon (par. 1223) the force surgeon shall have general supervision over all medical department activities of the force, and will be held responsible for the efficiency of all these activities. (c) He shall keep himself informed regarding the tactical plan of the force, and in the light of that plan, estimate the medical requirements for the operation. He shall advise his subordinate medical depart- ment personnel regarding his decision by a clear and concise order, plan, or annex to the operation order. (d) He shall maintain liaison with the force medical officer afloat. 1225. The Regimental Surgeon.—(a) The regimental surgeon is in charge of all regimental and battalion medical department personnel attached to the regiment. He serves in both an advisory and admin- istrative capacity. (b) Advisory duties.—As a member of the staff of the regimental commander he shall perform the general duties of a staff surgeon (par. 1223) and advise the regimental commander in matters of medical and sanitary importance. All advice given or recommenda- tions made must be consistent with policies of higher medical authority. (c) Administrative duties.—In providing a complete medical service for the regiment the more important administrative duties of the regimental surgeon are to— 95 1226 CH. 10.—SPECIAL ACTIVITIES (1) Organize the medical detachment of the regiment and plan its work in the light of the regiment’s mission. (2) Supervise all training of the medical personnel of the regiment. (3) Arrange for instruction of the entire personnel of the regiment in personal hygiene, field sanitation, and first aid. (4) Maintain such records and make such reports as may be required. (5) Prepare timely requisitions for medical and dental supplies and equipment. (6) Conduct sanitary inspections of water, kitchen, garbage, latrine, and bath installations and recommend sanitary procedures or pre- cautions necessary to preserve the health of the command. (7) Establish and command a regimental-aid station if indicated. (d) The assistant regimental surgeon shall perform such duties as may be assigned to him by the regimental surgeon and during that officer’s absence from the command serve as his relief. 1226. The Battalion Surgeon.—(a) In general, the duties of the battalion surgeon within the battalion are analogous to the duties of the regimental surgeon within the regiment. (b) In combat, a battalion-aid station, in charge of the battalion surgeon, is established and operated in accordance with the following principles: (1) The battalion commander, after consulation with the battalion surgeon, locates the aid station and reports location to the next higher command. (2) Only such part of the aid station is established as immediate circumstances require. Premature unpacking might immobilize it in a place where it could not exercise its full usefulness. (3) A battalion-aid station is established only when there is little or no progress by the assault elements. (4) It should be located in a defiladed area near the lines of drift from the front to the rear, between 300 and 800 yards from the front line. (5) Aid-station personnel must establish and maintain constant liaison with the combat units they serve. (6) The aid station evacuates the casuals from the front line, sorts the wounded, and renders emergency first aid only. (7) Normally, the work of the battalion medical detachment ends at the aid station; from here the wounded are evacuated and treated by supporting medical units. (8) Medical property evacuated with patients must be exchanged wdth the next medical echelon to the rear thus maintaining the principle of automatic supply. SEC. II.—FIELD SERVICE 1227-1229 (c) The assistant battalion surgeon performs such duties as may be assigned to him by his battalion surgeon and serves as his relief. 1227. Company Hospital Corpsmen.—One or more hospital corps- men, designated company-aid men, will be assigned to each company to function during combat, and will accompany and maintain close contact with the company during action. In stabilized situations they may estabbsb local aid posts, but in open warfare and in moving situations this is not practicable. Effectives should be treated promptly and returned to the front line, first-aid dressings will be applied, hemorrhage controlled, and fractures temporarily immobilized. Ambulant noneffectives should be directed toward the battalion-aid station. Wounded requiring transportation should be assembled at a fixed place, preferably to the rear of the inner flank of the company. This collection area should be designated by a conspicuous marker which can be readily identified by the collecting party. 1228. Litter Squad.—(a) The litter squads should form a part of the battalion medical detachment, and they should be men assigned from other branches who have bad special instruction and training in first-aid procedures and transportation of the wounded. The medical and surgical equipment of these men will be prescribed by the battalion surgeon. One litter will be provided for each pair of litter men. If the lines of communication are long, four bearers will be needed. (b) Litter bearers should total not less than 2 percent of the number of combatants. (c) During an engagement, in order to reduce the number of ineffectives to a minimum, the messmen, orderlies, and others who are not actually engaged in their own legitimate duties should, when practicable, be employed to reinforce the litter men. The litter bearers and those who assist them should adhere to the requirements of the Geneva Convention. (See appendix C.) 1229. Preparation for Field Service.—(a) Personal equipment and effects.—Uniforms, clothing, and personal effects to be taken will be governed by the nature of the expedition and climate antic- ipated and the baggage space available. Uniform requirements will ordinarily be promulgated by the organization commander prior to departure. For detailed list of items and information see the Landing Force Manual and Circular Letter P in appendix D of this manual. (b) Personal equipment and effects of medical department personnel serving with a Marine Corps expeditionary force: (1) Naval officers and enlisted men serving with an expeditionary force of marines may wear the field uniform prescribed for officers and enbsted men of the Marine Corps, respectively, substituting naval insignia, bronzed, for 97 1229 CH. 10. SPECIAL ACTIVITIES those of the Marine Corps. (See par. 134, Uniform Regulations, U. S. Navy.) (2) Officers’ individual equipment is prescribed and issued in accordance with the Marine Corps equipment, supply, and tonnage tables. (3) Officers’ baggage is prescribed by the Marine Corps Manual. (4) Officers’ accessory equipment will be governed by the nature of the mission. (5) The individual Marine Corps equipment for members of the Hospital Corps will be issued by the quartermaster at the point of mobilization, in accordance with Marine Corps equipment tables. The individual medical equipment will be issued by the medical officers. (See Circular Letter P in appendix D of this manual for current list of items and information relative to (2), (3), (4), and (5) above.) (c) Medical department supplies and equipment.—Ample preparations should be made for proper supply of instruments and dressings and other equipment for an expedition in accordance with the length and character of the service. An inspection should be made of all equipment to see that medicines, instruments, etc., are in proper condition. Reference should be made to supply table, medical department, united states navy, for materiel allowances and for itemized contents of the various units. This landing force equipment shall be inspected semiannually and tagged with date of inspection. (d) Identification tags.—All officers and men shall wear two identification tags attached to the neck. In case of injury or death one tag should be sent by a belligerent to the authorities of the man’s country as provided in Article 4, Geneva Convention of 1906; and Article 17, Hague Convention of 1929. The other tag should remain on the body of the man. (e) Medical records.—When a short engagement is anticipated, loose leaves from health records, Form F (cards), and diagnosis tags will ordinarily be the only materiel needed for keeping medical records. Upon return to the base the medical entries should be inserted in the proper health records. When a longer engagement is anticipated such records will be provided and kept as the force surgeon directs. (f) Arms.—The medical department personnel will ordinarily carry no weapons but will wear an arm badge (brassard) bearing a red cross on a white background. This brassard shall be worn on the left arm. Against a savage or uncivilized enemy, however, the members of the sanitary personnel may carry pistols and omit the red cross. 98 SEC. II.—FIELD SERVICE 1230-1231 1230. Plans and Orders.—An operation order is the medium by which a commander conveys his will to his subordinates for a tactical operation. Staff surgeons must comprehend the operation order and have an accurate mental or written estimate of the situation upon which to base the medical plan or order. Surgeons should conform with the instructions contained in chapter 7, of this manual, in so far as they are applicable to field organizations. 1231. Deployment and Function of Medical Units.—(a) General principles.—(1) Medical troops attached to a combatant unit remain with and serve this unit in camp, on the march, or in combat. (2) All medical arrangements are based upon and conform with combat orders and plans. (3) Normally contact is established and maintained in combat from rear to front. (4) Military necessities, not humanitarian reasons, govern the disposition of casualties. (5) During action, treatment and return of effectives to their com- bat units have priority. (6) In the execution of collection, evacuation, and hospitalization, the requirements of the military situation are paramount. (7) Casualties are collected and evacuated in the axis of their organization. (8) Normally a medical unit evacuates casualties no further to the rear than its own station. (9) A constant sorting and classification of casualties takes place from the advanced positions to the rear. (10) No cases are sent further to the rear than their own condition or the military situation warrants. (11) The general movement of the seriously wounded is to the rear until they have reached a medical establishment or hospital where definitive treatment can be undertaken. (b) Medical supply.—(1) The quantity of medical supplies and type of equipment to be furnished each of the medical echelons in combat are subject to variable factors, such as available transportation facilities, anticipated number of casualties, possible changes in military plans, stabilized or mobile warfare, etc. Reference should be made to Circular Letter P for current allowances for these stations. (2) Medical materiel for each medical unit should accompany that unit’s personnel in an advance or withdrawal. (3) Resupply of medical materiel will be by automatic property exchange. (c) Medical treatment of casualties.—The professional at- tention given casualties is the responsibility of the attendant medical 99 1232 CH. 10.—SPECIAL ACTIVITIES personnel. Personnel of medical echelons should be thoroughly trained in the sorting and treatment of casualties. Litter men, par- ticularly, will need to be drilled in the proper handling of casualties. Reference should be made to Circular Letter P for current advice on the treatment of particular types of injury. (d) Record of meritorious service.—Surgeons should keep a record of and report to their commanding officers those instances of valor of their personnel that merit special reward. They shall keep a daily written record of medical events of importance. (e) Parades, reviews, and drills.—(1) In peacetime when troops are landed for parades etc., the medical department personnel will be governed by reference instructions (par. 1201) and such orders as may be issued by their commanding officer. (2) On parades medical units will be prepared to administer first aid to men in parade. The medical units will not be massed, but each will follow its own organization, each litter being carried by two litter men in file and the pairs of litter men in formation abreast. In no case will the pairs form a front exceeding that of their unit. 1232. Echelons of Medical Assistance.—(a) Company aid.—This may be an established position if the company is in a stable situation. (1) Personnel.—One or more company hospital corpsmen as dressers. (2) Location.—About 100 yards to the rear of firing line. (3) Employment.—In general, the company aid maintains the highest degree of mobility consistent with the proper care of the wounded. In attack the company corpsman administers first aid to the wounded where they fall, places them in a protected spot, if possible, and continues with his troops. (4) Evacuation.—Battalion-aid station personnel evacuate casual- ties from the company aid. The noneffectives either walk or are transported by litter squads. (b) Battalion-aid station.—(1) Personnel.—Attached medical troops consisting of battalion medical officers, hospital corpsmen, and litter bearers. (2) Location.—Depends on the terrain and available shelter, probably should be about 300 to 800 yards to the rear of the firing line and in a defiladed area near the natural line of drift of the wounded to the rear. (3) Employment.—Evacuates casualties from the company aid, returns effectives to their combat units, treats and records casualties. (4) Evacuation.—By personnel attached to collecting station. (c) Regimental medical headquarters.—(1) Ordinarily the personnel of this station consists of the regimental surgeon, assistant 100 SEC. II.—FIELD SERVICE 1232 regimental surgeon, and hospital corpsmen to maintain contact with the battalion-aid stations. (2) This station becomes an echelon of medical assistance only when a regiment is acting independently, in which case it becomes the regimental-aid station. (d) Collecting station.—(1) Personnel.—Collecting section of a medical company: 1. Liaison group, to maintain contact with for- ward medical stations. 2. Collecting station group. 8. Litter bearer group. 4. Additional litter bearers as needed, to be assigned from other units for this duty. (2) Location.—At or near the normal drift of the wounded; avoid sensitive points. Depends upon the terrain and available shelter, usually about 300 to 1,200 yards to the rear of the battalion-aid stations. (3) Employment.—Evacuates casualties by litter from the battalion- aid station, records casualties, verifies diagnosis tags, and renders necessary treatment. (4) Evacuation.—By ambulances of service section. (e) Ambulance service.—(1) One or more ambulances of a hos- pital company at station with the remaining elements in support and to the rear. (2) Location in combat.—The ambulance service headquarters is usually located on firm ground in a sheltered area about a mile or two towards the rear of the collecting station, which it evacuates. How- ever the ambulance head may be located at, forward of, or to the rear of the collecting station. It marks the farthest point forward that the ambulances reach. (3) Employment in combat.—1. The evacuation of casualties from collecting stations, and, if the situation permits, from regimental- and battalion-aid stations, to the advanced-hospital station (s). 2. Evacuation from the advanced-hospital station (s) to the rear. (f) Rear hospitals in support of the medical companies.—(1) The establishment of supporting hospitals in the rear of the field force will be determined by the size of the force, length of the lines of com- munication, and anticipated strength of the opposition. (2) Advanced-hospital station.—1. Personnel.—One platoon of a medical company, a complete medical company, or two medical com- panies, depending on the situation. 2. Location.—In a protected area, on or near a good road on the route of evacuation from front to rear, about 4 to 6 miles from the front. 3. Employment.—Record, sort, and group all patients received. Except in special situations, it acts as a clearing station rather than 101 1261 ch. io.—special activities a hospital. Clean and redress wounds. Emergency surgery to save life and to control serious hemorrhage. If. Evacuation. Evacuate to the rear by ambulance as safely and as rapidly as the patient’s condition and the situation permits. Patients usually retained from 12 to 72 hours. (3) Rear-hospital station.—Personnel and junction.—This sta- tion will normally consist of the second medical company. If the operation is stabilized and further advance is unlikely this unit may take on the characteristics of a stationary hospital for definitive treatment of cases evacuated from the advanced-hospital station. If the advance is still in progress this station will be advanced beyond the advanced-hospital station and assume its function and the former advanced station will in turn become the rear-hospital station. This leap-frog advance of the medical companies will continue throughout the period of mobility of the brigade. (g) Additional hospital assistance.—Should hospital support be required in addition to that provided by the medical companies and in the absence of the hospital ship or other suitable vessel designated to provide definitive treatment, a field hospital adequately manned and supplied to meet the requirements of the forces landed should be established. As a guide to the personnel and equipment required for such a hospital, details can be made available for medical facilities appropriate to fulfill the needs of almost any specific situation. SECTION III. AVIATION SERVICE Paragraph Organization and Duties of the Medical Division 1261 Flight Surgeon as Junior Medical Officer 1262 Study of Conditions 1263 Recommendations 1264 Physical Examinations..... 1265 Transfer of an Aviator 1266 1261. Organization and Duties of the Medical Division.—(a) The function of the medical department will, in general, be that for the general service. Where the medical department has the dual respon- sibility of providing for the special demands incident to aviation, in addition to those for the general service, it shall be the duty of the medical officers properly to coordinate the functions of the medical department to meet these demands. The flight surgeons will be encouraged in the performance of their special duties. Emergency bills should be prepared to render efficient and prompt assistance in case of an accident. 102 SEC. III.—AVIATION SERVICE 1262-1265 (b) Air forces afloat.—In the case of aircraft carriers and tend- ers, an emergency bill should be prepared for flight operations which makes due provision for prompt medical assistance in the case of an accident. (c) Air forces ashore.—The medical officer of an air station shall make due provision for the rendering of prompt medical assistance in the case of an accident. Medical aid should be available at all times during flight operations. Where the medical department is not read- ily accessible to the flying line, or where flight activities occur at dis- tant or outlying fields, a medical officer or hospital corpsman, when practicable, will be in attendance, to render immediate first aid. Since many accidents in naval aviation result in drowning, hospital corpsmen should be thoroughly instructed in the methods of resuscita- tion, and due provisions should be made to meet this emergency at any time. 1262. Flight Surgeon as Junior Medical Officer.—If the flight sur- geon assigned to aviation duty is junior in rank to the medical officer of the ship or station, he is the assistant of the latter, but he should be given every facility for performing his special duties and for acquir- ing additional information relative to the medical problems of flying. 1263. Study of Conditions.—The flight surgeon should live in as close contact with the flying personnel as is consistent with existing con- ditions and should, when practicable, accompany pilots on flights in order personally to experience the various problems encountered while in the air. He should interest himself in medical problems connected with aviation with a view to improving flying conditions. 1264. Recommendations.—Based on his technical knowledge and special training, the flight surgeon shall make such reports and recom- mendations to the commanding officer as he deems proper, concerning: (1) Reports on the physical fitness of flying personnel, collectively and individually. (2) Recommendations concerning measures for the promotion of the physical welfare and improvement of flying personnel, with particular reference to physical exercise, recreation, rest, and leave periods, where such are considered necessary. (3) Recommendations concerning temporary relief of personnel from flying due to staleness or other cause, and the relief of flying personnel from flight duty when found not physically or tempera- mentally qualified for such duty. Recommendations from the flight surgeon shall be made via the medical officer. 1265. Physical Examinations.—The flight surgeon shall conduct such physical examinations of flying personnel, as may be required. Physical examinations of flying personnel and health record entries 103 1266-1276 OH. 10. SPECIAL ACTIVITIES and reports will be made in accordance with instructions contained in chapter 11 and paragraph 2331 of this manual. 1266. Transfer of an Aviator.—(a) When an officer or enlisted man reports for duty involving flying, he will, by direction of the commanding officer, report to the medical officer for verification of his physical qualifications for such duty at the time of reporting. The medical officer will notify the commanding officer in writing, the results of such examination. (b) Upon the transfer of a naval aviator, naval aviation pilot, naval aviation cadet, or naval aviation observer, the medical officer will forward to the medical officer of the new station, a copy of the latest Aviation Form No. 1, bearing the indorsement of the Bureau. Paragraph General Duty 1276 Inspections 1277 Instruction of Personnel 1278 Physical Examinations 1279 Illness due to Occupational Hazards 1280 Venereal Diseases 1281 Ventilation of Submarines. 1282 Annual Sanitary Report 1283 SECTION IV. SUBMARINE AND DIVING SERVICES 1276. General Duty.—(a). Submarine service and diving service are correlated duty. Problems of air conditioning and the physiological effects of increased air pressure are of great importance in each. It is essential that medical officers detailed to submarine or diving duty thoroughly familiarize themselves with these conditions, their effects, and the required protective measures. This understanding should include a clear appreciation of— (1) The relative importance of air temperature, humidity, and turbulence as they effect a satisfactory air condition. (2) Factors peculiar to submarines that affect air condition. (3) The physiology of respiration under increased air pressure. (4) Safety measures provided for personnel, the principle of their operation, their mechanism, the proper mode of operating them, and a method of effectively inspecting them. (b) Personnel detailed to submarine and diving duty represent a select group working under stress of hazard. In submarines their work requires close personal contact and a high degree of cooperation. The morale of such a crew demands men physically fit and functioning with- out friction. The medical officer has a major responsibility in assisting to maintain this morale. He should make a conscientious effort to acquire the trust and confidence of his submarine crews. He should be 104 SEC. IV. SUBMARINE AND DIVING SERVICES 1277-1278 sufficiently familiar with this personnel to detect and treat early signs of physical disease or mental deterioration. He should give all incom- ing drafts a critical inspection for factors detrimental to a crew. The obviously unfit should be hospitalized and doubtful cases held for observation. (c) The medical officer detailed with submarine or diving personnel is in a position to observe the function of these activities in actual practice. He should observe both critically from the standpoint of defects or methods of improving appliances or practices affecting the health of personnel. Such observations should be reported to the Bureau for analysis and development. 1277. Inspections.—The medical officer will make the following inspections: (a) Such inspections of personnel and materiel as directed by his commanding or superior officer. (b) Sanitary inspections of each submarine should be held fre- quently and inquiry made particularly into: (1) Adequacy and condition of supplies for first aid and proficiency of personnel assigned to administer first aid. (2) Condition of submarine escape appliances. (3) Condition of special emergency canisters for attachment to the submarine escape appliance. (4) Readiness for use of oxygen cylinders, C02 absorbent, and emergency supply of drinking water in each compartment. (5) Condition of living spaces as to bedding and vermin, air condi- tioning, food preparation, etc. (c) Observe the submarine under operating conditions, in order to familiarize himself with the living and working conditions on board and to obtain a direct knowledge of the methods provided for the protection of the personnel against all possible atmospheric and other hazards under both surface and submerged conditions. See ch. 17 for standards and methods of determining efficiency of air condi- tioning. (d) Examine all personnel prior to patrol run or prolonged cruise to detect physical conditions likely to lead to disability during the cruise. On completion of such patrol run or prolonged cruise examine the crew (of one submarine if several are participating) for any dis- ability resulting from such service. The findings of this latter ex- amination will be reported in the annual sanitary report. 1278. Instruction of Personnel.—The medical officer shall instruct all submarine personnel, both officers and men, in first aid and sub- marine hygiene, emphasizing the following: (1) Artificial respiration; (2) treatment of oil and acid bums; (3) protection of ears against in- 105 1279 CH. 10.—SPECIAL ACTIVITIES creased air pressure; (4) protection of the eyes from electric flash (5) protection against atmospheric hazards such as chlorine gas, carbon monoxide, increased carbon dioxide, oxygen deficiency, arsine, hydro- gen, heat prostration; (6) air conditioning; (7) handling of accidents in the use of the submarine escape appliance; (8) compressed-air illness. 1279. Physical Examinations.—(a) Physical examinations of sub- marine and diving personnel shall be conducted in accordance with instructions contained in chapter 11 and paragraphs 1277 and 2331 of this manual. In the physical examination and treatment of such personnel particular emphasis will be placed upon dental and naso- pharyngeal conditions. (b) Preliminary physical examination for diving.—The medical officer shall examine all officers and enlisted men who are candidates for the course of instruction at the Deep Sea Diving School, Navy Yard, Washington, D. C. Applicants for the designation of diver must meet the physical requirements of deep diving as set forth in chapter 11 of this manual. Scrupulous care should be taken that the physical standards are satisfied in order that rejections at the Deep Sea Diving School may be avoided as far as possible. Otherwise, the quota of classes is not filled, the services of personnel are lost and an unneces- sary cost of transportation is expended. The reexamination of candi- dates at the Deep Sea Diving School is intended to supplement the original examination conducted on the ship or station and not to replace it. Candidates for training for diver, second class, to be carried out on board naval vessels, shall satisfy the same physical requirements prescribed for applicants for the Deep Sea Diving School. This shall also apply to candidates for instruction in diving at the school for torpedo men, Torpedo Station, Newport, R. I. (c) Periodic physical examination of divers.—(1) Annual 'physical examination.—All divers shall undergo a complete physical examination in January of each year in order to determine whether physically qualified to continue in this activity. A notation to this effect shall be placed in the health record. Under ordinary circum- stances divers over 40 years of age are automatically disqualified from diving exceeding 15 fathoms in depth (par. 1537). (2) Prior to each dive.—Divers shall ordinarily be medically ex- amined prior to each dive. However, in extensive rescue or salvage operations with men descending day after day, the initial examination will be made and subsequent examinations at the discretion of the medical officer. 106 SEC. IV.—SUBMARINE AND DIVING SERVICES 1280-1282 (3) Special precautions.— 1. Removal of dentures.—The medical officer on examination of divers preparatory to descent shall ascertain that all dentures have been removed. 2. Interval after a meal.—A diver should not descend after a full meal until a reasonable interval has elapsed. Gas formed in the alimentary tract while under pressure expands on decom- pression, tending to obstruct the circulation and thereby increas- ing the tendency to bubble formation. 1280. Illness Due to Occupational Hazards.—(a) All cases of disease or injury that can be directly attributed to factors peculiar to submarine or diving duty should be admitted to the sick list, if only for record, in order that the statistical data may be complete for these diseases. (b) The medical officer shall submit a detailed report to the Bureau of all serious accidents or unusual conditions. Every case of com- pressed-air illness, diver’s squeeze, and asphyxia shall be reported. The depth of the dive, time on the bottom, decompression schedule of ascent, and decompression procedure employed for treatment of cases of compressed-air illness should all be included. (c) Under the conditions of a rescue or salvage operation involving extensive diving, it is desired that the medical officer submit a statis- tical report at the conclusion including the following data as far as is practicable: Depth, number and duration of dives per diver, decom- pression schedules for ascent and departures therefrom, and complete data for all cases of compressed-air illness. 1281. Venereal Diseases.—(a) In cases of venereal disease develop- ing among submarine personnel the patients shall be transferred to the tender or shore for treatment. Cases of gonococcus and chancroi- dal infection shall be so retained during the entire necessary period of such treatment. Men who have been infected with syphilis may be returned to duty aboard submarines when the disease is regarded as arrested and in need of no further treatment. Men with a history of neurosyphilis will not be assigned to duty aboard submarines (par. 1535 (9)). (b) From time to time when so directed by the senior officer present, the medical officer shall hold frequent inspections of the crew to detect the presence of venereal diseases. He shall supply sub- marines, when on detached cruising, with prophylactic remedies and instruct the crew in their use. 1282. Ventilation of Submarines.—(a) Surface conditions.—The adequacy of air supply to all compartments when at anchor, at dock or cruising on the surface under various conditions should be noted. 107 1283 CH. 10.—SPECIAL ACTIVITIES (b) Submerged conditions.—(1) Air-purification and air-con- ditioning equipment: Medical officers should consult the Bureau of Construction and Repair Manual which is available in all vessels for information relative to atmospheric hazards in submarines and the operation of air-purification and air-conditioning equipment. (2) Arsine (AsH3): Medical officers should know the method for detecting this gas in the air and conditions under which it may be formed from impurities in the electric storage batteries. 1283. Annual Sanitary Report.—The medical officer will carefully observe the effects of submarine duty on the personnel and report to the Bureau in the annual sanitary report the results of his observa- tions and the steps taken and recommendations made to remedy the defects found. The following headings are given as examples of sub- jects which may be included in the annual sanitary report: (1) Effects on personnel of protracted service in submarines. (2) Conditions arising from deleterious atmospheric conditions in submarines. (3) Diseases or disabilities peculiar to duty in submarines. (4) Ventilation, use of air-purification apparatus, etc. (5) Eye strain in relation to periscope work; effects of electric welding on the eyes. (6) The submarine ration. 108 CHAPTER 11 PHYSICAL EXAMINATIONS Paragraphs Section I. PRELIMINARY 1401-1407 II. GENERAL INSTRUCTIONS FOR THE EXAMINATION 1411-1416 III. GENERAL PROVISIONS GOVERNING EXAMINATIONS. _ _ 1417-1425 IV. THE EYES 1426-1432 V. THE EARS 1433-1437 VI. GENERAL EXAMINATION, INCLUDING HEIGHT, WEIGHT, AND CHEST MEASUREMENT 1439-1448 VII. THE SKIN 1449-1450 VIII. THE HEAD 1451-1452 IX. THE FACE 1453 X. THE MOUTH, NOSE, FAUCES, PHARYNX, LARYNX, TRA- CHEA, AND OESOPHAGUS 1454-1455 XI. THE TEETH 1458-1462 XII. THE NECK 1463-1464 XIII. THE SPINE 1467-1468 XVI. THE CHEST 1471-1472 XV. THE LUNGS 1475-1477 XVI. THE HEART AND BLOOD VESSELS 1481-1492 XVII. THE ABDOMEN 1493-1495 XVIII. THE PELVIS, INCLUDING THE SACRO-ILIAC AND LUMBO- SACRAL JOINTS 1498-1499 XIX. GENITO-URINARY SYSTEM, AND VENEREAL DISEASE. _ 1502-1508 XX. THE EXTREMITIES 1510-1511 XXI. THE NERVOUS SYSTEM 1514-1519 XXII. ANNUAL AND SPECIAL EXAMINATIONS 152G-1537 XXIII. AVIATION, INSTRUCTIONS AND REQUIREMENTS 1538-1565 XXIV. IDENTIFICATION RECORDS 1570-1578 XXV. CIVIL EMPLOYEES, PHYSICAL EXAMINATIONS OF 1594-1597 Paragraph Purpose of the Standards 1401 Application of Standards to Candidates for Commission or Enlistment— 1402 Candidates for the Naval Academy 1403 Fundamental Qualifications of All Personnel 1404 Rejection for Causes Not Specifically Noted 1405 Enlistment of Former Enlisted Men Who at Date of Last Discharge were not Physically Qualified For Reenlistment 1406 Waiver of Disqualifying Defects 1407 SECTION I. PRELIMINARY 1401. Purpose of Standards.—The purpose of the standards of physical examination is to secure the greatest efficiency and uniformity in making physical examinations for entrance into the Navy and Marine Corps. Medical examiners should interpret the standards 109 1402-1403 CH. 11.—PHYSICAL EXAMINATIONS with discretion and should not construe them too arbitrarily, the object being to procure personnel which is physically fit. 1402. Application of Standards to Candidates for Commission or Enlistment.—(a) The standards as prescribed for candidates for commission or enlistment will apply uniformly to those seeking commission or enlistment in the Navy, Marine Corps, and the Reserve, except as otherwise provided in these regulations. (b) Candidates for commission or enlistment in the Reserve will be required to conform to the standards as prescribed for candidates for commission or enlistment in the regular services and must be free from any defect or pathological condition which would interfere with the performance of the duty expected of them in the service or which would as a result of service be especially liable to undergo progressive change or to become the basis of a claim against the Government in the event of call to active service. Additional information is contained in Bureau of Navigation Manual, part H, and Regulations for Adminis- tration and Training, Naval Reserve Officers Training Corps 1935, article 402. (c) Applicants for enlistment in the enlisted ratings in the Reserve will be required to conform to the standards as prescribed for appli- cants for enlistment and are subject to the same provisions as stated above (Bu. Nav. Man. pt. H). 1403. Candidates for the Naval Academy.—(a) Medical officers are required to examine physically any candidate for the Naval Academy who may present a letter from a Member of Congress so requesting. The candidate should be informed of the result of the examination. A copy of the report (Form Y) shall be forwarded to the Member of Congress concerned, a copy to the Bureau of Navigation, a copy to the Superintendent, United States Naval Academy, and the original to the Bureau. Each examination report shall show the name of the Senator or Representative requesting the examination and shall con- tain a definite statement as to whether the candidate, in the opinion of the medical examiner, does or does not meet physical requirements for admission. The candidate should be informed that the examina- tion is only preliminary and that his final fitness for the Naval Academy will be determined by a board of medical examiners after he has passed the mental examination. In every border-line case wherein the examiner himself is uncertain as to the outcome, the candidate and Member of Congress shall be clearly and unmistakably informed that the case is a doubtful one and notation to that effect shall be made on the report of examination (Form Y). In border-line or doubtful cases where a candidate has been examined at a place other than a naval hospital, or the Naval Academy, he should be 110 SEO. I.—PRELIMINARY 1403 advised to go to the nearest naval hospital for further examination, or preferably to present himself before the permanent medical examining board at the Naval Academy before going to the expense of an extensive preparatory course of study. A candidate presenting a request from the Bureau of Navigation or a son or dependent relative of an officer of the Army, Navy, or Marine Corps presenting a request signed by the officer concerned shall also be examined. (b) Medical examiners should bear in mind that the primary object of this examination is to eliminate those who are obviously disqualified, rather than to give assurance to any candidate that he will subsequently pass the official examination. A high standard of physical excellence is essential in the cases of all candidates pre- senting themselves for admission to the Naval Academy, and medical officers should always keep in view the fact that the physical effi- ciency of officers of the Navy will depend largely upon the manner in which this important and exacting duty is performed. Special attention shall be given to the following defects or disabilities: Flat feet (par. 1511 {a a) (a &)), defective posture, defective vision or hearing, defective color perception, defective teeth, heart or lung trouble, and diseases of the kidneys. Blood pressure and pulse readings before and after exercise shall be recorded (pars. 1482 and 1490 (g)). (c) Medical officers conducting preliminary physical examination of candidates for midshipmen are directed to examine, under a cyclo- plegic, the eyes of all candidates and to reject those whose eyes show any degree of myopia or myopic astigmatism. Vision before and after instillation of a cycloplegic shall be recorded on Form Y. Vision with correction under cycloplegic and the corrective lenses required shall also be recorded on Form Y. Medical officers not equipped to make the above examination shall inform candidates and note on the report of preliminary physical examination (Form Y) that admission to the Naval Academy will be contingent upon the results of refraction under a cycloplegic and that the candidate and the Member of Con- gress concerned have been so informed. In order to save subsequent disappointment and expense, they shall urge candidates who are qualified in other respects to have their eyes examined at the nearest naval medical activity equipped to do refractions, preferably at a naval hospital. (d) Except where otherwise noted the physical qualifications for candidates for the Naval Academy shall be the same as candidates for commission and applicants for enlistment. (e) Enlisted candidates of the Navy or Marine Corps for the United States Naval Academy preparatory class shall be examined and the report submitted as required by the Bureau of Navigation Manual, article D-6103 (c). 1404 CH. 1 1.—PHYSICAL EXAMINATIONS (f) Enlisted men of the Naval Reserve, candidates for appoint- ment as midshipmen, should be examined and report forwarded as required by the Bureau of Navigation Manual, part H. 1404. Fundamental Qualifications of All Personnel.—(a) All appli- cants for admission to the naval service shall be required to conform to the physical standards as set forth in this chapter. No educational standard has been officially established for recruits presenting them- selves for enlistment in the naval service. The regulations require, however, that a candidate shall be able to read and write and that he should possess a reasonably quick and clear understanding. His general intelligence may be estimated by his manner of answering the questions addressed to him in obtaining the data required in the health record, and any impediments of speech noted. (b) Section 1420 of the Revised Statutes forbids the enlistment in the naval service of any intoxicated person. The evident inten- tion of the law was not only to prevent the admission into the serv- ice of men who at the time of presenting themselves for enlistment were under the influence of alcoholic stimulants or drugs, but of those also who were of intemperate habits. A thorough inquiry should be made into the history of any applicant in whom habits of intemperance are suspected. (Consult par. 1516.) Medical officers should endeavor to eliminate the insane, vagrant, and criminal classes by a careful study of the personal characteristics of each applicant. Any doubt as to the mental stability of the applicant should deter- mine a careful investigation directed toward his previous history. (c) Slight physical defects in those applicants who have matured are of less importance than when occurring in minors and are not necessarily a cause of rejection in cases of reenlistment and continu- ous service. Slight physical defects in applicants who belong to the seafaring class or in those who have had experience in military life have less significance than they might have in the cases of recruits whose lives have been passed in occupations of a more confining and debilitating character. In the latter class of candidates the unusual and peculiar services that would necessarily be exacted of them might develop any weakness or constitutional physical traits that existed prior to enlistment. (d) The examining surgeon shall consider carefully the physical adaptability of the applicant in relation to the character of the duties which he may be called upon to perform. While it is not always expected that candidates for special ratings should possess the physique and endurance of those actively engaged in strictly 112 SEC. II.—GENERAL INSTRUCTIONS 1405-12 military duties, the examining surgeon should remember that all candidates examined for the several special ratings are enlisted for the performance of all duties pertaining to the naval service ashore and afloat. 1405. Rejection for Causes Not Specifically Noted.—If any applicant for enlistment or candidate for commission is regarded by the medical examiner as physically unfit for the naval service by reason of a con- dition not specially noted in this manual as a cause for rejection, he will, nevertheless, be rejected, and a full statement of the reasons therefor entered on the proper form. 1406. Enlistment of Former Enlisted Men Who at Date of Last Discharge Were Not Physically Qualified for Reenlistment.—No former enlisted man who was discharged by medical survey or who at time of last discharge was not recommended for reenlistmcnt due to physical disability will be enlisted without authority from the Navy Department. In requesting authority for the enlistment a complete report of notations made on last discharge and statement of his present physical condition will be submitted with the request for waiver (par. 1407). 1407. Waivers.—When an applicant for enlistment is disqualified, according to naval standards, by reason of a minor physical defect, which in the opinion of the examining surgeon would not incapacitate for full duty, a waiver may be requested either by telegram or on the prescribed form (N. Nav. 54 or N. M. C. 588) if the individual is otherwise physically qualified and desirable material for the service. The nature of the defect should be clearly and specifically stated. Paragraph Care 1411 Additional Diagnostic Procedures 1412 Applicants for Enlistment 1414 Candidates for Commission and Applicants for Appointment as Warrant Officers 1415 Special Examination for Flying and for Aviation Cadets __ 1416 SECTION II. GENERAL INSTRUCTIONS FOR THE EXAMINATION 1411. Care.—The applicant or candidate shall be carefully ques- tioned about his past and present physical condition, special inquiry being made regarding any serious illness, injury, or operation he may have had. During the entire examination all examiners should be especially observant with a view to determining the mental charac- teristic of the examinee. 1412. Additional Diagnostic Procedures.—In doubtful cases the medical examiner shall employ every diagnostic procedure at his 113 1414-1416 ch. n.—physical examinations disposal, including the use of the microscope, the x-ray, or other laboratory methods, with a view to determining the true condition of the applicant before he is finally accepted. 1414. Applicants for Enlistment.—The physical examination of applicants for enlistment in the regular or reserve Navy or Marine Corps shall be made by medical officers of the Navy. The results of the examination shall be recorded on the health and enlistment record. The examination shall be thorough in every detail. Applicants unfit for service by reason of a disease not of a serious nature, and which it is believed can be cured within a short time, may be advised to seek treatment with a view to their enlistment upon recovery. WTien candidates are accepted, including those where waiver is recom- mended, all physical defects shall be recorded. No applicant shall be accepted for enlistment who does not conform to the standards set forth herein. Men desiring to reenlist who have defects which would be cause for rejection for original enlistment, but not such as to prevent the performance of the duties to be expected of them, shall be referred to the Bureau of Navigation or the Major General Com- mandant and the Bureau with recommendation for waiver (par. 1407). 1415. Candidates for Commission and Applicants for Appointment as Warrant Officers.—The physical examination of candidates for commission or warrant shall be conducted by a board of medical examiners. Each candidate shall be subjected to a thorough and rigid physical examination. All medical officers engaged in making these examinations are enjoined to exercise the greatest care and diligence in this procedure and to assure themselves that all findings are fully and accurately recorded. Each defect noted must be recorded in such a clear and complete manner that no question as to its character, degree, and significance can arise when the report of the board is reviewed in the Navy Department. When a candidate is rejected, the cause must be clearly established and so definitely recorded as to be conclusive regarding the propriety of the rejection. Symptoms of disease will not be noted as causes of rejection if it is possible to arrive at a definite diagnosis. A candidate who does not conform to the standard of requirements shall be rejected by the med- ical examiners. Candidates shall not be accepted subject to the performance of surgical operations for the removal or cure of defects (par. 1507). 1416. Special Examination for Flying and for Aviation Cadets.— (a) Flying.—Candidates for aviation duty shall be given the addi- tional physical examination required by section XXIII of this chapter. (b) Aviation cadets.—Applicants for enlistment as seaman second class V-5, U. S. N. R., as candidates for subsequent appointment as 114 SEC. III. GENERAL PROVISIONS 1417-1419 aviation cadet, U. S. N. R., shall be subject to the following physical requirements: (1) The same physical requirements for the general service as pre- scribed for candidates for commission (par. 1415), provided, however, that the physical examination may be conducted by a medical officer of the naval service in lieu of appearing before a board of medical examiners. (2) In addition to the physical requirements for the general service as prescribed above, the applicant shall be required to pass the physical and psychological examination for flying as prescribed in section xxm, chapter 11, Manual of the Medical Department (pt. H, Bureau of Navigation Manual). SECTION III. GENERAL PROVISIONS GOVERNING EXAMINATIONS Paragraph Appointments and Enlistments 1417 Bureau Requirements 1418 How Conducted 1419 Promotions 1420 Retirement of Officers 1421 The Marine Corps 1422 Records 1423 Reenlistments > 1424 Service Records 1425 1417. Appointments and Enlistments.—(a) No person shall be ap- pointed to any office in the Navy until he shall have passed a physical examination, which shall precede the mental and professional examination. (b) Every person before being enlisted shall pass a physical exami- nation conducted in accordance with the instructions in this manual, and no person shall be enlisted unless pronounced fit by the command- ing and medical officers except by special authority in each case from the Navy Department. 1418. Bureau Requirements.—The Bureau is required to provide for the physical examination of officers and enlisted men with a view to the selection or retention of those only whose physical condition is such as to maintain or improve the military efficiency of the service if admitted or retained therein. 1419. How Conducted.—(a) All physical examinations shall be con- ducted by medical officers, and the examination in each case must be completed according to the official forms (art. 1200, N. R.). (b) Boards of medical examiners shall be guided by the instruc- tions contained in Naval Courts and Boards. 115 1420-1422 CH. 11.—PHYSICAL EXAMINATIONS 1420. Promotions.—(a) “No officer shall be promoted to a higher grade on the active list of the Navy, except in the case provided in the next section, until he has been examined by a board of naval surgeons and pronounced physically qualified to perform all his duties at sea” (sec. 1493, R. S.). Reference should also be made to section 883, naval courts and boards (1937). (b) “The provisions of the preceding section shall not exclude from the promotion to which he would otherwise be regularly entitled any officer in whose case such medical board may report that his physical disqualification was occasioned by wounds received in the line of his duty, and that such wounds do not incapacitate him for other duties in the grade to which he shall be promoted” (sec. 1494, R. S.). (c) Members of boards of medical examiners and medical survey and medical members of Naval Retiring Boards, therefore, have the obligation and responsibility of expressing an opinion regarding the qualifications of the candidate being examined to perform all the duties of the grade to which he is being promoted or retained and to this end shall carefully consider all physical defects including those of vision. Consideration shall also be given to the exacting nature of duties in the field required of officers of the United States Marine Corps (par. 1523). 1421. Retirement of Officers.—Physical examinations for retirement will be conducted in accordance with the instructions in Naval Courts and Boards. Detailed information concerning appointments, promo- tions, and retirements will be found in chapter 44, United States Navy Regulations. 1422. The Marine Corps.—Article 579, Navy Regulations states: (1) Every person before being enlisted or enrolled must pass the physical exami- nation ; and no person shall be enlisted unless pronounced fit by the commanding and medical officers, except by special authorization, in each case, from the Major General Commandant of the Marine Corps and Surgeon General of the Navy. (2) Enlisted men of good character and faithful service who, at the expiration of their terms, are undergoing treatment for injuries incurred or disease contracted not due to his own misconduct may be reenlisted if they so elect, and, if the disa- bility prove to be permanent, they will subsequently be discharged on certificates of disability. An enlisted man not under treatment, but who has contracted infirmities not due to his own misconduct that may raise a question of physical eligibility to reenlistment, but not such as to prevent his performing the duties of a marine, may be reenlisted by authority of the Major General Commandant on application made through the surgeon and proper official channels in time to receive a decision before the date of discharge. (3) ' In the case of a person having physical disabilities, who has been enlisted by authorization as above, the physical condition of the enlisted man must be fully described in his enlistment paper in order that no improper claims for pension may be allowed. 116 SEC. III.—GENERAL PROVISIONS 1423 1423. Records.—(a) The examination for enlistment having been concluded and the candidate found qualified for the service, the medical examiner shall enter his descriptive list upon the blank service record furnished by the Chief of the Bureau of Navigation or the Major Gen- eral Commandant of the Marine Corps and, having signed it, shall transmit the record to the commanding officer. He shall also make the necessary entries upon the blank health records furnished by the Chief of the Bureau, retaining such records until the recruits are transferred, when they shall be duly forwarded, as provided in the Manual of the Medical Department (ch. 14). (b) Upon the transfer at any time of an enlisted person the medical officers shall make the necessary entries upon the service and health records (art. 1201, N. K.). (c) Whenever any person is examined physically for the Navy or Marine Corps, whether subsequently enlisted or rejected, his name and the particulars shall at once be entered on Form X (rough), being careful to strike through with ink the term not applicable to the case. Form X (rough) shall be prepared for each applicant examined, whether accepted or rejected, for original entry or reenlistment, and will be kept for the purpose of preparing Form X. It shall be re- tained for ship or station files and shall be filed alphabetically by calendar years, according to the applicant’s surname, in order that information may be furnished the bureau on request. (d) Civilian medical examiners at substations of the Marine Corps shall prepare and forward Form X (rough) to the district head- quarters stations. (e) In every case of rejection the disability unfitting the applicant for services, and in other cases, any abnormal condition, former grave illness, or serious injury not inconsistent with present bodily vigor shall be entered on Form X (rough). (f) Form X shall be prepared from Form X (rough), kept for the purpose. (g) Central recruiting stations shall include in their report the substations and traveling parties coming under their jurisdiction, and medical officers of ships, naval stations, or yards making examinations for ships or stations to which no medical officer is assigned shall include these items in their reports. (h) Marine recruit depots shall distinguish between accepted applicants transferred from recruiting stations to the depot and those applying originally at the depot by making the proper entry in the space provided on this form. (i) In case a waiver is requested the action will be noted on Form X (rough) after the cause of rejection and, in cases where physical 117 1424-1427 CH. 11. PHYSICAL EXAMINATIONS disqualifications are waived by the Navy Department, the medical examiners shall fully describe the same on all records of enlistment (art. 1202, N. R.). 1424. Reenlistments.—A reenlistment in the Navy may be made in any one of the ratings shown in the table for first enlistments with- out regard to age limits, provided the applicant is physically and otherwise qualified for enlistment in that rating. Previous Army service shall not determine a reenlistment. Previous Navy or Marine Corps service shall determine a reenlistment in the Navy, and pre- vious Marine Corps or naval service shall determine a reenlistment in the Marine Corps, so far as it applies for use in the preparation of Form X. 1425. Service records.—(a) A service record, which is to accompany each person during his term of enlistment, must be prepared at the rendezvous or on board the vessel where the enlistment is made. It must be signed by the medical officer and by the recruiting officer making the enlistment and, if made on board ship, approved by the commanding officer (Bureau of Navigation Manual, D-4004). (b) The service record shall give a full description of the physical condition of every person having physical disabilities whose enlist- ment has been authorized by the Department. Paragraph Inspection for Disease 1426 Determination of Visual Acuity 1427 Determination of Color Perception 1428 Standards for Applicants for Enlistment 1429 Standards for Gun Pointer, Spotter, or Range-Finder Operator 1430 Standards for Candidates for Commission and Promotion 1431 Standards for Candidates for the Naval Academy 1432 SECTION IV. THE EYES 1426. Inspection for Disease.—Each eye will be inspected for evi- dence of muscular or other defect and for disease, the lids being everted. 1427. Determination of Visual Acuity.—To determine the acuity of vision, place the person being examined at a distance of 20 feet from the test types, which should be placed on a level with and at a right angle to the candidate’s line of vision. Examine each eye separately, without glasses, covering the other eye, especial care being taken to see that vision in the covered eye is completely occluded. No pressure should be applied to the occluded eye. The applicant or candidate is directed to read the test types, and his acuity of vision is recorded for each eye separately. The examination for visual acuity is of the utmost importance and shall be conducted by the 118 1428-1429 SEC. IV.—THE EYES medical officer with the greatest care and patience. An appreciable percentage of men are the subjects of slight visual defects, and in the cases of many of those presenting themselves for reenlistment and enlistment these defects may not be sufficiently serious to dis- qualify them for the naval service. Slight errors on the part of the applicant, such as misreading a P or T for F, provided the majority of the letters or test characters are read with facility, need not be sufficient cause for rejection. Vision is to be expressed as a frac- tion, of which the numerator shall be the distance at which Snellen’s 20-foot test letters can be determined, and the denominator 20. When vision is better than normal, the denominator shall be 15 or 10 as the case may be. Thus 20/20 indicates normal vision, 15/20, less than normal and 20/15 or 20/10 better than normal. Special care should be taken to make certain that the candidate has not memorized the letters on any line. Reading the lines backward or identifying certain letters when the others are covered are methods of overcoming such attempts to deceive. 1428. Determination of Color Perception.—(a) Applicants for enlist- ment and reenlistment in all branches of the Navy and Marine Corps shall be required to pass the first five groups of Stilling’s test. In the case of enlisted men who fail to pass the test upon examination for reenlistment, a waiver shall be submitted to the Bureau stating all the facts. (b) Candidates for entrance to the United States Naval Academy and for all primary appointments to the commissioned branches of the Navy and Marine Corps shall be required to satisfactorily pass the complete Stilling’s test. (c) The Edridge-Green lamp shall be the qualifying test for mid- shipmen and for officers in the service, using a standard distance of 10 feet with a 2-centimeter aperture. The correct recognition of white, green, and red lights, clear and when fogged, shall be required (par. 1520 (f)). 1429. Standards for Applicants for Enlistment.—(a) A minimum vision of 15/20 in each eye, correctible to 20/20, when no organic disease of either eye exists, is required (Aviation, par. 1549). (b) The following conditions are causes for rejection: (1) Trachoma, or xerophthalmia. (2) Chronic conjunctivitis. (3) Pterygium encroaching upon the cornea. (4) Complete or extensive destruction of the eyelids, disfiguring cicatrices adhesions of the lids to each other or to the eyeball. (5) Inversion or eversion of the eyelids, or lagophthalmus. (6) Trichiasis, ptosis, blepharospasm, or chronic blepharitis. (7) Epiphora, chronic dacryocystitis, or lachrymal fistula. 119 1430 CH. 11.—PHYSICAL EXAMINATIONS (8) Chronic keratitis, ulcers of the cornea, staphyloma, or corneal opacities encroaching on the pupillary area and reducing the acuity of vision below the standard noted above. (9) Irregularities in the form of the iris, or anterior or posterior synechiae sufficient to reduce the visual acuity below the standard. (10) Opacities of the lens or its capsule sufficient to reduce the acuity of vision below the standard, or progressive cataract of any degree. (11) Extensive coloboma of the choroid or iris, absence of pigment (albino) glaucoma, iritis, or extensive or progressive choroiditis of any degree. (12) Retinitis, detachment of the retina, neuroretinitis, optic neuritis, or atrophy of the optic nerve. (13) Loss or disorganization of either eye, or pronounced exophthalmos. (14) Pronounced nystagmus or well-marked strabismus. (15) Diplopia, or night blindness. (16) Abnormal condition of the eye due to diseases of the brain. (17) Malignant tumors of lids or eyeballs. (18) Asthenopia accompanying any ocular defect. 1430. Standards for Gun Pointer, Spotter, or Range-Finder Opera- tor-(a) All candidates for the position of gun pointer, spotter, or range-finder operator shall, before being placed in training, be referred by the commanding officer, to the medical officer for examination. (b) Gun pointer and coincidence range-finder operator.— Candidates must have good vision in order to see the target clearly and no man shall be trained as gun pointer or coincidence range-finder operator who cannot read with the right eye (or left eye if used in aiming) at 20 feet the line on Snellen’s test card which is normally seen at 15 feet—20/15 vision—and a minimum of 20/20 shall be required with the eye not used in aiming. Before each record target practice, all qualified and acting gun pointers and range-finder opera- tors shall be examined for acuity of vision and the results entered on the gunnery record and abstract of physical qualifications for special duties. (c) Spotter and stereoscopic range-finder operator.—Candi- dates for spotter or stereoscopic range-finder operator shall have a visual acuity of not less than 20/20 and preferably 20/15 in each eye. Visual acuity in one eye should closely approximate that in the other. There should be good muscle balance and actual stereoscopic vision, or ability to acquire such vision. Use of the range finder should improve true stereoscopic vision rather than develop a pseudo-type which latter condition should be carefully guarded against. When- ever practicable, therefore, these candidates shall be accorded the examination and comply with the requirements outlined for vision of aviators in paragraphs 1549 to 1561 inclusive. Refraction of the eyes under a cycloplegic shall be done in those cases where myopia or astigmatism is suspected. The results of the examination shall be entered on the abstract of physical qualifications for special duties. 120 SEC. IV.—THE EYES 1431-1432 1431. Standards for Candidates for Commission and Promotion.—- (a) For commission in the line of the. Navy, the minimum visual standards shall be an acuity of not less than 18/20 in each eye capable of correction by lenses to 20/20. (b) (c) For commission in all staff corps of the navy, the minimum visual standards shall be an acuity of not less than 12/20 in each eye, capable of correction to 20/20. (d) For the Marine Corps, the standards are the same as for the line of the Navy. (e) For aviation cadets, the standards are the same as for the line of the Navy. (f) In other respects the standards are the same as for applicants for enlistment. (g) In the case of promotion of officers the nature of the duties of the candidate should be considered but, as a general rule, an officer of the line below the grade of lieutenant commander should have not less than 8/20 each eye, unaided by lenses and capable of correction by lenses to 20/20 together with binocular vision, unaided by lenses, of not less than 10/20. 1432. Standards for Candidates for the Naval Academy.—(a) Each candidate on entrance to the Naval Academy must have normal or 20/20 vision in each eye and must submit to refraction under a cycloplegic. Any degree of myopia or myopic astigmatism shall cause the rejection of the candidate. (b) For commission upon graduation the standards are the same as those stated in paragraph 1431. (c) AnjT midshipman whose vision in either eye during his period of service falls below 18/20, shall be subject to rejection except those specifically designated for staff corps. (d) Defective vision due to disease of the eye grounds shall be a cause for rejection at any time. (e) Both eyes must be free from any disfiguring or incapacitating abnormality and from acute or chronic disease. (f) The above requirements are considered necessary in order to graduate midshipmen with eyesight which does not require glasses when on sea duty. 121 1433-1434 CH. 11.—PHYSICAL EXAMINATIONS SECTION V. THE EARS Paragraph Examination for Disease 1433 Determination of Auditory Acuity 1434 Standards for Applicants for Enlistment ! 1435 Standards for Candidates for Commission and Promotion 1436 Standards for Candidates for the Naval Academy 1437 1433. Examination for Disease.—The external ears, auditory canals, the tympanic membranes, and the mastoid regions shall be exami- ined, using all available apparatus. 1434. Determination of Auditory Acuity.—To determine the acuity of hearing, place the applicant, with the ear to be tested opposite the assistant, 15 feet distant, and direct him to repeat promptly the words whispered by the assistant. If the applicant can not hear the words at 15 feet, the assistant should approach foot by foot, using the same tone of voice, until the words are repeated correctly. Examine each ear separately, closing the other ear by pressing the tragus firmly against the meatus; the examiner may face in the same direction as the applicant and close one of his own ears in the same way as a control. The assistant should speak in a whisper, just plainly audible to the examiner, and should use numerals, names of places, or other words or sentences until the condition of the applicant’s hearing is evident. The acuity of hearing should be expressed in a fraction, the numerator indicating the distance in feet at which the words are heard by the candidate, and the denominator 15, indicating the normal distance. Thus 15/15 indicates normal hearing, 10/15 partial hearing of a degree indicated by the fraction; that is, the applicant only hears at 10 feet distance the words which a normal ear hears at 15 feet. If any doubt arises as to the correct- ness of the answer given, the applicant may be blindfolded and a watch acoumeter or coin click used to determine the distance at which it can be heard, care being taken that the applicant does not know the distance from the ear at which it is being held. The watch used should be one whose ticking strength has been tested by determining the distance at which it can be heard by a normal ear. Hearing shall be expressed as a fraction, of which the numerator shall be the distance in inches at which the ticking of an ordinary watch is heard, and the denominator 40. The voice is a more reliable method of determining the acuteness of hearing than the watch test, as it allows for variations in hearing with the modifications produced by changes in pitch and tone, and the voice can be raised if there are noises in the vicinity of the examining room. In every case, whether the hearing is normal or defective, the medical examiner shall make 122 SEC. V.—THE EARS 1435-1437 a careful otoscopic examination of the auditory canal and tympanic membranes to detect cases of otitis media and perforated drums. 1435. Standards for Applicants for Enlistment.—(a) The acuity of hearing must be at least 15/15 by whispered voice, 40/40 by watch, or 20/20 by acoumeter, or coin click in each ear (par. 1562). (b) The following conditions are causes for rejection: (1) The total loss of an external ear, marked hypertrophy or atrophy, or disfiguring deformity of the organ. (2) Atresia of the external auditory canal, or tumors of this part. (3) Acute or chronic suppurative otitis media, or chronic catarrhal otitis media. (4) Mastoiditis, acute or chronic. (5) Existing perforation of the membrana tympani. (6) Deafness of one or both ears. 1436. Standards for Candidates for Commission and Promotion.— (a) For commission in the Navy, hearing in each ear must be 15/15 by whispered voice or 40/40 by watch. (b) In the case of promotion of officers the nature of the duties of the candidate should be considered, but, as a rule, less than 7/15 binaural hearing of the spoken voice (ordinary conversation) is a disqualifying defect. (c) In other respects the standards are the same as for applicants for enlistment. 1437. Standards for Candidates for the Naval Academy,—Same as for commission. Any chronic disease of the external, middle, or in- ternal ear will be sufficient cause for rejection. Existing perforation of the membrane tympani from any cause whatever is disqualifying. Both ears must be free from any disfiguring or incapacitating abnor- mality and from acute or chronic disease. SECTION VI. GENERAL EXAMINATION, INCLUDING HEIGHT, WEIGHT, AND CHEST MEASUREMENT Paragraph Facts Determined by Inspection 1439 Weight 1440 Directions for Taking Chest Measurements 1441 Standards for Height, Weight, and Chest Measurement.. 1442 Exercises.. 1443 Results of Exercises 1444 Standards for Applicants for Enlistment 1445 Standards for Applicants for Commission 1446 Standards for Candidates for the Naval Academy 1447 Standards for Women 1448 123 1439-1442 CH. 11.—PHYSICAL EXAMINATIONS 1439. Facts Determined by Inspection.—Examination will be con- ducted with the applicant entirely nude. A thorough general inspec- tion of the entire body will be made, noting the proportion and symmetry of the various parts of the body, the chest development, the condition and tone of the muscles, the general nutrition, the character of the skin, the presence of any deformities or of signs of immaturity. This examination frequently determines the fact of the applicant’s unfitness for .the service; it may show him to be under- sized, underweight, undeveloped, pale and emaciated, poorly nour- ished, with thin flabby muscles, or manifestly lacking in stamina and resistance to disease. 1440. Weight.—The applicant will be weighed on a standard set of scales which are known to be correct. The weight will be recorded in pounds (fractions of pounds will not be recorded). 1441. Directions for Taking Chest Measurements.—The applicant will be made to stand erect with his heels together and arms hanging loosely at the sides. The measuring tape will be carefully adjusted around the chest, with the upper edge of the tape just below the lower angles of the shoulder blades behind and the nipples in front. The tape should be approximately horizontal. The applicant will then be directed to take several deep breaths, followed by complete exhalation, in order to verify the maximum and minimum measure- ments. Care must be taken not to displace the tape and to avoid muscular contortions, which frequently cause a greater inspiratory measurement than the actual lung capacity warrants. Great patience and care are often necessary to obtain correct results in these meas- urements, as many men do not know how to expand the chest cor- rectly and must be taught the proper method. The chest measure- ment at inspiration and expiration will be recorded in inches and fractions of an inch to quarters. The mobility is the difference between the measurements recorded at inspiration and expiration. 1442. Standards for Height, Weight, and Chest Measurement.—The following tables of physical proportions for height, weight, and chest measurement are intended for the guidance of the examiner. Marked disproportion in the physical proportions is a cause for rejection. In the case of an especially desirable applicant of otherwise good physique, any defects within reasonable limits will be brought to the attention of the Bureau with recommendation for waiver, satis- factory reason being offered as to why waiver is recommended (par. 1407). 124 SEC. VI. GENERAL EXAMINATION 1442 (a) Standards for officers, midshipmen, and enlisted men: Age Height Weight Chest at expira- tion Expan- sion re- quired [62 and under 65 109 29 2 65 and under 68 112 30 2 68 and under 70. 117 3034 2 70 and Under 72 122 31 234 72and under 74 128 32 234 74-76 132 33 2V$ 63 and under 65 no 30 2 65 and tinder 68 114 31 2 17 68 and under 70 . 119 31 2 70 and under 72.. 125 32' 234 72 and under 74 - 130 3234 234 74-76- 137 33V$ 2H 64 115 31J4 2 65 and under 68 — 119 32' 2 68 and under 70 - - - 124 3234 234 70 and under 72 130 3234 234 72 and under 74. - 135 33 34 234 74-76... .... 142 34 34 234 64 120 32 2 65 and under 68—. 124 32)4 2 68 and under 70 129 33 234 70 and under 72 — 135 3334 234 72 and under 74.. 140 3334 234 .. . 145 3434 234 64 . .. 125 32 2 65 and under 68 129 3234 2 68 and under 70... 134 33 234 70 and under 72 140 3334 234 72 and under 74.. 148 3434 234 74-76 153 3534 234 64 - . . 128 32 2 65 and under 68.. 136 33 2 68 and under 70.. 148 3334 234 70 and under 72 152 34 234 72 and under 74 157 35 234 74-76 162 3534 234 64 133 3234 2 65 and under 68 141 33' 2 68 and under 70 153 3334 234 25 70 and under 72 L57 34 234 72 and under 74 162 35 3 74-76 168 3534 3 [64 133 33 2 65 137 33 2 66.. 141 3334 234 67 145 3314 2U 68 - 149 34' 2 26 69 153 343i 234 to 70- 157 3434 3 29 71 162 34% 3 72.. 167 35 3 73 175 3534 3 74 182 3534 3 75 190 36 3 ,76 200 36 3 [64 136 33 2 65 140 33 2 66 ... 144 3334 234 67 148 3334 234 68 152 34 234 30 69 156 3434 234 to 70 161 3434 3' ■ 34 71 166 3434 3 72 172 35 3 73 178 35 3 74 188 3534 3 75 195 3534 3 \76 200 36 3 1443 CH. 11. PHYSICAL EXAMINATIONS (b) Standards for enlistment of Filipinos: Height (Inches) Weight Chest measure- ment at expira- tion Height (inches) Weight Chest measure- ment at expira- tion 69 . Pounds 100 101 102 103 105 107 Inches 28H 28 X 29 29}* 29M 29}* 65 Pounds 110 113 118 124 127 130 Inches 30 30}* 30 H 305* 31 315* 60 . 66 61 67 . . . 62 . 68 . 63 69 64... 70... (c) Standards for women: Height (inches) Ages and weights 22-24 25-29 30-34 35-39 40-44 45-49 50 and over 60 114 117 119 122 125 128 130 61... 116 118 121 124 128 131 133 62 118 120 123 127 132 134 137 63 122 124 127 131 135 138 141 64 125 127 130 134 138 142 145 65 128 131 135 139 143 147 149 66 132 135 139 143 146 151 153 67 135 139 143 147 150 154 157 68 140 143 147 151 155 158 161 69. 144 147 151 155 159 163 166 70 147 151 155 159 163 167 170 Weight to be taken without shoes and 5 pounds will be deducted for clothing. 1443. Exercises.—The applicant will be put through a series of movements similar to those described below, which will bring into action the various joints and muscles of the body. This purpose is best accomplished by requiring the applicant to follow the move- ments as made by the examiner or an assistant. (a) The elbows should be brought firmly to the sides of the body and the forearms extended to the front, palms of the hands upper- most; extend and flex each finger separately; bring the tips of the thumbs to the base of the little finger; close the hands, with the thumbs covering the fingers; extend and flex the hands on the wrists; rotate the hands so that the finger nails will first be up and then down; move the hands from side to side. Extend the arms and fore- arms fully to the front and rotate them at the shoulders; flex the fore- arms on the arms sharply, striking the shoulders with the fists. Extend the arms at right angles with the body; place the thumbs on the points of the shoulders; raise and lower the arms, bringing them sharply to the sides at each motion. Let the arms hang loosely by the sides; swing the right arm in a circle rapidly from the shoul- 126 SEC. VI. GENERAL EXAMINATION 1444-1445 der, first to the front and then to the rear; swing the left arm in the same manner. Extend the arms fully to the front, keeping the palms of the hands together and the thumbs up; carry the arms quickly back as far as possible, keeping the thumbs up, and at the same time raise the body on the toes. Extend the arms above the head, locking the thumbs, and bend over to touch the ground with the hands, keeping the knees straight. (b) Extend one leg, lifting the heel from the floor, and move all the toes freely; move the foot up and down and from side to side, bending the ankle joint, the knee being kept rigid; bend the knee freely; kick forcibly backward and forward; throw the leg out to the side as far as possible, keeping the body squarely to the front; repeat all these movements with the other foot and leg; strike the breast first with one knee and then with the other, stand upon the toes of both feet; squat sharply several times; kneel upon both knees at the same time (if the man comes down on one knee after the other there is reason to suspect infirmity). (c) Take the position to fire kneeling; stand erect, present the back to the examiner, and then hold up to view the sole of each foot; leap directly up, striking the buttocks with both heels at the same time; hop the length of the room on the ball of first one foot and then the other; make a standing jump as far as possible and repeat it several times; run the length of the room several times. 1444. Results of Exercises.—While the exercises prescribed may cause some breathlessness and accelerated throbbing of the blood vessels, they should not cause manifest exhaustion or great distress in a healthy man. Lack of ability to perform any of these exercises indicates some defect or deformity that should be investigated further. 1445. Standards for Applicants for Enlistment.—(a) For the accept- ance of an enlisted man 21 years old or over (Filipinos excepted) a minimum height of 64 inches without shoes, a minimum weight of 128 pounds, and a minimum of 2% inches chest expansion, is required. The maximum height is 76 inches. In the case of minors, the figures in the table should be adhered to, bearing in mind that a growth of 1 inch per year may be expected. (b) The standards as to the relationship between height, weight and chest measurement given in the tables relate to young men between 16 and 30 years of age, and in general an applicant will not be accepted whose weight and chest measurement are not proportion- ate to his height, as prescribed in the tables. 127 1445 CH. 11.—PHYSICAL EXAMINATIONS (c) Variations in weight above the standard are disqualifying if sufficient to constitute such obesity as to interfere actually or poten- tially with normal physical activity, as may be evidenced by high blood pressure, a beginning nephritis, breaking down of the arches of the feet, or other defects incident to such condition. A variation of 10 pounds under the standard given in the table is admissible when the applicant for enlistment is active, has firm muscles, and is evi- dently vigorous and healthy, except for enlistment in the rate of fireman, third class, for which rate full standard measurements will be required. Greater variations may be allowed upon recommenda- tion for waiver. A chest expansion of less than 2 inches in a minor or less than 2% inches in an adult is a sufficient cause for rejection. (d) The following conditions are causes for rejection: (1) Any deformity which is repulsive or which prevents the proper func- tioning of any part to a degree interfering with military efficiency. (2) Obesity. (3) A height of more than 76 inches (75 inches under 18 years of age) or less than 64 inches. (4) Deficient muscular development. (5) Deficient nutrition. (6) Evidences of physical characteristics of congenital asthenia. The physical characteristics of congenital asthenia are slender bones, a weak, ill-developed thorax, nephroptosis, gastroptosis, constipation, the “drop" heart, with its peculiar attenuation and weak and easily fatigued musculature. (7) All acute communicable diseases. (8) All diseases and conditions which are not easily remediable or that tend physically to incapacitate the individual, such as— (o) Chronic malaria or malarial cachexia. (6) Uncinariasis. (c) Tuberculosis, of whatever degree and whether general or localized. (d) Leprosy or actinomycosis. (e) Pellagra or beriberi. (/) Recurrent attacks of rheumatic fever, chronic articular rheu- matism, or chronic arthritis. (g) Cellulitis or osteomyelitis. (h) Malignant disease of all kinds in any location. (t) Hemophilia or purpura. O') Leukemia of all types. (A) Pernicious anemia. (0 Splenic anemia. (m) Filariasis or trypanosomiasis. (n) Diabetes ipellitus or insipidus. (o) Acromegaly, gigantism, myxedema, cretinism, Addison’s dis- ease, and other endocrine diseases. (p) Chronic metallic poisoning. 128 SEC. VI. GENERAL EXAMINATION 1446-1447 1446. Standards for Candidates for Commission.—(a) The same as for applicants for enlistment except that for an officer, the minimum height is 66 inches and the maximum 76 inches. The minimum weight is 132 pounds, and the minimum chest expansion is 2% inches. Varia- tions in weight exceeding 15 percent above the standards given in the table are disqualifying if sufficient to constitute such obesity as to interfere actually or potentially with normal physical activity. The medical officer may make further allowance for increased weight if the excess is due to large bony framework and large musculature. Variations not to exceed 15 pounds (not to fall below 132 pounds) in weight or 1 inch in the chest measurement at expiration below the standards given in the table may be allowed, provided the candi- date for appointment is active, has firm muscles, and is evidently vigorous and healthy. A chest expansion of less than 2% inches is a sufficient cause for rejection of the applicant. (b) Applicants for enrollment in the Naval Reserve Officers Train- ing Corps, or commission in the United States Naval Reserve should be allowed a greater variation for maximum weight especially in regard to large boned and muscular individuals who actively partici- pate in athletics. The medical officer will use his judgment in these cases. (c) Other disqualifying defects in this connection are the same as stated in paragraph 1445 (d). 1447. Standards for Candidates for the Naval Academy.—(a) The figures in the preceding tables of physical proportions are minimum for growing youths and are for the guidance of medical officers in con- nection with the other data obtained at the examination, a considera- tion of all of which will determine the candidate’s physical eligibility. The physical requirements will be those of the age at the birthday nearest the date of examination. Fractions greater than one-half inch in height will be considered as an additional inch. (b) Attention will be paid to the stature of the candidate, and no one manifestly undersize for his age will be received at the academy. The height of candidates for admission shall not be less than 5 feet 5% inches (65% inches), regardless of age, and no increase in height will be required for commission upon graduation. The maximum height is 76 inches. Any marked deviation in the height and weight relative to the age of a candidate will add materially to considerations for rejection. (c) Other disqualifying defects in this connection will be the same as stated in paragraph 1445 (d). 129 1448-1450 CH. 11.—PHYSICAL EXAMINATIONS (d) Enlisted men candidates for the Naval Academy preparatory class shall be examined as required by the Bureau of Navigation Manual D-6103 (c). 1448. Standards for Women.—The weight is taken with clothing. The above weights are those after the estimated weight of clothing (5 pounds) has been deducted. The minimum height for acceptance is 60 inches. A variation not exceeding 1 inch is permissible if the applicant is in good health and desirable. The minimum weight for acceptance is 100 pounds. A variation of 15 pounds, not to fall below 100 pounds in weight, below the standard given in the table is admissible when the applicant is active and evidently vigorous and healthy. A chest expansion of less than 2% inches is a sufficient cause for rejection. The table is given to show what is regarded as a fair standard of physical proportions and not as an absolute guide to be followed in deciding upon the acceptance of applicants. Marked disproportion of weight over height is cause for rejection. SECTION VII. THE SKIN Paragraph Examination for Disease 1449 Standards for Applicants for Enlistment or Commission 1450 1449. Examination for Disease.—The skin will be inspected for eruptions and for signs of anemia, jaundice, and other symptoms of disease, for hypodermic and other scars, and for pediculi. In a con- sideration of disease of the skin as a cause for rejection, particularly scabies and pediculosis, special attention should be given to the pro- visions of paragraph 1414 with a view to their cure and subsequent enlistment. As a general rule applicants extensively infested with vermin and filthy in person and clothing should be rejected as prob- ably being unsuited for the military service by reason of habits, character, or mental deficiency. 1450. Standards for Applicants for Enlistment or Commission.— The following conditions are causes for rejection: (a) Eczema of long standing or which is rebellious to treatment. (b) Chronic impetigo, pemphigus, lupus, or sycosis. (c) Actinomycosis, dermatitis herpetiformis, or mycosis fungoides. (d) Extensive psoriasis, or ichthyosis. (e) Acne upon face or neck which is so pronounced as to amount to positive deformity. (/) Elephantiasis. (gr) Pediculosis or scabies. (h) Carbuncle. 130 SEC. IX.—THE FACE 1451-1453 (i) Ulcerations of the skin not amenable to treatment, or those of long standing, or of considerable extent, or of syphilitic or malignant origin. (j) Extensive, deep, or adherent scars that interfere with muscular movements or with the wearing of equipment, or that show a tendency to break down and ulcerate. (k) Naevi and other erectile tumors if extensive, disfiguring, or exposed to constant pressure. (l) Obscene, offensive, or indecent tattooing. Paragraph Examination for Defects 1451 Standards for Applicants for Enlistment or Commission 1452 SECTION VIII. THE HEAD 1451. Examination for Defects.—The head will be carefully in- spected for stigmata of degeneration. Every portion of the cranium will be palpated for evidence of former injury, depressions from any cause, and for other deformity. 1452. Standards for Applicants for Enlistment or Commission.— The following conditions are causes for rejection: (o) Tinea in any form. (b) All tumors which are of sufficient size to interfere with the wearing of military headgear. (c) Imperfect ossification of the cranial bones or persistence of the anterior fontanelles. (d) Extensive cicatrices, especially such adherent scars as show a tendency to break down and ulcerate. (e) Depressed fractures or depressions, or loss of bony substance of the skull, unless the examiner is certain the defect is slight and will cause no future trouble. (/) Monstrosity cf the head, or hydrocephalus. (g) Hernia of the brain. (h) Deformities of the skull of any degree associated with evidence of disease of the brain, spinal cord, or peripheral nerves. SECTION IX. THE FACE Paragraph Standards for Applicants for Enlistment or Commission 1453 1453. Standards for Applicants for Enlistment or Commission.— The following conditions are causes for rejection: (а) Extreme ugliness. (б) Unsightly deformities, such as large birthmarks, large hairy moles, extensive cicatrices, mutilations due to injuries or surgical operations, tumors, ulcerations, fistulse, atrophy of a part of the face, or lack of symmetrical development. (c) Persistent neuralgia, tic doloreux, oi paralyses of central nervous origin. (d) Ununited fractures of the maxillary bones, deformities of either maxillary bone interfering with mastication or speech, extensive exostosis, caries, necrosis, or osseous cysts. (e) Chronic arthritis of the temporo-maxillary articulation, badly reduced or recurrent dislocations of this joint, or ankylosis, complete or partial. 131 1454-1455 CH. 11.—PHYSICAL EXAMINATIONS SECTION X. THE MOUTH, NOSE, FAUCES, PHARYNX, LARYNX, TRACHEA, AND (ESOPHAGUS Paragraph Methods of Examination 1454 Standards for Applicants for Enlistment or Commission 1455 1454. Methods of Examination.—A complete examination by re- flected light will be made of the anterior and posterior nares, the naso- pharynx, and the pharynx, and when necessary the larynx. When considered necessary, transillumination and studies by the x-ray will be employed. 1455. Standards for Applicants for Enlistment or Commission.—The following conditions are causes for rejection: (a) Harelip, loss of the whole or a large part of either lip, unsightly mutilations of the lips from wounds, burns, or disease. (b) Malformation, partial loss, atrophy, or hypertrophy of the tongue, split or bifid tongue, or adhesions of the tongue to the sides of the mouth, provided these conditions interfere with mastication, speech, or swallowing, or appear to be progressive. (c) Malignant tumors of the tongue, or benign tumors that interfere with its functions. (d) Marked stomatitis, or ulcerations, or severe leukoplakia. (e) Ranula if at all extensive, or salivary fistula. (/) Perforation or extensive loss of substance or ulceration of the hard or soft palate, extensive adhesions of the soft palate to the pharynx, or paralysis of the soft palate. (fir) Loss of the nose, malformation, or deformities thereof that interfere with speech or breathing, or extensive ulcerations. (h) Perforated nasal septum. (i) Nasal obstruction due to septal deviation, hypertrophic rhinitis, or other causes, if sufficient to produce mouth breathing. (j) Acute or chronic inflammation of the accessory sinuses of the nose, or hay fever. (k) Chronic atrophic rhinitis, if marked and accompanied by ozena. (0 Malformations or deformities of the pharynx of sufficient degree to interfere with function. (m) Postnasal adenoids interfering with respiration or associated with middle- ear disease. (n) Marked enlargement of the tonsils or diseased tonsils. (o) Laryngitis from any cause. (p) Paralysis of the vocal cords, or aphonia. 132 SEC. XI.—THE TEETH 1458-1460 SECTION XI. THE TEETH Paragraph Standards to Qualify for Enlistment 1458 Standards to Qualify for a Commission 1459 Standards to Qualify for Appointment as Midshipmen 1460 Explanation of Standards 1461 Causes for Rejection 1462 1458. Standards to Qualify for Enlistment.—The teeth and mouth shall be examined by a dental surgeon, if one be available. (a) To be accepted for enlistment an applicant must have a mini- mum of 20 vital serviceable permanent teeth including 4 opposed molars, 2 of which are directly opposed on each side of the dental arch, and 4 directly opposed incisors. (b) In order to be accepted for enlistment as a bugler, trumpeter, or musician playing a wind instrument, an applicant, as well as meet- ing the standards in (a) above, must have, in serviceable condition, the six upper and the six lower anterior teeth, namely, right and left central incisors, right and left lateral incisors, and right and left cuspids, none of which may be markedly out of alignment or rotated sufficiently to present other than a labial surface to the lip. (c) The explanation of standards, in paragraph 1461 shall apply in interpreting the above requirements. 1459. Standards to Qualify for a Commission.—The teeth and mouth shall be examined by an officer of the Navy Dental Corps who shall state in the record of findings whether or not the candidate is dentally qualified for appointment. A candidate, in order to qualify for a commission, must meet the standards required for enlistment as set forth in paragraph 1458, and in addition shall present a higher standard as to the formation and condition of the teeth, occlusion, the condition of the soft tissues, and such restorations and replacements as may be present. 1460. Standards to Qualify for Appointment as Midshipmen.—The teeth and mouth shall be examined by an officer of the Navy Dental Corps who shall state in the record of findings whether or not the candidate is dentally qualified for appointment. (a) A candidate, in order to qualify for appointment as a midship- man at the Naval Academy, must meet the dental requirements for commission except that the teeth and soft tissues shall conform to a higher standard. There must be fewer restorations and those present must be of a higher quality. The deviation from normal occlusion, if any, must be minor, and good functional occlusion must be demon- strable as well as absence of interference with speech. 133 1461-1462 OH. 11. PHYSICAL EXAMINATIONS (b) At the time of acceptance of the candidate he must have re- ceived all required dental treatment including permanent restorations of carious teeth and the removal of deposits. 1461. Explanation of Standards.—(a) A vital tooth is a tooth con- taining a vital dental pulp. (b) A serviceable tooth is one which is fully effective functionally, is free from advanced disease, is adequately supported by normal tissues, and does not have a faulty restoration, or faulty crown 01 bridge attachment. (c) A permanent tooth is a natural tooth of the normal second dentition. Deciduous and supernumerary teeth shall not be included. (d) An opposed tooth is one that comes into functional contact with one or more teeth of the opposite arch. (e) A vital tooth which is carious to a limited extent and which is otherwise serviceable and which can be restored satisfactorily without endangering the dental pulp may be counted as a serviceable tooth. Appointees as midshipmen must have had all carious teeth restored or extracted. (f) A biscuspid may not be counted as a molar nor may a cuspid be counted as an incisor. (g) An abutment tooth (a natural tooth to which a bridge is at- tached) may be counted as serviceable only when the pulp is vital, the tooth is sound, supported by healthy tissue, is in useful occlusion, and the bridge attachment is well designed and in good condition. 1462. Causes for Rejection.—The following conditions are causes for rejection: (a) The loss of teeth in excess of the standards noted in paragraph 1458. (b) Marked protrusion or retrusion of the mandible. (c) Marked deformity of the maxillae or mandible. (d) Marked malocclusion. (e) Dento-facial deformity. (/) Lack of serviceable occlusion. (g) Overbite with impingement of lower teeth upon upper gingiva. (h) Numerous or wide spaces that are edentulous (without natural teeth). (i) Extensive or numerous unsatisfactory restorations by fillings, inlays, crowns, bridges, or dentures. (j) Teeth generally unserviceable because of insufficient size or poor formation. (k) Teeth generally involved with caries. (Z) Teeth generally unsound or unsightly because of faulty calcification. (m) Pulpless teeth with defective or no pulp canal fillings. (n) Apical or extensive pericemental areas of infection. (o) Teeth carious beyond restoration. (p) Large deposits of salivary calculus. (9) Advanced or extensive pyorrhea alveolaris. 134 SEC. XIII. THE SPINE 1463-1468 (r) Infectious disease of the soft tissues, including Vincent’s stomatitis, (a) Syphilitic lesions. (0 Malignant tumors. (u) Benign tumors or cysts likely to enlarge. Paragraph Significance of Cervical Adenitis 1463 Standards for Applicants for Enlistment or Commission 1464 SECTION XII. THE NECK 1463. Significance of Cervical Adenitis.—Cervical adenitis must be given careful consideration with a view to determining its cause. If the condition is of benign origin, such as dental caries or pediculo- sis, it is not a cause for rejection per se. Adenitis in the submaxil- lary, parotid, and auricular region is usually of benign origin; in the clavicular and lower carotid regions it is frequently tubercular. The presence of adenitis should always be borne in mind as a possible symptom of syphilis. 1464. Standards for Applicants for Enlistment or Commission.—The following conditions are causes for rejection: (а) Cervical adenitis of other than benign origin, including cancer, Hodg- kin’s disease, leukemia, tuberculosis, syphilis, etc. (б) Adherent or disfiguring scars from disease, injuries, or burns. (c) Extensive or progressive goiter interfering with breathing or with the wearing of clothing. (d) Exophthalmic goiter or myxedema. (e) Thyroid enlargement from any cause associated with toxic symptoms. if) Benign tumors or cysts which are so large as to interfere with the wearing of a uniform or military equipment. (g) Torticollis. (ft) Tracheal openings, thyroglossal, or cervical fistulae. SECTION XIII. THE SPINE Paragraph Examination for Disease 1467 Standards for Applicants for Enlistment or Commission 1468 1467. Examination for Disease.—The mobility will be observed while the applicant is performing the exercises directed in paragraph 1443. When necessary, x-ray examinations will be made. 1468. Standards for Applicants for Enlistment or Commission.—The following conditions are causes for rejection: (а) Lateral deviation of the spine from the normal midline of more than 2 inches (scoliosis). (б) Curvature of the spine of any degree in which function is interfered with or in which there is noticeable deformity when the applicant is dressed (scoliosis, kyphosis, or lordosis). 135 1471-1472 CH. 11.—PHYSICAL EXAMINATIONS (c) Fractures or dislocations of the vertebrae. (d) Vertebral caries (Pott’s disease). (e) Abscess of the spinal column or its vicinity. (/) Osteoarthritis of the spinal column, partial or complete. (g) Fracture of the coccyx, spina bifida. Paragraph Study of Conformation 1471 Standards for Applicants for Enlistment or Commission 1472 SECTION XIV. THE CHEST 1471. Study of Conformation.—It is essential that the chest be well developed and justly proportioned to the other body measurements. Any marked deviation in form, either a flattening of the chest or more especially a persistence of the round or infantile type, is an element of weakness. Abnormal development, such as pigeon breast, funnel chest, or rachitic chest, is also to be regarded with suspicion, as such conditions usually coincide with a somewhat enfeebled con- stitution and a predisposition to disease of the lungs. Hence, any anomaly in the shape of the chest must be given careful considera- tion, especially in connection with the results found in the examina- tion of the contained organs and of other parts of the body. 1472. Standards for Applicants for Enlistment or Commission.—The following conditions are causes for rejection: (o) Deficient expansion of the chest. (b) Congenital malformations or acquired deformities which result in re- ducing the chest capacity and diminishing the respiratory functions to such a degree as to interfere with vigorous physical exertion or that produce dis- figurement when the applicant is dressed. (c) Pronounced contractions of the chest with adhesions following pleurisy or empyema. (d) Deformities of the scapulae sufficient to interfere with the carrying of equipment. (e) Absence or faulty development of the clavicle. (/) Old fracture of the clavicle where there is much deformity or interference with the carrying of equipment, ununited fractures, or partial or complete dislo- cation of either end of the clavicle. (g) Suppurative periostitis or caries or necrosis of the ribs, the sternum, the clavicles, or the scapulae. (h) Old fractures of the ribs with faulty union, if interfering with function. (*) Tumors of the breast or chest wall which interfere with the wearing of a uniform or of equipment. (j) Unhealed sinuses of the chest wall following operation. (k) Scars of old operations for empyema unless the examiner is assured that the respiratory function is entirely normal. 136 SEC. XV. THE LUNGS 1475-1477 SECTION XV. THE LUNGS Paragraph General Considerations 1475 Interpretation of Physical Signs 1476 Standards for Applicants for Enlistment or Commission 1477 1475. General Considerations.—The lungs will be examined by in- spection, palpation, percussion, and auscultation of the chest. When desirable, radiographic studies and laboratory methods, including examination of sputum, will be used. In the inspection and interro- gation of applicants the following points should lead to a suspicion of pulmonary tuberculosis: Apparent undue prominence of the clav- icle on one side, caused by a deepening of the hollow above and a flattening of the space beneath; a wasting of the muscles of the shoul- der girdle on one side, as evidenced by apparent excessive prominence of the shoulder and scapula; a history of recent loss of weight, especi- ally if associated with long and severe cough and night sweats. In suspected cases observation, with complete record of temperature, pulse, and respiration, may be of assistance. As pleurisy, with or without effusion, is a very frequent incidence of early tuberculosis, examiners will examine with the greatest care applicants who have apparently recovered from pleurisy. 1476. Interpretation of Physical Signs.—Each applicant should be required to exhale his breath, cough, and immediately breathe in. The chest should be auscultated during this process. All men who show moist rales during cough or during respiration should be classed as doubtful cases. All cases should also be classed as doubtful in which there is well-marked dullness on percussion, well-marked in- creased transmission of voice, harsh respiration, and well-marked prolonged expiration, even though there be no r&les present. Men under weight or with sunken or deformed chests should be considered with special care, and if the conditions be marked should be classed as doubtful, even though definite signs of tuberulosis are not detected. Doubtful cases, even in the absence of a positive diagnosis, should normally be rejected. 1477. Standards for Applicants for Enlistment or Commission.—The following conditions are causes for rejection: (a) Active or inactive pulmonary tuberculosis. (£>) Acute or chronic pleurisy, or empyema. (c) Pneumothorax or hydrothorax. (d) Chronic bronchitis, chronic pneumonia, pulmonary emphysema, asthma, or bronchiectasis. (e) Actinomycosis, hydatid cysts, or abscess of the lung. (/) Tumor of lungs, pleura or mediastinum. 137 1481 CH. 11. PHYSICAL EXAMINATIONS SECTION XVI. THE HEART AND BLOOD VESSELS Paragraph Methods of Examination of Heart and Blood Vessels 1481 Examination After Exercise 1482 Consideration of Blood Pressure 1483 Interpretation of Abnormal Signs and Symptoms 1484 Hypertrophy and Dilatation 1485 Physiological Murmurs 1487 Systolic Murmurs 1488 Diastolic Murmurs 1489 Standards for Applicants for Enlistment 1490 Standards for Candidates for Commission 1491 Standards for Candidates for the Naval Academy 1492 1481. Methods of Examination of Heart and Blood Vessels.—(a) General.—The applicant should stand before the examiner with direct light falling upon his chest. He should stand at ease, with the arms relaxed and hanging by his sides. The examiner should not permit the applicant to move his body from side to side or twist it in an endeavor to assist in the examination, as these maneuvers may distort landmarks and increase muscular resistance of the chest wall. The heart should be examined by the following methods: Inspection, palpation, percussion, auscultation, and when considered necessary by mensuration. Blood-pressure readings and palpation of the pulse are required for candidates for commission and for applicants for enlistment. Electrocardiograms should be made in doubtful cases, if the apparatus is available. (b) Inspection.—Begin from above downward, with especial ref- erence to the following: Condition and color of skin and mucous membranes; eyes for arcus senilis; visible pulsations of the vessels of the neck; enlargement of the thyroid gland; the shape of the chest, for any malformation which might change the normal relations of the heart; pulsations in the suprasternal notch, and in the second inter- spaces to right and left of the sternum; character of the precordial impulse, and the location and character of the maximum impulse, epigastric pulsations or pulsations in the hepatic region, and any pulsations or retractions in the back. (c) Palpation.—Palpate first for the detection of thrills over the carotids (aortic stenosis), thyroid gland (exophthalmic goiter), supra- sternal notch (aneurysm), apex of heart (mitral stenosis), and at the base (aortic stenosis). Use palms of hands in palpating and use light pressure, as hard pressure may obliterate a thrill. To locate the maximum cardiac impulse, have the applicant stoop and throw shoul- ders slightly forward, thus bringing heart into the closest possible relation with the chest wall Palpate both radials at the same time for equality in rate and volume. Run the finger along the artery to 138 SEC. XVI. THE HEART AND BLOOD VESSELS 1481 note any changes in its walls. Place the palm of one hand over the heart and fingers of the other over the radial to see if all ventricular contractions are transmitted. Palpate to determine the degree of tension or compressibility of the pulse. In estimating pulse rates the excitement of undergoing a physical examination must be considered and a rate of 90 may be considered normal, provided the heart re- sponds normally to the exercise test. A rate of 50 or below should excite suspicion of heart block and be made the subject of further investigation. Rates of 100 or over should be investigated with a view to the exclusion of heart lesions and hyperthyroidism. (d) Percussion.—Light mediate percussion should be used. The right and left cardiac borders, as well as the diameter of the trans- verse arch may be determined by percussion. In doubtful cases where it is important to determine the actual cardiac boundaries, x-ray pictures should be taken and also cardiac mensuration made. (e) Mensuration.—Draw a line down the midstemum, from the suprasternal notch to the tip of the ensiform cartilage. Measure- ments are made at right angles to this line, at the second interspace (aortic dullness), at the fourth interspace to the right for any increase in the right border, and at the fifth interspace to the left for any increase in the left border. The following measurements may be considered normal for the aver- age young adult: From midsternal line to right border at fourth interspace, 3 cm. From midsternal line to left border along fifth interspace, 8% cm. The normal aortic dullness at the second interspace to the right and left of the midsternal line is 5j4 cm. (f) Auscultation.—In auscultating the heart, the examiner should bear in mind the four points where the normal sounds of the heart are heard with maximum intensity, viz: (1) Aortic area, second interspace to right of sternum. Here the second sound is distinct. (2) Tricuspid area, at the junction of the fifth rib with the sternum. Here the first sound is distinct. (3) Pulmonic area, second interspace to left of sternum. Here the second sound is most distinct. (4) Mitral area, fifth interspace to left of sternum. Here the first sound is most clearly heard. In doubtful cases the examiner should make inquiry into the use of alcohol or tobacco, overindulgence in athletics, habitual use of coal- tar derivatives, or narcotic drugs. He should also ascertain whether the applicant has had any of the following diseases: Scarlet fever, chorea, diphtheria, measles, rheumatic fever, tonsillitis, influenza, typhoid fever, syphilis, gonorrhea, tuberculosis, chronic focal infec- tions, etc. 139 1482-1484 CH. 11.—PHYSICAL EXAMINATIONS 1482. Examination After Exercise.—Examiners will use judgment and discretion in applying the exercise test to those who present evi- dence of incompetency of the heart. An exercise test is required in order to determine the efficiency of the heart muscle. Have the ap- plicant hop 20 times on one foot, not faster than one hop per second, clearing the floor about 1 inch at each hop. Record pulse rate and blood pressure before exercise. Immediately after exercise, record pulse rate, and 2 minutes later record pulse rate and blood pressure. Examples of normal response: Before exercise, 80. Immediately after, 120. Two minutes after, 84. Immediately after the exercise auscultation should be repeated with particular reference to the detection of murmurs previously inaudi- ble. Note should be made of the degree of dyspnea and other symptoms of circulatory failure. 1483. Consideration of Blood Pressure. In considering the blood pressure, due regard must be given to the age of the applicant and to physiological causes, such as excitement, recent exercises, and diges- tion. The condition of the arteries, the tenseness of the pulse, and the degree of accentuation of the aortic second sound must be taken into consideration, as will also the relation between the systolic and diastolic pressure. No applicant will be rejected as a result of a single reading. When the blood pressure estimation at the first examination is regarded as abnormal, or in case of doubt, the pro- cedure will be repeated twice daily (in the morning and in the after- noon) for a sufficient number of days to enable the examiner to arrive at a definite conclusion. 1484. Interpretation of Abnormal Signs and Symptoms.—The following principles are laid down for the guidance of examiners in their interpretation of abnormal signs and symptoms. In many instances the interpretation must be purely individual and based on the cumu- lative evidence of a number of relatively slight deviations from the normal. It should be strongly emphasized that, given a heart of normal size and responding normally to effort, any murmur is to be considered functional and insignificant unless it can be positively demonstrated that it is a mitral or aortic diastolic murmur, or unless a definite history of rheumatic fever or other acute infection or evidence of chronic focal infection is obtained. It should also be constantly borne in mind that the excitement of the examination may produce violent and rapid heart action, often associated with a transient systolic murmur, which conditions may erroneously be 140 SEC. XVI. THE HEART AND BLOOD VESSELS 1485-1488 attributed to the effects of exertion. These conditions usually disap- pear promptly in the recumbent posture, but the examiner must be careful to distinguish the excitable individuals and take measures to eliminate psychic influences from the test so far as possible. 1485. Hypertrophy and Dilatation.—An apex beat located at or be- yond the left nipple line, or below the sixth rib, and of a heaving character, indicates an enlargement sufficient to disqualify for mili- tary service. Its cause, either valvular disease or hypertension in the majority of cases, should be sought for. Enlargement should not be made a primary diagnosis unless careful examination fails to reveal a cause. 1487. Physiological Murmurs.—Cardiac murmurs are the most certain physical signs by which valvular disease may be recognized and its location determined. The discovery of any murmur always de- mands diligent search for other evidence of heart disease. However murmurs may occur in the absence of valvular lesions or other cardiac disease. Such murmurs are always systolic in time, seldom associated with thrill, and they do not replace or mask the normal heart sounds. The most frequent of these are: (a) Those heard over the second and third left interspaces during expiration, disappearing during forced inspiration. These are particularly common in men with flexible chests, who can produce extreme forced expiration and under such circumstances may be associated with definite thrill. (b) Cardio-respiratory murmurs occasioned by movements of the heart against air in a part of the lung overlapping the heart. These usually vary in different phases of respiration, and at times disappear completely on holding the breath. (c) Prolongation of apical first sound is often mistaken for a murmur. 1488. Systolic Murmurs.—(a) Systolic murmurs unassociated with history of rheumatic fever, or other acute infection, with enlarge- ment of the heart, with alteration of the first sound, or with abnormal response to exercise may also be considered as without significance. (b) Loud systolic murmurs, audible at the apex and in the left back, if associated with any enlargement of the heart, with a snap- ping first sound, or accentuation of the pulmonic second sound, indi- cate organic disease, disqualifying for the service; also harsh and blowing murmurs, and those persisting throughout systole, trans- mitted to the axilla or back, if associated with a history of rheumatic fever, or other acute infection, or with poor or dubious response to exercise are disqualifying (c) Systolic murmurs at the base, except as specified above, espe- cially those heard in the second right intercostal space, require more careful scrutiny. They may be due to disease of the aortic valves. In this case they should be harsh, conveyed well into the neck, asso- ciated with an aortic diastolic murmur, with thrill or with a marked 141 1489-1490 CH. 11.—PHYSICAL EXAMINATIONS enfeeblement of the aortic second sound. They are more often due to dilation of the aorta, either syphilitic or arteriosclerotic. The other signs of dilation should then be sought, viz, increased dullness in the first and second interspaces to either side of the manubrium, pulsation in this area, and accentuation of the aortic second sound. In doubtful cases, x-ray examination and Kahn test should be made: 1489. Diastolic Murmurs.—(a) All diastolic murmurs, at apex or base, including presystolic murmurs, should be considered suggestive of organic disease. The soft, low-pitched diastolic murmur of aortic insufficiency may be audible to the ear when not heard through the stethoscope. The secondary signs should be sought for, viz, enlarge- ment of one or both sides of the heart, alteration of the first or second sound, particularly a snapping first sound and accentuated pulmonic second sound in mitral disease, and the characteristic pulse of aortic insufficiency. In doubtful cases a definite history of rheumatic fever or other acute infection may be given weight. (b) It should be borne in mind that the characteristic presystolic murmur in certain cases of mitral stenosis may not be audible during rest. It is therefore important in every doubtful case that ausculta- tion be made immediately after the exercise test and in both the erect and the recumbent positions. On the other hand, many cases of tachycardia or overacting heart present physical signs very sug- gestive of mitral stenosis (sharp, tapping apex beat, sharp, loud, first sound, suggestion of apical thrill, etc.), and the diagnosis of mitral stenosis should not be made unless a distinct presystolic or diastolic murmur is heard. A presystolic thrill when present at or near the heart’s apex is practically pathogomonic of mitral stenosis. 1490. Standards for Applicants for Enlistment.—The following conditions are causes for rejection: (a) All valvular diseases of the heart. (&) Hypertrophy or dilation of the heart, as indicated in paragraph 1485. (c) Pericarditis, endocarditis, myocarditis, or angina pectoris. (d) A heart rate of 100 or over, or of 50 or under, when these are proved to be persistent in the recumbent posture and on observation and reexamination over a sufficient period of time. (e) Marked cardiac arrhythmia or irregularity. (f) Arteriosclerosis. (g) Hypertension evidenced by a persistent systolic blood pressure above 150. In person under 25 years of age a persistent systolic pressure of or above 140 or a persistent diastolic pressure of 95 or over before or after exercise, is a cause for rejection. (h) Aneurysm of any variety in any situation. (*) Intermittent claudication. (j) Raynaud’s disease. (k) Thrombophlebitis of one or more extremities, if there is a persistence of the thrombus or any evidence of obstruction to circulation in the involved vein or veins. 142 1491-1495 SEO. XVII. THE ABDOMEN 1491, Standards for Candidates for Commission.—(a) No candidate with a systolic murmur at the apex which is transmitted to axilla or angle of scapula will be accepted for commission. (b) In other respects the standards are the same as for applicants for enlistment. 1492, Standards for Candidates for the Naval Academy.—The same as for candidates for commission and enlistment. Paragraph Examination for Disease 1493 Observation for Uncinariasis and Malaria 1494 Standards for Applicants for Enlistment or Commission.. 1495 SECTION XVII. THE ABDOMEN 1493. Examination for Disease.—The abdomen will be examined by inspection and if necessary by palpation and percussion. When indicated, x-ray examinations and laboratory tests will be made. 1494. Observation for Uncinariasis and Malaria.—Applicants ac- cepted from regions in which uncinariasis or malaria is prevalent, and who present symptoms of anemia or enlargement of the spleen, should be placed under observation for these diseases (examination of feces and blood). This applies also to the dysenteries, especially the entamebic form. 1495. Standards for Applicants for Enlistment or Commission.—The following conditions are causes for rejection: (а) Wounds, injuries, cicatrices, or muscular ruptures of the abdominal walls sufficient to interfere with function. (б) Fistulae from visceral or bony lesions or following operation. (c) Hernia of any variety. (d) Large tumors of the abdominal walls. (e) Scar pain, if severe. (f) Chronic diseases of the stomach or intestines. (g) Gastro-enterostomy. (h) Blood in the feces unless shown to be due to unimportant causes. (t) Ptosis of the stomach or intestines. O’) Chronic appendicitis. (k) Chronic diseases of the liver, gall bladder, pancreas, or spleen. (l) Chronic peritonitis or peritoneal adhesions. (m) Chronic enlargement of the liver. (») Chronic enlargement of the spleen, if marked. (o) Jaundice. (p) Proctitis or stricture of the rectum. (q) Hemorrhoids. (See sec. XVIII.) (r) Fistula in ano. (See sec. XVIII.) (s) Incontinence of feces. (f) Uncinariasis. 143 1498-1503 CH. 11.—PHYSICAL EXAMINATIONS SECTION XVIII. THE PELVIS, INCLUDING THE SACRO-ILIAC AND LUMBOSACRAL JOINTS Paragraph Examination for Disease 1498 Standards for Applicants for Enlistment or Commission 1499 1498. Examination for Disease.—To inspect the anal region the applicant will be directed to bend forward from the hips and to draw apart the buttocks with both hands. Digital examination of the rectum and proctoscopy will be used if necessary. 1499. Standards for Applicants for Enlistment or Commission.— The following conditions are causes for rejection: (а) Malformation and deformities of the pelvis sufficient to interfere with function. (б) Disease of the sacro-iliac or lumbosacral joints. (c) Urinary fistula. (d) Stricture or prolapse of the rectum. (e) Fissure of the anus or pruritis ani. (/) Fistula in ano or ischiorectal abscess. (p) External hemorrhoids sufficient in size to produce marked symptoms. Internal hemorrhoids, if large or accompanied with hemorrhage, or protruding intermittently or constantly. SECTION XIX. GENITO-URINARY SYSTEM AND VENEREAL DISEASE Paragraph Methods of Examination 1602 Procedure When Albumin or Casts Are Found 1503 Procedure When Specific Gravity Is Abnormally Low 1504 Procedure When Glycosuria Is Detected 1505 Kahn (Wassermann) Test 1506 Standards for Appointment of Enlisted Men to Warrant Rank 1507 Standards for Applicants for Enlistment or Commission 1508 1502. Methods of examination.—Evidence of venereal disease or malformation will be searched for. The glans penis and corona will be exposed and the penis stripped. Both sides of the scrotum will be palpated, as will also the inguinal glands. The urine of all appli- cants for enlistment will be examined for albumin, sugar, and specific gravity. Urinalysis, including tests for albumin, specific gravity, and sugar, and a microscopic examination of the sediment, will be made in the case of all candidates for admission, commission, or promotion, the urine being voided in the presence of one of the examiners. 1503. Procedure When Albumin or Casts Are Found.—The term albuminuria will not ordinarily be used as a cause of rejection, nor does its presence alone justify a diagnosis of nephritis. When albumin or casts are found in the urine the applicant will be retained under observation and daily complete examinations of the urine will 144 SEC. XIX.—THE GENITOURINARY SYSTEM 1504-1508 be made for at least three days, unless the presence of albumin and casts is associated with enlargement of the left heart, high blood pres- sure, and other evidence of cardiovascular disturbance to such a degree that a diagnosis of chronic nephritis may be made immedi- ately. When albumin is constantly or intermittently present the underlying pathological condition must, if possible, be determined and stated as the cause for rejection; but if albuminuria be present daily during a period of three days, it should be regarded as reason for rejection, even if the origin can not be determined. 1504. Procedure When Specific Gravity Is Abnormally Low.— When the specific gravity of the specimen first examined is under 1.010, further observation of the applicant and repeated complete urinary examinations are indicated. 1505. Procedure When Glycosuria Is Detected.—If glucose be found in the urine at the first examination, further observation is indicated, including an estimation of the 24-liour amount of urine and the employment of more than one test to demonstrate the possible exist- ence of diabetes. When considered necessary, blood-sugar estima- tions should also be made. 1506. Kahn (Wassermann) Test.—(a) All applicants and recruits for the naval service shall be subjected to a serologic test for syphilis. (b) A persistently positive serologic reaction will be cause for re- jection. All applicants giving a positive serum reaction shall after several days be sufficiently checked, preferably by another laboratory, to assure persistence of reaction and to minimize chance of error. Care will be exercised at the time of obtaining serum to insure that applicant neither has, nor is convalescent from, any acute infectious disease or other recent fever from any cause. (c) Recruits will have the serologic test as soon as possible after arrival at a recruit training activity and those who show a persistently positive reaction will be reported to the commanding officer with the recommendation that they be discharged from the naval service. 1507. Standards for Appointment of Enlisted Men to Warrant Rank.—No applicant for warrant rank is considered physically quali- fied for appointment whose medical record shows that he has had at any time a clearly defined infection with syphilis. 1508. Standards for Applicants for Enlistment or Commission.— The following conditions are causes for rejection: (а) Acute or chronic nephritis, or diabetes mellitus or insipidus. (б) Blood, pus, or albumin in the urine, if persistent. (c) Floating kidney, hydronephrosis, pyonephrosis,, pyelitis, tumors of the kidney, renal calculi, or absence of one kidney. (d) Acute or chronic cystitis. (e) Vesical calculi, tumors of the bladder, incontinence of urine, enuresis, or retention of urine. 145 1510-1511 CH. 11. PHYSICAL EXAMINATIONS (/) Hypertrophy or abscess of the prostate gland, or chronic prostatitis. (g) Urethral stricture or urinary fistula. (h) Epispadias or hypospadias. (i) Phimosis when prepuce is adherent in whole or in part to the glans. (j) Hermaphroditism. (k) Amputation of the penis. (Z) Varicocele, if large and painful, or hydrocele. (m) Pronounced atrophy of both testicles or loss of both. (») Undescended testicle. Infantile genital organs. (o) Chronic orchitis or epididymitis. (p) Syphilis in any stage, or a clearly defined history thereof upon original enlist- ment or commission. (q) Gonococcus infections, acute or chronic (including gonorrheal arthritis), chancroids, or buboes. Paragraph Examination for Defects 1510 Standards for Applicants for Enlistment or Commission 1511 SECTION XX. THE EXTREMITIES 1510. Examination for defects.—The extremities will be carefully examined for deformities, old fractures, and dislocations, amputa- tions, partially flexed or ankylosed joints, impaired functions of any degree, varicose veins, and edema. The feet will be especially examined for flat foot, corns, ingrowing nails, bunions, deformed or missing toes, hyperidrosis, bromidrosis, and clubfoot. When any degree of flat foot is found, the strength of the feet should be ascer- tained by requiring the applicant to hop on the toes of each foot for a sufficient time and by requiring him to alight on the toes after jumping up several times. 1511. Standards for Applicants for Enlistment or Commission.—The following conditions are causes for rejection: (а) All anomalies in the number, the form, the proportion, and the move- ments of the extremities which produce noticeable deformity or interfere with function. (б) Atrophy of the muscles of any part, if progressive or if sufficient to interfere with function. (c) Benign tumors if sufficiently large to interfere with function. (d) Ununited fractures, fractures with shortening or callus formation suffi- cient to interfere with function, old dislocations unreduced or partially reduced, complete or partial ankylosis of a joint, or relaxed articular ligaments permit- ting of frequent voluntary or involuntary displacement. (e) Reduced dislocations or united fractures with incomplete restoration of function. (/) Amputation of any portion of a limb, except fingers or toes, or resection of a joint. (g) Excessive curvature of a long bone or extensive, deep, or adherent scars interfering with motion. (h) Severe sprains. (i) Disease of the bones or joints. SEC. XX.—THE EXTREMITIES 1511 (j) Chronic synovitis, or floating cartilage, or other internal derangement in a joint. (k) Varicose veins in an extremity when they cover a large area or are markedly tortuous or much dilated, or are associated with edema, varicocele, or hemorr- hoids, or are accompanied by subjective symptoms. (l) Varices of any kind situated in the leg below the knee, if associated with varicose ulcers or scars from old ulcerations. (m) Chronic edema of a limb. (n) Chronic or obstinate neuralgias, particularly sciatica. (o) Deviation of the normal axis of the forearm to such a degree as to interfere with the proper execution of the manual of arms. (p) Adherent or united fingers (web fingers). (q) Permanent flexion or extension of one or more fingers, as well as irreme- diable loss of motion of these parts, if sufficient to interfere with proper execu- tion of duties. (r) Total loss of either thumb. (s) Mutilation of either thumb to such an extent as to produce material loss of flexion or strength of the member. (t) Loss of more than one phalanx of the right index finger. (u) Loss of the terminal and middle phalanges of any two fingers on the same hand. (v) Entire loss of any finger except the little finger of either hand or the ring finger of left hand. (w) Perceptible lameness or limping. (x) Knock-knee, when the gait is clumsy or ungainly, or when subjective symptoms of weakness are present. (y) Bowlegs if so marked as to produce noticeable deformity when the appli- cant is dressed. (z) Clubfoot unless the defect is so slight as to produce no symptoms during vigorous exercise. (aa) Pes cavus if extreme and causing symptoms. (ab) Flat foot when accompanied with symptoms of weak foot or when the foot is weak on test. Pronounced cases of flat foot attended with decided ever- sion of the foot and marked bulging of the inner border, due to inward rotation of the astragalus, are disqualifying, regardless of the presence or absence of subjective symptoms. (ac) Loss of either great toe or loss of any two toes on the same foot. (ad) Webbing of all the toes. (ae) Overriding or superposition of any of the toes to such a degree as will produce pain when wearing the military shoe. (af) Ingrowing toenails when marked or painful. (ag) Hallux valgus when sufficiently marked to interfere with locomotion or when accompanied with a painful bunion. (ah) Bunions sufficiently pronounced to interfere with function. (ai) Hammer toes when existing to such a degree as to interfere with function when wearing shoes. (aj) Corns or callus on the sole of the foot when they are tender or painful. (ak) Hyperidrosis or bromidrosis when present to a marked degree. (al) Habitually sodden feet with blistered skin. (am) Unusually large or deformed feet for which proper shoes can not be readily obtained. 147 1514-1516 CH. 11.—PHYSICAL EXAMINATIONS Paragraph General Considerations 1514 Methods of Examination 1515 R6sum4 of the More Common Abnormal Conditions 1516 Standards for Applicants for Enlistment 1517 Standards for Candidates for Commission 1518 Standards for Candidates for the Naval Academy 1519 SECTION XXI. THE NERVOUS SYSTEM 1514. General Considerations.—The detection of mental and nerv- ous diseases is perhaps the most difficult part of the examination of applicants. At the time of examination there may be no obvious defects such as present themselves in other pathological conditions. Every effort must be made to reject the mentally deficient and those showing evidence of serious nervous affections. The importance and value of a thorough and effective examination of the applicant’s mental suitability for the service cannot be overestimated. Morons and those mentally deficient are always a continuous source of weak- ness and detriment. Such men should under no circumstances be accepted for enlistment. 1515. Methods of Examination.—The applicant will be required to stand erect with the inner borders of the feet together, arms hori- zontal, hands extended, fingers apart, and eyes closed, and will be examined for tremors and nervous instability (Romberg sign). The pupillary reactions to light and distance and the knee jerks should always be tested, and in doubtful cases the other reflexes. When desirable, laboratory tests will be made. 1516. RSsumS of the More Common Abnormal Conditions.—The brief summary regarding certain stigmata of degeneration, drug ad- dictions, and nervous and mental diseases which follows is intended as a general guide for examiners. In estimating the value of the vari- ous marks of degeneracy, the occurrence of a very few in any indi- vidual case would not justify classification of the case as a defective. The presence, however, of numerous stigmata indicates a probable instability in the nervous organization that is disqualifying for the military service. (a) Anatomical stigmata of degeneration.—Cranial abnormalities in out- line, capacity, or dimensions; excessive development of the occipital protuber- ance and ridges, the frontal eminences, and the mastoid processes; reduction of the facial angle; asymmetrical facial development; lower jaw disproportionately large and prognathic; hard palate sharply vaulted; dental arches narrowed or angular; teeth defective or misplaced; ears disproportionate in size or mal- formed; extreme refractive anomalies and strabismus; deviation of the nose; septal deformities; harelip; cleft palate; remnants of branchial clefts; spina bifida; sacral growths of hair; deep sternal furrows and concavities; dispropor- tion between thorax and abdomen; upper and lower limbs disproportioned to each other or to the trunk; abnormality in size of hands or feet; tendency to left- 148 SEO. XXI.—THE NERVOUS SYSTEM 1516 sided overdevelopment; deformities of the fingers; syndactyly; excessive length or shortness of the fingers; undersize of the ring and little fingers; genitalia unde- veloped; hypospadias; epispadias; scrotal fissure; albinism; melanism; multiple naevi; defective development of hair and nails. The degenerate physique as a whole is often marked by diminished stature and inferior vigor; males may present the general body conformation of the opposite sex, with sloping narrow shoulders, broad hips, excessive pectoral and pubic adipose deposits, with lack of masculine hirsute and muscular marking. (b) Functional stigmata of degeneration.—Defective mental qualities; moral delinquencies, such as willfulness, deceitfulness, indecency; stammering; urinary incontinence; regurgitation and rechewing of food; perverted tastes and cravings leading to alcoholism and drug habits; sexual perversion. (c) Chronic alcoholism.—Suffused eyes; prominent superficial blood vessels of the nose and cheek; flabby, bloated face; reddened aspect of the face; red or pale purplish discoloration of mucous membrane of the pharynx and soft palate; muscular tremor of the protruded tongue and extended fingers; tremulous hand- writing. (d) Drug habit.—Peculiar pallor and dryness of the skin; needle marks and scars on skin of arms and thighs; in opium users, contracted pupils; in users of cocaine, widely dilated pupils. (e) Dementia prajcox.—Indifference, apathy, withdrawal from environment; ideas on reference and persecution; feelings that the mind is being tampered with or that thought is being controlled by hypnotic, spiritualistic, or other mysterious agencies; hallucinations of hearing; bodily hallucinations, frequently of electrical or sexual character; meaningless smiles; in general, inappropriate emotional reaction and lack of connectedness in conversation. There may be sudden emotional or motor outbursts. The history of family life and school, vocational, and personal career will usually show erratic and more or less irra- tional conduct. (/) Manic-depressive insanity.—Mild depression, with or without feeling of inadequacy; mild manic states with exhilaration, talkativeness, and overactivity. (g) Paresis (general paralysis).—The diagnosis of paresis may be made when at the examination of the applicant a majority of the following signs and symptoms are demonstrated: Argyll-Robertson pupil or pupils; facial tremor; speech defect in test phrases and in the slurring or distortion of words in con- versation; writing defects, consisting of omissions and the distortion of words; apathetic, depressed, or euphoric mood. These applicants may show memory loss or discrepancies in relating facts of life; the knee jerks may be plus, minus, or normal. (h) Tabes dorsalis (locomotor ataxia).—The diagnosis of this disease should be made when at the examination of the applicant several of the following signs and symptoms are present: Argyll-Robertson pupil or pupils; absent knee jerk; Romberg sign; ataxia of hands or legs (especially when the eyes are closed); hypotonia, anesthetic areas of the skin. The history of locomotor ataxia is usu- ally that of slow progression, of failing sexual power, and of pains in the legs or back which are often described as rheumatic. (t) Cerebrospinal syphilis.—The prominent diagnostic signs and symptoms are headaches, varying deep and superficial reflexes, pupillary changes, ptosis, ocular palsies, facial paresis. The mental state is normal, dull, or apathetic. Comparative motor weakness may occur in one side of the body or in one extremity. 149 1516 CH. 11. PHYSICAL EXAMINATIONS (j) Multiple sclerosis.—The diagnosis of this disease rests upon the follow- ing signs and symptoms: Intention tremor, nystagmus, absent abdominal re- flexes, increased tendon reflexes, and scanning speech. In cases of this kind the history obtained is not characteristic, but sometimes there may be a history of urinary disturbances. (k) Paraplegia.—The diagnosis of paraplegia from whatever cause will rest upon weakness of the lower extremities, associated with lost or increased knee jerk, Babinski reflex, disturbances of the sphincters of the rectum and bladder, and sometimes a girdle sensation. Sensory disturbance of the skin may or may not be present. Muscle sensibility may be diminished. (l) Syringomyelia.—Syringomyelia is usually evidenced by more or less loss of power and atrophy of groups of muscles of one or more extremities with dis- turbance of the sensations of the skin, more especially in the form of analgesias and diminution of the temperature sense. If in the upper dorsal cord, it is often associated with stooped shoulder posture; if in the lower dorsal, with weakness in one or both lower extremities. (m) Muscular atrophies and dystrophies.—-The signs and symptoms of muscular atrophies and dystrophies are atrophy of the small muscles of the hand and of the muscle groups of the shoulder, associated with fibrillary twitchings. The history of these defects rarely furnishes reliable data, although it will usually be found that the applicant has shown evidences of awkwardness. There is never a history of pain in the affected muscles. (n) Multiple neuritis.—The chief manifestations are more or less pain in the course of the affected nerves, with tenderness over the trunks of the nerves and of the muscles supplied by them; lessened muscular power of varying degrees; more or less atrophy of muscles, with or without contraction; and evidences of trophic changes of the skin. The deep and superficial reflexes may be diminished or absent; the sphincters are not involved. A history of recent infectious diseases or of exposure to poisons, such as alcohol, lead, or arsenic, is of importance. (o) Mental deficiency and moron state.—Mental deficiency is that state in which the mind has failed to attain normal development. The term moron is applied to an individual with defective mentality, but who possesses a greater degree of intelligence than the imbecile and the idiot. (p) Constitutional psychopathic states.—There is a large group of indi- viduals who, though not necessarily suffering from epileptic, psychotic, or psycho- neurotic symptoms, alcoholic or drug addiction, or feeble-mindedness in the strict sense of the term, are nevertheless incapable of attaining a satisfactory adjust- ment to the average environment of civilized society. This group is very hetero- geneous, yet there is much evidence, in family and personal histories and in clinical manifestations, to show that the various conditions comprised in it are in some way related to one another and to other neuropathic conditions. A study of the individual’s past life may show a psychopathic makeup, if one exist. The types are— (1) Inadequate personality. (5) Pathological lying. (2) Paranoid personality. (6) Sexual psychopathy. (3) Emotional instability. (7) Nomadism. (4) Criminalism. (q) Psychoneuroses: Hysteria, neurasthenia, and psychasthenia.— These conditions being functional, often with no objective signs, may escape notice. Such individuals show emotional disturbances, having hypochondriacal com- pliants, undue fatigability, and general nervous instability. The history of these conditions and of interference with progress in civil life is important. 150 SEC. XXI. THE NERVOUS SYSTEM 1517-1518 (r) Epilepsy.—History of dizziness (without definite cause), many severe headaches, and undue muscular tire in early morning are often due to epilepsy. Unexplained scars on tongue, chin, or face give reason to suspect epilepsy. Epi- leptics often refer to seizures as “fainting fits” or “spells of dizziness.” (s) Head injuries.—History of severe head injuries must be fully investi- gated and persistent symptoms referable to trauma should be carefully consid- ered. Change in disposition or shifting occupational history, following accident, should be regarded as disqualifying. (0 Peripheral nerve injuries.—These conditions are manifested by history of injury with localized motor or sensory disturbances. Any such case with an incomplete regeneration is a poor risk. (u) Endocrinopathies.—Functional disturbances of ductless glands are very important in the production of neuropsychiatric conditions. The applicant should be closely observed for evidences of such functional disturbances as goiter, exophthalmos, tremors, tachycardia, acromegaly, myxedema, cretinism, smooth glassy skin, brittle nails, absent or unnatural hair distribution, faulty skeletal development, infantile or hypertrophied genitals, scanty and downy beard, female figure, and vasomotor disturbances. 1517. Standards for Applicants for Enlistment.—The following con- ditions are causes for rejection: (а) Insanity, epilepsy, or convulsions of any character, or history thereof. (б) Idiocy, imbecility, mental deficiency, or moronism. (c) Constitutional psychopathic states. (d) Chronic alcoholism or drug addiction. (e) Locomotor ataxia, paresis, or cerebrospinal syphilis. (f) Multiple sclerosis, syringomyelia, paralysis, paraplegia, monoplegia, hemi- plegia, or hemiparesis. (g) Psychoneurosis, neurasthenia, psvchasthenia, "hysteria, hysterical paraly- sis, or hysterical stigmata. (h) Chorea or marked muscular tremors. (t) Somnambulism, or history thereof. (j) Neuritis, beriberi, or severe neuralgia. (k) Muscular atrophies or dystrophies. (l) Stuttering or stammering. (m) Unequal or irregular pupils, unless cause is definitely determined to be other than neurological. (n) Brain tumors. (o) History of having been committed to an institution for the care of the insane. (p) History of injury to skull, with secondary symptoms, or any evidence of impaired nervous function. (q) History of excessive nervousness, or depression to an undue extent. (r) Endocrine disturbances that can be diagnosed by ordinary examination. (s) Injuries involving peripheral nerves. (0 Other organic or severe functional diseases of the nervous system. 1518. Standards for Candidates for Commission.—The same as for applicants for enlistment, except as to mentality, which will be as prescribed in other regulations. 151 1519-1520 CH. 11.—PHYSICAL EXAMINATIONS 1519. Standards for Candidates for the Naval Academy.—The same as for candidates for commission and enlistment. SECTION XXII. ANNUAL AND SPECIAL EXAMINATIONS Paragraph Annual Physical Examination of Officers and Warrant Officers 1520 Annual Physical Examination of Midshipmen 1521 Annual Physical Examination for Nurses 1522 Physical Examination, Special, of Officers 1523 Physical Examination of Officers for Promotion 1524 Physical Examination of Officers and Warrant Officers Prior to Resignation, Discharge, or Dismissal 1525 Physical Examination of Retired Officers on Detail to Active Duty 1526 Physical Examination of Applicants for, and Members of, the Navy Nurse Corps 1527 Physical Examination of Deserters 1528 Physical Examination of Enlisted Men Prior to Discharge or Retirement 1529 Physical Examination of Prisoners 1530 Physical Examination of Enlisted Men Selected for Detail to Attend a Service School or to Recruiting Duty 1531 Physical Examination of Enlisted Men Prior to Transfer to Service in the Tropics or in Alaska 1532 Physical Examination of Applicants for the Rating of Fireman 1533 Physical Examination of Applicants for Rating of Mess Attendant 1534 Physical Examination of Officers and Enlisted Men for the Submarine Service 1535 Physical Examination for Training in Deep-sea Diving Simulated Deep-sea Diving and in use of Rescue Apparatus 1536 Physical Standards for Continuance in Deep-sea Diving 1537 1520. Annual Physical Examination of Officers and Warrant Offi- cers.—(a) Object.—Conservation and promotion of health is the principal object of the annual physical examination and, for officers detailed to duty involving flying, to determine the individual’s fitness to perform all the duties of his grade in aviation. (b) Procedure.—The examination will be thorough, and, in devia- tions from the normal, medical examiners will employ all recognized diagnostic procedures at their command in an effort to determine the character of incipient or obscure physical or mental defects which impair, or which may develop into conditions which will impair, the health and usefulness of the officer being examined. When such abnormalities are discovered, the examining officers will, as required by (j), make suitable recommendations for the institution of cor- rective measures. In arriving at a decision as to whether or not a defect or a combination of defects disclosed by the examination per- manently incapacitates for service, medical examiners will carefully consider the age and grade of the officer concerned and the duties 152 SEC. XXII.—ANNUAL AND SPECIAL EXAMINATIONS 1520 which normally would devolve upon him. Naval aviation personnel shall be examined in accordance with paragraph 1543 (c). (c) Standards.—The physical requirements will be the same as those prescribed for the examination of officers for promotion. (d) Composition of the board.—The examination shall be con- ducted by a board of medical officers appointed in accordance with instructions contained in the current general order covering annual physical examination of officers. Whenever practicable, the board shall include an internist, an eye, ear, Pose and throat specialist, and a dental officer. At least one member of a board of medical officers appointed to examine aviation personnel shall be qualified in aviation medicine. (e) When and where held.—Officers on active duty will be examined annually in accordance with the current general order and Bureau instructions. (f) Special instructions.—Vision.—The vision shall be tested in a good light and defects (hyperopia, myopia, astigmatism, etc.) should be recorded. If possible, the prescription for lenses necessary to correct errors of refraction shall also be recorded. Color perception.—As the Edridge-Green lamp is the qualifying test after original appointment, no recommendation shall be made in the case of officers failing to pass the Stilling’s test until checked with the Edridge-Green lamp. If the officer passes the latter test his color vision shall be reported as normal but should he be unable to pass this test he should be reported as failing to pass the Edridge-Green lamp test and considered color blind (par. 1428). Cardiovascular efficiency test and blood pressure determination.—These determinations shall be conducted in accordance with the current instructions issued by the Bureau. Teeth.—The chart on Form Y should be used to note reparative dental procedures, dentures, replacements, etc. Dental cases shall be classified in conformity with instructions issued by the Bureau. Urine.—All specimens of urine should be examined microscopically and all abnormal findings, such as casts, pus cells, or red-blood cells, noted in the report. Albumin in the urine will ordinarily be deter- mined by the nitric acid or heat test. If other tests be used, it will be so stated in the report. The Fehling or Benedict test will be used for the detection of sugar in the urine. When positive for albumin or sugar, a series of tests will be made on different days and the result of each noted on Form Y and in the officer’s health record. (g) Temporary and unimportant abnormalities.—Such abnor- malities shall be thoroughly investigated before adverse reports are forwarded. Entries for physical conditions which are nonsympto- 153 1520 CH. 11.—physical examinations matic and not interfering in any measure with the officer’s present or prospective fitness for duty, such as flat feet, varicocele, slight varicose veins, slight deviation of nasal septum, and slight hemorrhoidal tags, should be noted but not recorded as disqualifying defects. (h) Observation in case of doubt.—In case of doubt as to physi- cal fitness at the time of examination, the officer or warrant officer shall be placed under observation for such period as may be necessary to enable the board to make supplementary examinations and to reach a definite conclusion. If suitable facilities are not available for such observation on the ship or station to which regularly attached, the officer should be transferred to a naval hospital at the first opportunity. (i) Manifest disability.—When a manifest disability exists, the medical officer or officers conducting the examination shall follow the procedure outlined in current general order governing physical exami- nations. (See art. 1195 (2), N. R.) (j) Correction of physical abnormalities—notations to be made on report.—The report by the board will contain full details of 154 SEC. XXII.—ANNUAL AND SPECIAL EXAMINATIONS 1521-1523 the observations made, conditions found, and recommendations per- taining thereto. If any physical abnormality be found which might in the future develop into a physical disqualification, detailed statement to that effect will be entered on the report of the examination, and by letter to the individual’s commanding officer, together with recommendations for such corrective or remedial measures as may be considered necessary with a view to improving the physical fitness of the individual concerned (par. 2, G. O. No. 61). (k) Form to be used for report.—Bureau of Medicine and Sur- gery Form Y shall be used in all cases (except aviation personnel) for the report of the annual physical examination. All spaces on the report shall be used. Duplicate copies may be made where the officer being examined desires a copy. The Bureau desires only the original Form Y accompanied by the medical history sheets for the preceding year (par. 2217). The information contained in these reports shall not be furnished other than to the person examined, and shall not be shown to anyone outside of the examining board, except for official purposes, or where official action may have to be taken; e. g., to send the person being examined to a naval hospital for observation or treat- ment. These reports, however, shall not be forwarded as confidential mail. The report of the last annual physical examination is now used as the basis in the certification of physical fitness by the Bureau to the Bureau of Navigation of officers eligible for consideration by selection boards. The board of medical officers shall make, therefore, a definite recommendation in each case on the report (Form Y) that the indi- vidual is or is not physically qualified to perform all his duties at sea, or for officers of the United States Marine Corps, at sea and in the field. Reports in cases of aviation personnel shall be submitted, in duplicate, on NMS—Form Aviation—1 (physical examination for flying). 1521. Annual Physical Examination of Midshipmen.—This examina- tion will be held in accordance with the regulations governing the Naval Academy and at such time as may be determined by the superintendent. 1522. Annual Physical Examination for Nurses.—This physical examination is to follow the same procedure as prescribed for officers. 1523. Physical Examination, Special, of Officers.—(a) Officers eligible for selection.—A special board of medical examiners may- be convened when an officer who becomes eligible for consideration by a selection board for promotion has, since the last examination for promotion, been subjected to severe illness, severe operation, or whose medical record in the grade he actually holds shows that a chronic disease or disability may exist, or that restoration to health from a 155 1524-1525 CH. 11. PHYSICAL EXAMINATIONS previous disease or disability has not been complete. This special board will be ordered only at the request of the officer concerned and will submit a report as indicated in paragraph 862, naval courts and boards (1937). A report on Form Y shall also be forwarded to the Bureau. (b) For tropical duty.—Officers about to be assigned to duty in Samoa or Guam shall be given a physical examination prior to sailing to determine their fitness for duty at those places and a report for- warded on Form Y to the Bureau. (c) Officers families.—It is recommended that the families of officers be examined physically prior to departure from the United States for Samoa or Guam. The examination of dependents must necessarily be left to the discretion of the individuals concerned. 1524. Physical Examination of Officers for Promotion.—(a) Stand- ards.—Boards of medical examiners will exercise their own judgment in making recommendations as to the physical qualifications of officers of the Navy and Marine Corps who are candidates for promotion. Careful consideration should be given to candidates presenting phys- ical defects which, from the evidence at hand, have not interfered with the proper performance of duty. This applies particularly to delects of vision and hearing. Whenever it is the opinion of the medical examiners that any defect which is discovered will not interfere with the proper performance of unlimited active duty consistent with the rank and age of the officer concerned, he will be reported by them as physically qualified for promotion. All deviations from the normal, however, will be noted. Blood pressure and pulse readings before and after exercise shall be recorded. (b) Forms to be used for report.—The report shall be rendered in accordance with the procedure in naval courts and boards (1937) section 883. A report shall also be made on Form Y and the original forwarded direct to the Bureau. (See pars. 1420 and 1543 (b)). 1525. Physical Examination of Officers and Warrant Officers Prior to Resignation, Discharge, or Dismissal.—In general, the same as pre- scribed for enlisted men prior to discharge or retirement except that officers (not including midshipmen) and warrant officers shall appear before a board of medical examiners. The examination may be con- ducted at a naval hospital if the officer so elects. The report on Form Y shall be submitted to the Bureau. Whenever physical defects are discovered which may have serious import, the officer shall be trans- ferred to a naval hospital for medical survey. This is considered necessary for the protection of individual officers and their dependents as well as the Government. 156 sec. xxn.—annual and special examinations 1526-1527 1526. Physical Examination of Retired officers on Detail to Active Duty.—Upon detail of a retired officer to active duty he should be examined physically by a medical officer at the first opportunity. The medical officer shall render a report on Form Y in duplicate and shall certify that there is no disability which is liable to incapaci- tate the officer for the duties which will be required of him while on active duty. 1527. Physical Examination of Applicants for, and Members of, the Navy Nurse Corps.—(a) For admission to the Navy Nurse Corps.— (1) Where and by whom made.—The applicant’s physical fitness for service will be ascertained by a thorough physical examination made, when practicable, by an officer of the Medical Corps of the Navy. However, when this would require the applicant to make an unrea- sonably long journey, the nurse may be authorized by the Bureau to have a civilian physician conduct her physical examination. When- ever the preliminary examination for appointment was not conducted by an officer of the Medical Corps, the Surgeon General will direct the senior medical officer at the station to which the nurse is ordered to duty to have a physical examination held prior to the nurse being assigned to any duty. Should the nurse fail at this time to meet the physical requirements of the service, she shall not be placed on duty, but shall be rejected for service. These findings shall be re- ported to the Bureau and orders requested for the nurse to return to her home. Should the findings of the preliminary physical examina- tion be confirmed and the nurse be found physically qualified, she may be assigned to duty at once. (2) Standard.—In general, due consideration being given to differ- ence in sex, the standards prescribed for candidates for commission will apply, except as regards those pertaining to height, weight, and chest measurements, which will be as in paragraphs 1442 (c) and 1448; however, marked disproportion of height and weight will be a cause for rejection. No applicant will be accepted who is less than 60 inches in height or who weighs less than 100 pounds. Recommendations for waivers from the prescribed standards will be considered if the exam- ining medical officers are satisfied that the defects will not interfere with the prospective duties of the candidate as a member of the Navy Nurse Corps. (b) Upon expiration of probationary period. (See par. 345.) (c) Prior to service beyond the continental limits of the United States.—Before a member of the Navy Nurse Corps is ordered to a station beyond the continental limits of the United States, a physical examination to determine her fitness for such service shall be held. 157 1528-1531 ch. n.—physical examinations (d) Prior to release from active duty.—Before a nurse leaves her station for release from active duty, a physical examination shall be held. In case physical disability is found, the nurse must be examined by a board of medical survey before being released from active duty. (e) Reports; form used; to whom rendered.—Reports of the examination shall be forwarded to the Bureau on Form Y, and on Form M when indicated. 1528. Physical Examination of Deserters.—(a) Standard.—The physical examination of a deserter will conform to the standards pre- scribed for entrance into the Navy, with special reference as to his mental condition, including, if possible, an examination by a psychiatrist. (b) Report to be furnished the commanding officer.—The medical officer making the examination will furnish the commanding officer a report thereof, including therein the nature and cause of any mental or physical disability found. 1529. Physical Examination of Enlisted Men Prior to Discharge or Retirement.—(a) When made.—Every enlisted man not discharged for physical disability shall be given a thorough physical examination by a medical officer, when such officer is available, within a period of 72 hours prior to his discharge or retirement from active service. Whenever practicable, each man should be examined by two medical officers. A careful record of all physical defects, however trivial, and other data shall be made in the health record. In case physical dis- ability sufficient to disqualify for reenlistment or for continuation in the service is found the individual must be examined by a board of medical survey before discharge or release from active duty. (b) Requirements.—The nature and location of any defect, wound, injury, or disease shall be stated in the health record and in the report of medical survey when indicated, together with the opinion of the medical officer as to whether or not the wound, injury, or disease (1) is likely to result in death or disability, (2) was or was not due to misconduct while in the Navy or Marine Corps service, and (3) was incurred in or aggravated by the naval service (par. 3426). 1530. Physical Examination of Prisoners.—Article 1148, Navy Regu- lations, requires the medical officer to examine men sentenced by a summary court-martial to be confined for a period exceeding 10 days on diminished rations or on bread and water. The prison manual requires physical examination by a medical officer of all prisoners upon arrival at a prison. 1531. Physical Examination of Enlisted Men Selected for Detail to Attend a Service School or to Recruiting Duty.—(a) Enlisted men 158 sec. xxii.—annual and special examinations 1532-1534 selected for detail to attend a service school shall be given a physical examination as required by article 1142 (3), Navy Regulations, and, in addition, such special examinations as may be required by the kind of service to be performed (aviation, submarine, diving, etc.). (b) Dental examination of enlisted men to be assigned to recruiting duty.—All enlisted men to be assigned duty at recruiting stations must be free of dental disease. Each man prior to transfer to such duty shall be examined by a dental officer who shall make an entry over his signature in the dental record that the man is dentally fit (par. 734 (d)). 1532. Physical Examination of Enlisted Men Prior to Transfer to Service in the Tropics or in Alaska.—(a) When an enlisted man is designated for transfer for service in a tropical country, particularly in Samoa or Guam, the medical officer shall, in addition to the examina- tion required by article 1142 (3), Navy Regulations, record any physical defects which would unfit him for, or become aggravated by, tropical service and make appropriate recommendations to the com- manding officer. (b) Enlisted men suffering from an active venereal disease or who have had syphilis shall not be considered physically qualified for duty in American Samoa or Guam. (c) Enlisted men in need of prosthetic dental treatment shall not be considered physically qualified for duty in Samoa or Guam. (d) Families of enlisted men should be examined in accordance with paragraph 1523 (c). (e) All personnel assigned to permanent duty at the Fleet Air Base, Sitka, Alaska, or other similar fleet activities in Alaska, shall be carefully examined, eliminating those having chronic or latent ailments such as, carious teeth, chronic sinusitis, chronic pyelitis, renal calculus, chronic peptic ulcer, and syphilis. 1533. Physical Examination of Applicants for the Rating of Fire- man.—In all cases where men request to be transferred from the seaman branch to the rating of fireman, third class, they shall be examined physically by a medical officer, and the result of such examination reported to the commanding officer. No written report of such examination need be made other than an entry on the man’s health record that the examination has been made and the man found fit or unfit. As a general rule, minors should not be recom- mended for the ratings of fireman. 1534. Physical Examination of Applicants for Rating of Mess Attend- ant.—When practicable, applicants for the rating of mess attendant, natives of insular or tropical possessions of the United States, will 159 1535 CH. 11.—PHYSICAL EXAMINATIONS be examined for the presence of intestinal parasites, and such, if found, will constitute cause for rejection. All mess attendants shall be examined for venereal disease. 1535. Physical Examination of Officers and Enlisted Men for the Submarine Service.—(a) Preliminary examination.—In view of the special conditions characteristic of the submarine service all officers and enlisted men who are candidates for submarine training shall con- form to the standards herein set forth. Particular care must be exer- cised in the preliminary examination on ships and at shore stations in order that candidates may not be unnecessarily rejected as a result of reexamination at the Submarine School, New London, Conn., thus avoiding needless cost of transportation, loss of services, and incom- plete quota of classes. (b) Standards.—Are those for general service with especial attem tion to the following conditions: (1) Vision.—In view of the requirements of operation of the peri- scope, the vision of officers shall be a minimum of 20/20 in each eye; of enlisted men of the seamen’s branch also 20/20 in each eye. All letters on the 20 foot line shall be read within a period of 4 seconds. For all other candidates the minimum vision shall be 15/20. No recommendation for waiver below these standards shall be made unless there is previous submarine experience. (2) Central color vision.—This shall be normal by the Stilling test. (3) Nose and throat.—The nares, nasopharnyx, and phamyx shall be carefully examined by reflected light. Obstruction to breathing such as marked deviation of the nasal septum, or any chronic inflam- matory condition such as infected hypertrophied tonsils, shall be sufficient to reject until such defects are remedied. (4) Ears.—Acute or chronic disease of the middle or internal ear or ruptured ear drums shall disqualify. The acuity of‘hearing in each ear shall be 15/15 by the whispered voice. A thorough otoscopic examination of the auditory canal and tympanic membranes shall be made (pars. 1434, 1562). (5) Teeth.—A complete dental examination shall be conducted by a dental officer. Present or prospective extensive restorations by crowns, bridges, or dentures, or teeth generally unserviceable, shall be a cause of rejection for the reason that effective gripping of the mouth- piece of the submarine escape apparatus or “lung” will be interfered with. Pyorrhea alveolaris shall disqualify. (6) Respiratory system.—Particular effort shall be made to detect latent tuberculosis or other chronic disease of the lungs. The candi- date shall demonstrate his ability to hold his breath for a minimum period of 55 seconds, following a deep inspiration preceded by a full 160 SEC. XXII.—ANNUAL AND SPECIAL EXAMINATIONS 1535 expiration. This should be based on the average result of three tests. (7) Cardiovascular system.—A systolic blood pressure established on repeated examination as exceeding 145 mm shall disqualify. The diastolic pressure should be roughly two-thirds of the systolic. Per- sistent tachycardia, marked arrhythmia except of the sinus type or any other disturbance of the heart or vascular system shall exclude. (8) Gastro-intestinal system.—Candidates with a definite tendency to any digestive disorder such as colitis associated with obstinate con- stipation or diarrhea should be excluded. (9) Venereal diseases.—A definitely established history of syphilis is sufficient to exclude. No candidate with any form of venereal dis- ease at the time of the examination shall be accepted (par. 1281). (10) Offensive breath, if persistent, and abnormally excessive or offensive perspiration are sufficient to exclude. (11) Disease of the skin.—Any definitely chronic skin disease shall disqualify. (12) Obesity.—Candidates presenting a variation in weight of more than 18 percent above that prescribed in relation to height in the table contained in paragraph 1442 of this manual shall be excluded, unless this overweight is mainly due to muscular and bony tissue. (c) Division commanders of submarines, in consideration of the fact that their duties do not involve the actual operating of these vessels, will be excepted from these special standards. These officers, however, shall be examined and shall conform to the standards of the general service commensurate with their rank and age. (d) Special examination at the Submarine School, New Lon- don, Conn.—(1) All officers and men on arrival at the Submarine School shall again be given a complete physical examination. This is intended to supplement the examination carried out by the medical officer of the ship or station and not to replace it. The following special examination shall be conducted: (2) All candidates shall be tested as to their ability to effectively clear the ears and to otherwise withstand an air pressure of 50 pounds to the square inch in a recompression chamber. This requirement must be satisfied in order that the personnel shall be qualified for training with the submarine escape appliance. It should be remem- bered, however, that there may be temporary difficulty due to acute congestion of the Eustachian tube incident to coryza or pharyngitis. (3) All officers and enlisted men of such ratings as may be assigned to listening duties shall be tested by the audiometer. The only permissible variation from the normal will be in the wave lengths of 128 c and 4096 c double frequencies. 161 1536 CH. 11.—PHYSICAL EXAMINATIONS 1536. Physical Examination for Training in Deep-Sea Diving, Simulated Deep-Sea Diving, and in Use of Rescue Apparatus.—(a) History—A history of any of the following shall be considered as disqualifying: (1) Syphilis. (2) Asthma. (3) Repeated attacks of sinusitis, rhinitis, tonsillitis, otitis, externa, otitis media, salpingitis eustachian. (4) Persistent tachycardia. (5) Psychoneurosis. (6) Chronic gastro-intestinal disturbance. (b) Age.—The most favorable age for training in deep-sea diving is from 20 to 30 years. Candidates for the designation of diver should not be considered for such training if over 30 years of age. The respiratory exchange in a young man is faster than in a middle- aged man and the circulation is faster. He, therefore, desaturates more rapidly and is less prone to caisson disease. Men over 40 years of age, except as noted in paragraph 1537, are automatically disqualified for diver, first class, but may continue as second class. The upper age limit for instruction in the case of medical officers and hospital corpsmen is 40 years. (c) Weight.—Fat absorbs nitrogen in much greater volume than blood and muscle and on decompression gives off its nitrogen more slowly than the other tissues. Consequently, there is a greater tendency to caisson disease in the fat individual. Candidates, therefore, presenting a variation in weight of more than 12 percent above that prescribed in relation to height in the table included in paragraph 1442 of this manual, shall be excluded from training unless their overweight is largely due to muscle and bone. (d) Vision.—A minimum vision of 20/20 in each eye shall be required for candidates for the designation of diver. All letters on the 20-foot line shall be read within a period of 4 seconds. The field of operations in submerged work is ordinarily inadequately illuminated even with the use of the diving lamp. It is impracticable to wear glasses in the diving helmet. A good degree of vision is, therefore, essential for under water activities. The minimum re- quirement for medical officers and hospital corpsmen shall be 15/20 in each eye. (e) Central color vision.—This shall be normal by the Stilling test. (f) Ear.—Disease of the ear disqualifies. Both external auditory canals and membrana tympani shall be examined by means of specu- lum with good illumination, all wax being removed from the canals. Perforation, evidence of present or serious past inflammation, or 162 SEC. XXII.—ANNUAL AND SPECIAL EXAMINATIONS 1536 marked retraction of the ear drum following chronic ear disease shall exclude. Hearing shall be normal for each ear as determined by the whispered voice, the coin click and watch tests as outlined in paragraph 1562 (b) of this manual. (g) Ability to equalize pressure.—If a recompression chamber is available candidates shall be subjected to a pressure of 50 pounds in order to determine if air pressure can be properly equalized on both sides of the ear drums. It should be remembered that men with slight head colds may be temporarily unable to equalize owing to congestion of the Eustachian tubes. Men must be competent ordinarily to clear their ears under air pressure to qualify for deep diving. (h) Breath holding.—Candidates should be capable of holding breath after full expiration and inspiration for a period of 55 seconds. This shall be based on the average result of three tests. (i) Respiratory system.—There must be no obstruction in the nares or naso-phamyx or evidence of chronic hypertrophic rhinitis or tonsillitis. The Eustachian tubes should be patent. There should be no deflection of the nasal septum. The lungs must be normal. (j) Cardiovascular system.—(1) Particular care should be given to examination of the peripheral vessels, particularly the temporal and radial. Evidence of arteriosclerosis is disqualifying. The heart sounds should be normal. The systolic blood pressure shall not exceed 140 mm. The diastolic should be roughly two-thirds of the systolic. If the systolic blood pressure is in excess of 140 mm at the first examination, this shall be repeated over a sufficient number of days to reach a definite conclusion. Persistent tachycardia or marked arrhythmia, except of the sinus type shall disqualify. Varicose veins or hemorrhoids or tendency thereto is disqualifying. (2) Circulatory efficiency test.—Candidates shall be subjected to the Schneider test for circulatory efficiency as outlined in article 1565 (f) of this manual. If, after repeated tests the circulatory efficiency rating be seven or less, it is considered sufficient to disqualify. Due care shall be taken to eliminate, as far as possible, such disturbing factors in the conduct of the test as emotional excitement, recent exercise, excessive eating, and fatigue due to excesses or insufficient sleep. (k) Genito-urinary system and skin.—There shall be no active skin or venereal disease. Disease of the kidneys must be excluded, a complete urine examination being made in all cases. (l) Gastro-intestinal system.—Men subject to gastro-intestinal disturbances, with a tendency to excessive gas formation in the stom- ach and intestines, should not be accepted. The marked expansion of 163 1537-1538 CH. 11.—PHYSICAL EXAMINATIONS such gas on ascending from even moderate depths may induce severe symptoms if not readily expelled. (m) Teeth.—A complete dental examination shall be conducted by a dental officer. Present or prospective extensive restorations by crowns, bridges, or denture, or the teeth generally unserviceable, shall be a cause for rejection. Pyorrhea alveolaris shall disqualify. (n) Temperament.—Men of nervous and excitable temperament should be excluded. (o) General physical type.—The most favorable type for deep- sea diving is the young man of 20 to 30 years of age, with no tendency to obesity, wiry, of phlegmatic temperament, and capable of with- standing considerable bodily strain. 1537. Physical Standards for Continuance in Deep-sea Diving.—A certain latitude may be allowed for a diver of long experience and a high degree of efficiency in diving. He must be free from any diseases of the cardiovascuar, respiratory, genito-urinary, gastro-intestinal systems, and of the ear. His ability to equalize air pressure must be maintained. A moderate degree of overweight may be disregarded if the diver is otherwise vigorous and active. Qualified deep-sea divers who desire to continue in that specialty and are about to reach the age limit shall be examined by a board of medical officers appointed by the senior officer present. At least one member of the board shall be qualified as a deep-sea diver or in submarine medicine. The report of the examination on Form Y with the recommendation of the board as to whether the individual is or is not physically qualified to continue as a deep-sea diver shall be forwarded to the Bureau for final decision and in time to reach the Bureau before the man attains the age of 40. SECTION XXIII. AVIATION, INSTRUCTIONS AND REQUIREMENTS Paragraphs General Provisions 1538-1544 Records 1545-1547 The Examination 1548-1564 General Provisions 1538. Object.—The object of the examination and the instructions incident thereto is to select for flying duty only such officers and enlisted men as are physically and mentally qualified for such duty, and to remove from flying duty those who may become temporarily or permanently unfitted for such duty because of physical or mental defects. Physical qualifications shall in general conform to the standards prescribed in previous sections. 164 sec. xxm.—aviation, instructions 1539-1540 1539. Personnel Requiring the Examination.—(a) Classification and requirements.—Aviation personnel is divided into 10 classes, as follows: (1) Naval aviators, (2) student naval aviators, (3) naval aviation pilots, (4) student naval aviation pilots, (5) naval aviation cadets, (6) naval aviators (airship), (7) student naval aviators (air- ship), (8) naval aviation observers (9) naval flight surgeons, (10) unclassified persons ordered to duty involving flying. Classes 1 to 7 inclusive are considered regular flying personnel and shall take the complete physical examination for flying. For this purpose, class (1) is further divided into flying service groups, based on years of naval service for which special physical requirements are prescribed. Classes 8 to 10 inclusive are considered nonflying personnel and shall meet the standard physical requirements for the general service, with such additional physical requirements as are prescribed. The physical requirements for the various flying service groups of class 1 and those for classes 8 to 10 inclusive, as approved by the Bureau of Navigation, are published in Bureau of Medicine and Surgery Circular Letter It, appendix D. When submitting report of physical examination for flying (NMSAv-Form 1), flight surgeons and aviation medical examin- ers shall state whether any defect noted is considered disqualifying. For procedure in case of disqualification for flying, see Circular Letter R, appendix D. (b) Eligibility for examination.—The examination shall be limited to members of the aeronautical organization and properly au- thorized applicants for this service. Applicants shall be given a pre- liminary physical examination by the local medical officer to eliminate those who obviously cannot meet the physical requirements for aviation. 1540. Restrictions Until Physically Qualified.—(a) No person should be assigned to duty involving actual flying until he has successfully passed the physical examination for flying prescribed herein, and, ex- cept as authorized in subparagraph (d), until official notification has been received from the Bureau that such person is physically qualified for that duty. (b) Applicant for aviation training.—An applicant (commis- sioned or enlisted) for aviation training shall be given the physical examination for flying, unless he has been found qualified within 6 months, before being assigned to duty involving flying. When an applicant for aviation training is not in the vicinity of one of the ships or stations where the physical examination for flying can be made he will be examined in accordance with the instructions governing the examination of candidates for commission and will be expected to meet the standards set forth as acceptable for a commissioned officer. 165 1541-1442 CH. 11.—PHYSICAL EXAMINATIONS Before being assigned to duty involving flying under training as a pilot, he will be given the complete physical examination for flying at the station to which he may be attached for training. (c) Naval Reserve.—Pilots of the Naval Reserve who apply for permission to pilot naval aircraft shall be subjected to the examination prescribed herein unless they present satisfactory evidence that they have passed such examination within 6 months of the date on which flight is desired. (d) Pending receipt of approved copy of record of physical examina- tion (par. 1545), or certificate from the Bureau that the record of physical examination has been approved, personnel may be considered physically qualified if an authorized medical examiner (par. 1544) certifies that the applicant has no physical or mental defect that would disqualify him for flying. 1541. Reexamination; Physical Incapacity.—(a) A reexamination of any individual shall be made whenever considered necessary by the Bureau of Medicine and Surgery, the Bureau of Aeronautics, or by the commanding officer, to determine his physical fitness to continue flying duty or flying training. (b) Upon recommendation by the flight surgeon, the commanding officer may relieve from flying duty or suspend the flying training of any individual reported physically incapacitated. When the indi- vidual is reported physically fit again by the flight surgeon, the com- manding officer may authorize resumption of such duty or training. (c) Aviation personnel of classes 1 to 7, inclusive (par. 1539), upon reporting for duty at a new ship or station, or upon reporting for duty following absence due to serious injury or illness, or upon return to duty from a protracted leave of absence, or when otherwise indi- cated, shall be given such physical examination as may be required to determine their physical fitness to resume their flying duty. 1542. Annual Physical Examination.—All aviation personnel listed in classes 1 to 7, inclusive, in paragraph 1539 shall be required to undergo the complete physical examination for flying annually in accordance with instructions incorporated in the current general order and Bureau instructions governing conduction of annual physical examinations. In the case of commissioned officers, this examination shall supplant the annual physical examination as set forth in para- graph 1520. Nonflying personnel in classes 8 to 10, inclusive, not serving as pilots, but who are performing flying duty, shall, in addition to the annual physical examination prescribed for the general service, meet the additional special requirements prescribed in Circular Letter It of appendix D. Reports of the physical examination of personnel listed in classes 1 to 9, inclusive, shall be submitted on NMSAv- Form 1. 166 SEC. XXIII.—AVIATION, INSTRUCTIONS 1543-1548 1543. Examination, Where Made.—(a) Equipment and personnel for conducting the physical examination for flying have been estab- lished afloat and ashore in accordance with the following detailed plan. (For detailed list, see Circular Letter R, appendix D.) (1) Forces afloat.—Aboard aircraft carriers and the large aircraft tenders, at fleet air bases and within certain flag commands to which staff flight surgeons are attached. (2) Forces ashore.—At naval air stations, Navy and Marine Corps air bases, Naval Reserve avaition bases, and other shore activities and commands within the cognizance of the commandants of the several naval districts, to which flight surgeons or qualified aviation medical examiners are attached and so serving. 1544. Examination, by Whom Made.—The physical examination for flying shall be made only by medical officers, who, after a special course of instruction, are qualified to conduct such examination. There are two groups of medical officers qualified to conduct the physical examination for flying: (1) Flight surgeons, who have qualified by taking the basic course in aviation medicine followed by additional indoctrinal flight training. (2) Aviation medical examiners, who have qualified by taking the basic course in aviation medicine but have not received indoctrinal flight training. Records 1545. Records.—A record of the physical examination for aviation duty prescribed herein shall be made on NMSAv-Form 1. This report shall be prepared and disposition made in accordance with instruc- tions in Circular Letter R, Appendix D of this manual. 1546. Transfer of Records.—Whenever an individual is transferred from one ship or station to another, the certified copy of his current NMSAv-Form 1 shall be forwarded to the medical officer of his new ship or station. 1547. Inspection of Records.—The physical examination records of aviation personnel in classes 1 to 7, inclusive, shall be inspected by the medical officer annually at the end of January. If a record is missing or incomplete in any particular, the medical officer shall so inform the commanding officer who shall direct the individual to report to the medical officer for the necessary examination to complete his records. The Examination 1548. General Examination.—(a) Except as modified by this para- graph, the general physical examination and general physical stand- ards shall be the same as those prescribed for the general service. 167 1548 CH. 11.—PHYSICAL examinations (b) History.—A history of any of the following should be con- sidered as disqualifying: Syphilis. Repeated attacks of hay fever or asthma. Recent attacks of malaria . Paroxysmal tachycardia. The presence of any organic heart disease. Recurrent attacks of any of the rheumatic group. Renal calculus (recent). Encephalitis lethargica, or any illness accompanied by diplopia and lethargy. (c) Height and Weight.—The minimum height for enlisted men is 64 inches. In the case of officers and examinees who may be subject to commissioning, as in the case of aviation cadets, the mini- mun height requirement is 66 inches. The maximum height is 76 inches. The minimum acceptable weight for aviation is 124 pounds. The maximum weight is 200 pounds. If the examinee is a subject for commission, the minimum weight is 132 pounds. Individuals shall be well proportioned and shall be near the weight for height as given in the table in section VI. It is particularly necessary for examinees whose weight is near the maximum or the minimum requirement to conform closely to the prescribed ratio of height and weight for age. (d) Chest.—Any condition that serves to impair respiratory func- tion may be cause for rejection. The examinee if an average-sized individual, should normally have not less than 3 inches of expansion. A variation of one-half inch is allowable if the individual is otherwise acceptable. (e) Cardiovascular system.—Cardiac arrythmia or heart murmur or other evidence of cardiac abnormality shall be the cause of careful study, including recourse to an electrocardiographic examination when indicated. Evidence of heart disease shall be cause for rejection. (f) Blood pressure and pulse rate (circulatory efficiency test).— In considering the blood pressure due regard must be given to the age of the examinee and to physiological causes, such as excitement, recent exercise, and digestion. The condition of the arteries, the tenseness of the pulse, and the degree of accentuation of the aortic second sound must be taken into consideration, as will also the rela- tion between the systolic and diastolic pressures. No examinee will be rejected as the result of a single reading. When the blood pressure estimation at the first examination is regarded as abnormal, or in case of doubt, the procedure will be repeated twice daily (in the morn- 168 SEC. XXIII.—AVIATION, INSTRUCTIONS 1548 ing and in the afternoon) for a sufficient number of days to enable the examiner to arrive at a definite conclusion. In conducting the cir- culatory efficiency test (Schneider index), the examinee shall be afforded every opportunity to relax. Loud noise, conversation, and other distracting influences which may serve to excite or adversely affect the examinee, are to be avoided. The test should not be taken within 2 hours after a meal. Smoking, fatigue, and intercurrent infections will affect the score. To conduct the test the subject reclines in a quiet environment for not less than 5 minutes, following which the examination proceeds as follows: Method (1) Heart rate is counted for 20 seconds. When two consecutive 20-second counts are the same, this is multiplied by 3 and recorded. (2) The systolic pressure is taken by auscultation and recorded. Take two or three readings to be certain. (3) The subject then rises and stands for 2 minutes to allow the pulse to assume a uniform rate. When two consecutive 15-second counts are the same, multiply by 4 and record. This is the normal standing rate. (4) Standing pulse minus the reclining pulse gives the increase on standing. (5) The systolic pressure is taken as before and recorded. (6) Timed by a stop watch, the subject steps upon a chair 18K inches high, 5 times in 15 seconds. To make this uniform, the subject stands with one foot on the chair at the count 1. This foot remains on the chair and is not brought to the floor again until after count 5. At each count he brings the other foot on the chair and at the count “Down” replaces it on the floor. This should be timed accurately so that at the 15-second mark on the stop watch both feet are on the floor. (7) Start counting the pulse immediately at the 15-second mark on the stop watch and count for 15 seconds. Multiply by 4 and record. (8) Continue to take pulse in 15-second counts until the rate has returned to the normal standing rate. Note the number of seconds it takes for this to return and record. In computing this return count from the end of the 15 seconds of exercises to the beginning of the first 15-second pulse count. If the pulse has not returned to normal at the end of 2 minutes, record the number of beats above normal and discontinue counting. (9) Check up points and enter final rating as indicated in the table. If after repeated tests, the circulatory efficiency rating be 7 or less, it is considered sufficient to disqualify. 169 1548 CH. 11.—PHYSICAL EXAMINATIONS (10) Enter history of case, including amount of sleep, amount of smoking, kind of work (outdoor or indoor, active or sedentary, etc.), time since last meal, any personal worries, or any pathological condi- tion which might affect the condition of the subject. Table for grading cardiovascular changes B. Pulse rate increase on standing A. Reclining pulse rate 0-10 beats, 11-18 beats, 19-26 beats, 27-34 beats, 35-42 ' beats, Rate Points points points points points points 50-60 3 3 3 2 1 0 61-70 3 3 2 1 0 -1 71-80 2 3 2 0 -1 -2 81-90 1 2 1 -1 -2 -3 91-100 0 1 0 -2 -3 -3 101-110 -1 0 -1 -3 -3 -3 D. Pulse rate increase immediately after exercise C: Standing pulse rate 0-10 11-20 beats, points 21-30 beats, points 31-40 beats, points 41-50' Rate Points points points 60-70 3 3 3 2 1 0 71-80 3 3 2 1 0 0 81-90 2 3 2 1 0 -1 91-100 1 2 1 0 -1 -2 101-110 1 1 0 -1 -2 -3 111-120 0 1 -1 -2 -3 -3 121-130 0 0 -2 -3 -3 -3 131-140 -1 0 -3 -3 -3 -3 E. Return of pulse rate to standing normal after F. Systolic pressure, standing, compared with exercise reclining Seconds Points Change in mm. Points 0-30 3 Rise of 8 or more 3 31-60 2 Rise of 2-7. 2 61-90 1 No rise - i 91-120 0 Fall of 2-5. 0 After 120: 2- 10 beats above normaL .. -1 Fall of 6 or more _ _ -1 After 120: 11-30 beats above normal .. -2 Interpretation of Findings Blood pressure.—If the examinee is a candidate for flight training, the systolic blood pressure shall not persistently exceed 135 mm., nor the diastolic pressure exceed 90 mm. In the case of qualified pilots, if the examinee is over 25 years of age, the systolic blood pressure shall not persistently exceed 150 mm. If the examinee is 25 years of age or younger, the systolic pressure shall not persistently exceed 140 mm. A systolic blood pressure of less than 105 mm. disqualifies. A diastolic blood pressure persistently above 95 mm. is disqualifying. Abnormally low diastolic blood pressure should be viewed with concern, particularly with regard to its effect on vaso-motor tone while flying. In such cases, the underlying cause should be determined if possible. The condition, if sufficiently marked, may be considered as disqualifying. Circulatory index.—This index shall be regarded as a valuable check on the physical condition of the examinee. An index below 8 will be regarded as unsatisfactory. No individual shall be rejected because of a single failure to pass the test satisfactorily, but shall be recalled for further observation and study. Where the index is per- 170 SEC. XXIII.—AVIATION, INSTRUCTIONS 1548 sistently below the acceptable limit and is indicative of neurocircu- latory asthenia, or other abnormalities of the circulatory system, the examinee shall be disqualified. (g) Teeth.—Evidence of marked malocclusion, especially when associated with a weak or defective dental arch, or with evidence of extensive caries or loss of teeth, shall be cause for rejection. (h) Nervous system.—(1) Neuropsychiatrical examination.—Fol- lowing the completion of the general examination, the examiner shall make a careful study of the examinee’s family history for evidence of insanity, familiar traits of psychoneurotic manifestations, degener- ations, and inherited deficiencies. The examinee’s personal history shall be searched for significant factors which relate to the formative years that affect his personality trend. The infantile period shall be searched for evidence of retardation. Consideration shall be given to examination of the family life, play life, school life, sex life, and a care- ful search for epileptic equivalents. Determine the family attitude toward flying and the examinee’s reaction to the stresses of life and his general emotional response and control. The object of the examina- tion shall be to determine the individual’s basic stability and capacity to react favorably to the special stresses encountered in flying. This phase of the examination will be performed routinely only on appli- cants for flight training who are otherwise physically qualified. (2) Neurological examination.—A careful neurological examination shall be made, careful attention being given to the following examina- tions and report of findings: Pupils.—Regular, irregular, equal, unequal, do or do not react to light and accommodation. Deep sense (Romberg).—Negative, slightly positive, or pronounc- edly positive. Deep reflexes: Patellar, biceps, etc.—Absent (0), diminished (—), normal ( + ), hyperactive (++), and exaggerated (+ + +)• Superficial reflexes: Abdominal, cremasteric, etc.—Any abnormal- ities found. Sensory disturbances.—Any abnormalities found. Motor disturbances.—Evidence of muscle weakness, paresis, or any other abnormality. Trophic disturbances.—Evidence of atrophy, compensatory hyper- trophies or any other abnormality. Tremors.—State whether fine or coarse, and name parts affected. Tics.—Specify parts affected. Cranial nerves.—Examine carefully for evidence of impaired function or paresis. It should be remembered that some of the cranial nerves are subject to frequent involvement in a number of important dis- 171 1549 CH. 11.—PHYSICAL EXAMINATIONS eases, such as syphilis, meningitis, encephalitis lethargica, and in- juries to the cranium. Any abnormalities disclosed on the neurological examination should be carefully studied and an opinion expressed as to then- cause and significance and as to whether they are sufficient cause for rejection. (3) Psychomotor tension.—Ability voluntarily to relax. Tested by having examinee rest forearm upon palm of examiner and then testing the tendon reflexes of forearm with percussion hammer. The flight surgeon should keep himself informed regarding all indi- cations of staleness in order to recognize the earliest manifestations of that condition. (4) Peripheral circulation.—Examine for flushing, mottling, and cyanosis of face, trunk, and extremities. Question as to the presence of localized sweating (armpits and palms) and cold extremities. (i) Aeronautical adaptability.—After the examination has been completed, the examiner shall make an assessment of the individual’s qualifications for flying, based upon the physical findings and the result of the neuropsychiatric examination. While no individual will possess all good traits, or all bad ones, the examiner will summarize his impressions of the individual’s aeronautical adaptability, which shall be recorded as favorable or unfavorable. Where an individual is found to be physically qualified but his aeronautical adaptability is regarded as unfavorable, the entry of findings on NMSAv-Form 1, as finally recorded, shall be “ Physically qualified but not aeronautically adapted.” 1549. Visual Acuity.—(a) Apparatus and set-up.—Five Snellen test charts, each with a different arrangement of letters, and a blank card about 6 by 9 cm. Four test charts are cut off so that only the 20- foot and successive smaller rows of letters are used. The central chart is left fully exposed. The five charts are arranged in close formation against a neutral-colored wall at the end of the examining room and each is numbered. The numerals must be distinctly visible at a distance of 20 feet. Two 100-watt daylight Mazda lamps with re- flectors are installed about 4 feet above and in front of the test charts to provide uniform illumination. A single 200-watt daylight Mazda lamp in a suitable reflector may be substituted for the above. The switches controlling these lamps and the spotlight used with the phorometer trial frame should be located on the side wall, where they can be reached easily by the examiner as he stands beside the examinee’s chair. All windows and other sources of light located in front and to the side of the examinee are shaded during the examina- 172 SEC. XXIII.—AVIATION, INSTRUCTIONS 1550 tion. Other standard appliance acceptable to the Bureau for testing visual acuity may be used in lieu of the apparatus described above. (b) Procedure.—Upon entering the room the examinee occupies a chair facing the test charts exactly 20 feet away. In order to pre- vent study of the letters, the test is begun promptly. The examiner stands at one side of the examinee, using the 6 by 9 cm. blank card to cover the left eye while the right is being tested. Designating one of the small charts by number, the examiner instructs the exam- inee to read as many letters as possible. When the best vision for the right eye has been obtained, the card is shifted to cover the right eye and the left eye is tested on one of the other small charts. The large (complete) chart is used only when the vision is less than 20/20. The row of smallest letters read correctly determines the numerator of the fraction used in recording visual acuity. The num- ber of smaller letters read in the next line is added to this fraction following the plus sign; e.g., 20/20+4. (c) Precautions.—Every possible safeguard is thrown around the test to prevent memorizing the charts. Examinees awaiting their visual acuity test are not permitted to remain in the room within sight of the test letters nor where they can hear them read aloud. When the examinee is suspected of having memorized the charts, the examiner will select letters in the doubtful lines and have the examinee name them. The small charts should be given a different arrangement from time to time in order to prevent memorizing the letters according to the position of the charts on the wall. One eye is completely screened from the letters while the other is being tested. The use of the hand or of an opaque disk from the trial case as a screen does not insure a monocular test. (d) Interpretation of findings.—(1) On original examination jor flight training.—The minimal visual requirement for each eye is 20/20. (2) For qualified and experienced pilots.—In the case of qualified pilots visual acuity of not less than 15/20 for each eye unaided by glasses may be permitted where the pilot’s experience is sufficient to compensate for this departure from normal vision. 1550. Depth Perception at 6 Meters.—(a) Apparatus.—Depth perception apparatus may be obtained from the Navy Medical Supply Depot on approved requisition. The apparatus shall be installed in such manner as to receive adequate illumination without the examinee being subjected to the direct glare of the light. (b) Procedure.—The rods in the box are widely separated by the examiner and the examinee is required to manipulate the two cords so as to bring the movable rod beside the fixed one in such position that both appear to be the same distance from him. The test is repeated several times, the rods being widely separated before 173 1551 CH. 11.—physical examinations each trial. The examinee’s estimation of depth difference is read in millimeters directly from the scale and entered on the record. The test will be conducted at a distance of 20 feet. (c) Precautions.—No information concerning the results of the successive trials will be given the examinee until after the test is completed. The examinee is required to hold his head straight and not to one side or the other. Care will be taken by the examiner to avoid casting a shadow on the background, to avoid placing the hands so as to give the examinee information as to his error, and to avoid any facial expression from which the examinee might gain information as to the result of his efforts. (d) Interpretation of findings.—An average depth difference of more than 30 mm. in five readings disqualifies. An erratic result will necessitate an examination the following day and if still erratic will disqualify until consistently below 30 mm. 1551. The Maddox-rod Screen Test at 6 Meters.—(a) Apparatus.— A phorometer trial frame equipped with a pair of multiple Maddox rods and a pair of Risley rotary prisms, a blank card about 6 by 9 cm., which serves as a screen, and a blank card about 13 by 20 cm., with a 3-cm. hole in its center. (b) Procedure.—Before beginning the test the examinee’s fixing eye is determined. For this purpose the 13 by 20 cm. card is employed. The examinee seated, facing the spotlight 6 meters away, grasps the card by the long sides with both hands. While looking intently at the light he slowly raises the card at arm’s length and locates the light through the hole without closing either eye. Only one eye can see the light through the hole, and the eye selected for this purpose is the one used habitually for sighting or fixing. The phorometer trial frame is now properly leveled and adjusted closely in front of the examinee’s eyes. One of the multiple Maddox rods is swung into position before the nonfixing eye. A rotary prism is placed before the same eye. The sighting or fixing eye must have an unobstructed view of the spotlight. For the measurement of esophoria or exophoria, the Maddox rod is adjusted before the non- sighting eye to give a vertical line of light. The rotary prism is adjusted also before the nonsighting eye for the measurement of lateral deviation and set 4 or 5 prism diopters off the zero mark. This gives enough deflection at the first reading to detect an examinee who has been coached to say the line passes through the light. The 6 by 9 cm. card is moved from one eye to the other a few times to ascertain if the examinee sees both the line and the light. If the line is not seen readily, the Maddox rod is readjusted by centering it carefully in front of the pupil. Some further darkening of the room may be necessary to render it clearly visible. 174 SEC. XXIII.—AVIATION, INSTRUCTIONS 1552 When the examinee sees the line with one eye and the light with the other, the examiner holds the card or screen in front of the non- fixing eye to shut out the image of the line. The examinee now sees only the light. After he has fixed it for several seconds, the screen is removed for an instant and quickly replaced. In that brief interval the examinee will be able to see the line and locate it in reference to the light. After one or two such exposures, he will say that the line is to the right or left of the light or possibly through it. He is instructed to grasp the milled head that rotates the prism and turn it to bring the line directly into the light. To enable him to do this, the screen is removed from the eye at intervals and quickly replaced. Finally, the examinee will have rotated the prism enough to cause the line to pass through the light every time the screen is removed. The number of prism diopters necessary to do this is read from the scale of the rotary prism. This is entered on the record as esophoria if the prism is base out, and exophoria if the prism is base in. For the measurement of hyperphoria, the Maddox rod before the non- fixing eye is readjusted to give a horizontal line of light. The rotary prism is also readjusted before the same eye to measure vertical deviation. The screen is used exactly as before to give an occasional glimpse of the line. The number of prism diopters read from the scale is recorded as right hyperphoria if the prism is base down before the right eye, or base up before the left. It is recorded as left hyper- phoria if the prism is base up before the right eye or base down before the left. In testing for hyperphoria, the Stevens’ frame, which is normally a part of the phorometer mechanism, should be used instead of the large prisms. The Stevens’ frame attachment is composed of weaker prisms which are calibrated in tenths of a diopter and therefore permit more accurate readings for hyperphoria. (c) Precautions.—The Maddox rod and the measuring prism are used always together before the nonfixing eye and never before the fixing eye. The test gives an inaccurate result if the examinee is permitted to see the line for a longer time than is allowed by the momentary flash exposures described above. (d) Interpretation of findings.—Esophoria of more than 4 D., if associated with a prism divergence of less than 4 D., disqualifies. Esophoria of more than 10 D., disqualifies even if unassociated with any other visual defect. Exophoria of more than 5 D. disqualifies. Hyperphoria of more than 1 D. disqualifies. When the findings in the test for heterophoria exceed the maximum normally allowed, the red lens test shall be made for evidence of diplopia. 1552. Prism Divergence.—(a) Apparatus.—Phorometer trial frame and spotlight 1 cm. in diameter. 175 1553 CH. 11.—PHYSICAL EXAMINATIONS (b) Procedure.—The examinee is seated facing the spotlight 20 feet away. The rotary prism of the phorometer trial frame is adjusted before one eye so that by turning the milled head the prism will be acting base in. With the prism set at zero on the scale, the examinee should see but one spot of light. As the prism is slowly rotated base in, diplopia will be produced. The number of prism diopters which causes the onset of diplopia is read from the scale and entered on the record as prism divergence. (c) Precautions.—The test cannot be made if the examinee has diplopia when the prism is set at zero on the scale. If this condition obtains, the examinee is disqualified. (d) Interpretation of findings.—Where there exists an eso- phoria at 6 meters, the prism divergence shall equal or exceed the esophoria in prism diopters. Prism divergence of more than 15 D. or less than 2 D. disqualifies without further evidence. 1553. Red Lens Test.—(a) Apparatus.—Spectacle trial frame; red lens from trial lens case; small light, such as ophthalmoscope without head; and metric rule or tape. (b) Procedure.—The examinee is seated in the darkroom facing the dark Avail or tangent curtain at 75 cm. distance. The spectacle trial frame is adjusted in position and the red lens from the trial lens case is placed in one cell of the trial frame. With the examinee’s head in a fixed position, the small lamp is held directly in front of and on a level with the eyes, the light being directly before the dark wall or tangent curtain at 75 cm. distance from the eyes. The pres- ence or absence of diplopia in this position (primary) is noted. The light is then slowly moved from the central position toward the right for a distance of 50 cm. in the horizontal plane. In the same manner the light is moved in the remaining five cardinal directions, up and to the right, up and to the left, to the left, down and to the left, and down to the right. The presence or absence of diplopia in any of these positions should be noted. Normally, diplopia should not occur in any meridian within 50 cm. of the primary or central position. In the presence of diplopia, notation should be made as to whether it is crossed, homonomous, or vertical, and the distance in centimeters from the central position that diplopia occurs. Where diplopia is suspected and the examinee has been coached to deny its presence, a prism of 3 or 4 D. may be placed, either base up or down, in one cell of the trial frame, and if diplopia is still denied, the statement is obviously untrue. (c) Precautions.—The head of the examinee must remain fixed and the movement of the light followed only by the eyes. No tilting or rotation of the face shall be permitted. 176 1554-1555 SEC. XXIII.—AVIATION, INSTRUCTIONS (d) Interpretation of findings.—Diplopia within 50 cm of the primary position, in any meridian, disqualifies. 1554. Test of Associated Parallel Movements.—(a) Apparatus.— A pin with a white head 2 mm. in diameter. (b) Procedure.—The examinee stands near a window where good illumination falls on both eyes. The examiner holds the white- headed pin about 33 cm. directly in front of the examinee’s eyes and directs him to look at it steadily. Nystagmus in the primary position is to be noted at this stage of the test. The examinee is then instructed to hold his head still and watch the pin as it is moved slowly to his right. The pin is not carried beyond the field of binocular fixation, but is held motionless for a moment near the lateral limit of the field. Each eye is inspected to discover any failure in fixing the pin. The lagging or overaction of either eye is noted. The pin is then carried slowly to the extreme left, up and to the left, straight up, up and to the right, to the extreme right, down and to the right, straight down, and down and to the left. The lagging of either eye in any one of these eight cardinal directions is due to underaction of at least one of the extrinsic ocular muscles. The underaction is recorded by stating which eye lags and in which direction the lagging is observed. In the same way any overshooting of either eye is recorded by stating which eye is involved and in which direction. If any underaction or overaction is revealed by this test, the final diagnosis shall be made on the tangent curtain by means of the red lens test. (c) Interpretation of findings.—The examinee is disqualified if the underaction or overaction of any of the extrinsic ocular muscles results in heterophoria at 6 meters in excess of normal limits, or produces diplopia within 50 cm. of the primary position in any meridian as determined by the red lens test. 1555. Inspection of the eyes.—(a) Procedure.—Whenever pos- sible, the eyes are inspected by bright daylight. Every pathologic condition and congenital anomaly is recorded. The following con- ditions may be found by this procedure: Lids.—Ptosis, blepharitis, trichiasis, entropion, ectropion, and chalazion. Tear sacs.—Imperfect drainage. Lower puncta.—Failure of contact with bulbar conjunctiva. Conjunctivae.—Trachoma and old scars. Corneas.—Scars, pannus, and pterygium. Pupils.—Unequal size, irregular shape, and failure to react to light or accommodation. (b) Interpretation op findings.—Any pathologic condition which may become worse or interfere with the proper functioning of the eyes under the fatigue and exposure of flying disqualifies. 177 1556 CH. 11.—PHYSICAL EXAMINATIONS 1556. Accommodation.—(a) Apparatus.—The Prince rule; a small millimeter rule; a card with several rows of small letters. (b) Procedure.—Accommodation is measured from the anterior focus of the eye, which is about 11.5 mm. in front of the cornea. Using the millimeter rule, a pencil mark is made on each side of the exam- inee’s nose 11.5 mm. in front of the right and left cornea, respectively. In measuring the accommodation of the right eye, the flat side of the Prince rule is laid against the right side of the examinee’s nose, with the end of the rule at the pencil mark. The rule is held hori- zontally and extends directly to the front edge up. The card of test letters is held not more than 5 cm. in front of the examinee’s right eye. His left is screened from sight of the letters by the flat side of the rule. The card of test letters is now carried slowly away from the eye and the examinee instructed to begin reading the letters aloud as soon as they become legible. The card is halted the instant he begins to read the letters correctly and the point on the rule opposite the card is read off in diopters. This is the measure of accommodation of the right eye. To test the left eye, the rule is changed to the left side of the nose and the above procedure repeated, using a different line of letters. (c) Precautions.-—The examinee is placed with his back to good light, with the card well illuminated. The card is started from close to the eyes and carried away from them. The letters on the test card are read aloud. The same line of letters is not used for testing both eyes. (d) Interpretation of findings.—The following table gives the mean values of accommodation in diopters from 18 to 50 years of age. Accommodation may be regarded as within normal limits provided it is not more than 3 D. below the mean for the examinee’s age. The examinee is disqualified if his accommodation falls more than 3 D. below the mean for his age, but before an examinee is disqualified, his accommodation shall be taken on three successive days and an average of the three findings determined. Accommodation may be affected by fatigue, staleness, or other debilitating conditions. Table of mean values of accommodation power (Duane) Age Diopters Age Diopters Age Diopters Age Diopters 18 11.9 25 10. 2 31 8.6 37 6.8 19 11. 7 20 9.9 32. 8.3 38 6. 5 20 11.5 27 9.6 32 . 8.0 39 6.2 21 11. 2 28 9.4 34 7.7 40 5.9 22 10. 9 29 9.2 35 7.3 45 3.7 23 10. 6 30 8.9 36 7. 1 50 2.0 24 10.4 178 SEC. XXIII.—AVIATION, INSTRUCTIONS 1557 1557. Angle of Convergence.—(a) Near point of convergence (PcB).—(1) Apparatus.—The Prince rule; a pin with a white head 2 mm. in diameter. (2) Procedure.—The distance to this point is computed from the base line connecting the centers of rotation of the eyes. The end of the Prince rule is placed, edge up, at the mark on the right side of the nose, 11.5 mm. in front of the cornea. The white- headed pin is held 33 cm. away in the median line above the edge of the rule and the examinee is instructed to look at it intently. If both eyes are seen to converge upon the pin, it is then carried in the median line, along the edge of the rule, toward the root of the nose. The examinee’s eyes are carefully watched and the instant one is observed to swing outward the limit of convergence has been reached. The point on the rule opposite the pin is then read in millimeters. This test is repeated until a fairly constant reading is obtained. To this reading 25 mm. is added, which will give approximately the distance from the near point of convergence to the base line, PcB. (3) Precautions.—Both eyes must converge upon the pin at the start of the test. The examinee’s observation of the onset of diplopia is not relied upon to determine the near point, although, in order to test his veracity he is asked to state when he sees double. (4) Interpretation of findings.—The near point of convergence, un- like the near point of accommodation, varies little with age. Its measurement is of value only in computing the angle of convergence. Examinees are not qualified or disqualified on this measurement, but on the angle of convergence. (b) Interpupillary distance (Pd).—(1) Apparatus.—A small millimeter rule. (2) Procedure.—The examiner stands with his back to the light, face to face with the examinee. The rule is held in the examiner’s right hand and laid across the examinee’s nose in line with his pupils, as close to the two eyes as possible. The examiner closes his right eye and instructs the examinee to fix his eyes on the open left eye. With the eyes in this position, a predetermined mark on the rule is placed in line with the nasal border of the examinee’s right pupil. The rule must be held steadily in this position while the examiner opens his right eye and closes his left. The examinee is then instructed to look at the open right eye. The point on the rule in line with the temporal border of the examinee’s left pupil is read in millimeters and the exact difference in millimeters between the two points on the rule is the interpupillary distance. (c) Computing the angle of convergence.—(1) Procedure.—The following formula is used for computing the angle of convergence: Angle of convergence—}4PdX 100 + 3 PcB 179 1558-1560 CH. 11.—PHYSICAL EXAMINATIONS (2) Interpretation of findings.—An angle of convergence of less than 40° is undesirable, but is not disqualifying unless associated with excessive exoplioria or diplopia on the tangent curtain, except in the extreme positions. 1558. Central Color Vision.—(a) Equipment.—Pseudo-Isochromatic charts prescribed for the Navy. (b) Procedure.—The examinee is placed with his back to good light (natural light is preferable) in such a manner as to insure that the plates of the chart are illuminated and free of shadow. The plates are exposed to the examinee, who is required to call the numbers or letters indicated in the colored chart. The examinee may be permitted to tilt or alter the position of the charts to improve the light effect. His identification of the numbers should be reasonably prompt. (c) Interpretation of findings.—Evidence of color blindness as disclosed by this test shall disqualify. Minor confusion over certain plates will be considered with regard to their importance. In every case where the examinee manifests confusion or inability to pass the test for a certain plate, such plates shall be listed in the report of examination with the remark “Failed,” “Confused,” or “With diffi- culty,” as the case may be. 1559. Field of Vision.—(a) Finger fixation test.—The examiner faces the examinee at a distance of 2 feet. He instructs the examinee to close his left eye and to fix his right eye on the examiner’s left eye, the examiner’s right eye being closed. The examiner then brings his moving fingers in from the periphery midway between them. The examinee is instructed to say when he sees the fingers, and how many. He should see them as soon as the examiner, if normal. The fingers are brought in from all cardinal directions. The test is then repeated for the left eye. Any evidence of abnormality should be given detailed study on the perimeter. (b) Interpretation of findings.—The field of vision for each eye shall be normal as determined by the finger fixation test. Where there is evidence of abnormal contraction of the field of vision in either eye, the examinee will be subjected to perimetric study for form and color. Any contraction of the form field of 15° or more in any meridian shall disqualify. 1560. Refraction (to be done only on original examination or for some special indication).—(a) Apparatus and drugs.—Electric retinoscope, or plain retinoscope and wall lamp; trial case and trial frame; Snellen test type; and cycloplegic. (b) Procedure.—The tension of both eyes must be taken by pal- pation and found normal before instilling a cycloplegic. The fundus of both eyes must also be examined with the ophthalmoscope, and if 180 SEC. XXIII.—AVIATION, INSTRUCTIONS 1561-1562 evidences of glaucoma are found a cycloplegic will not be used. One drop of a 4 percent homatropine solution is placed in each eye every 10 minutes until 4 instillations have been made. At the end of 1 hour from the time of the first instillation, the examinee is ready for refrac- tion. Retinoscopic examination is conducted in the darkroom and the results of the refraction are then verified by having the examinee read the Snellen charts. The minimum correction required to enable the examinee to read 20/20 each eye is recorded, together with the true correction as determined by retinoscopy. (c) Interpretation of findings.—The examinee is disqualified if he requires more than 2 D. total correction in any meridian in order to read 20/20 each eye with the accommodation paralyzed. Of this allowable correction, not more than a total of 0.5 D. may be due to any form of myopia or astigmatism or any combination thereof. (d) After treatment.—After the use of a cycloplegic the examinee must wear dark glasses until the effects have disappeared. The in- stillation into each eye of a 1 percent solution of pilocarpine hydro- chloride in distilled water will contract the pupil and thus relieve the photophobia. 1561. Ophthalmoscopic Examination.—(a) Indication and pre- cautions.—The examination shall be conducted on original examina- tion and when otherwise indicated. The examination must not be made before the refraction is completed. In examining the macular region of the retina, the light should be reduced and the exposure made as brief as possible. (b) Interpretation of findings.—Any abnormality disclosed on ophthalmoscopic examination that materially interferes with normal ocular function disqualifies. Other abnormal disclosures indicative of disease, other than those directly affecting the eyes, will be con- sidered with regard to the importance of those conditions. 1562. Ear.—(a) General.—Both external auditory canals and membrani tympani are examined by means of a speculum and good light. Wax interfering with a good view of the tympanum must be removed from the external auditory canal. If external to the bend of the canal, this wax can usually be removed with an ear spud or forceps. If internal to the bend of the canal, the canal should be filled with a bland oil and blocked with cotton. The following day thorough washing of the external canal with a solution of sodium bicarbonate will remove the wax. The external canal is then examined throughout. Any serious permanent blocking of the canal or diseased condition which threatens trouble later on, such as the impairment of hearing, disqualifies. The tympanic membranes are then examined. A perforation or evidence of present inflammation disqualifies. Evi- 181 1563 CH. 11.—PHYSICAL EXAMINATIONS dences of serious past inflammation disqualify. The presence of a small scar, caused by trouble several years previous which has not recurred and with which there is no deficiency of hearing and no evidence of other inflammation, does not disqualify. Marked re- traction of a drum membrane, following chronic ear disease, disqualifies. (b) Hearing tests.—Hearing should be normal for each ear. To determine this the whispered-voice, the coin-click, and watch tests are to be used. A quiet room is essential. (1) Whisper ed-voice test.—The examinee should stand 15 feet from the examiner with the ear being tested turned toward him, the other ear being covered or closed. The examiner, after full expiration, will whisper a number or word and require the examinee to repeat it after him. Each ear will be tested in turn. If the examinee is unable to hear at 15 feet, the examiner will approach until he is able to distinguish the words or numbers, the distance being recorded in feet with 15 as the denominator. (2) Watch test.—The watch test is preferably made with a loud- ticking watch, such as the ordinary Ingersoll, which, while variable, should be heard at about 40 inches. Any watch used should have been previously tried out on at least five normal persons and the distance heard made a matter of record. If the examiner’s hearing is normal, he should check the distance at which the watch should be heard against his own hearing, the watch being equidistant from his own ear and that of the examinee. The distance in inches at which the watch is heard by the examinee, eyes closed and opposite ear occluded, is taken as the numerator and the distance the watch should be heard as the denominator. Hearing by this test should be equiva- lent to 40/40. (3) Coin-click test.—An assistant closes the ear not under examina- tion. The examiner, 20 feet back of the examinee, then clicks two coins softly together and the examinee is directed to count, aloud, the number of clicks each time. The other ear will then be tested in a similar manner. If unable to hear, the examiner will approach until the examinee does hear, the distance being recorded in feet. Hearing by this test should be equivalent to 20/20. (c) If the examiner is convinced from the results of the several tests that definite impairment of hearing exists, he will reject the examinee if lie be an applicant for aviation training. However, in the case of a qualified flyer, due allowance will be made. 1563. Nasopharynx.—In the examination of the nasopharynx the examiner shall, in general, be guided by the instructions and require- 182 SEC. XXIII.—AVIATION, INSTRUCTIONS 1564 ments prescribed for the general service as outlined in paragraphs 1454 and 1455 of this chapter. Any abnormality disclosed on exam- ination indicating an estimated 50 percent or more of nasal obstruc- tion, acute or chronic sinusitis, acute or chronic tonsillitis, nasal blockage, mechanical obstruction to drainage of accessory sinuses, occlusion of one or both eustachian tubes, or other abnormalities which may seriously interfere with normal function, shall be cause for rejection. 1564. Equilibrium (vestibular tests).—(a) Barany chair test.— The nystagmus and falling after turning are tested, when practicable, on original examination and when otherwise indicated. Where facili- ties are not available, or circumstances do not permit of this test, then the examination shall be limited to the self-balancing test as outlined in subparagraph (d). Inasmuch as the self-balancing test is in effect a modified Romberg test, all examinees shall undergo that test as a regular part of their examination. (b) Nystagmus.—Examinee’s head is inclined 30° forward, so that the tragus of the ear is on a horizontal line with the external can thus of the eye. The examinee is then asked to fix his eyes on a distant point and the chair turned slowly from side to side in order to note whether or not spontaneous nystagmus is present. Then turn examinee to the right, eyes closed, 10 times in exactly 20 seconds. The instant the chair is stopped, click the stop watch; examinee opens his eyes and looks straight ahead at some distant point. There should occur a horizontal nystagmus to the left of 26 seconds’ duration. Examinee then closes his eyes and is turned to the left; there should occur a horizontal nystagmus to the right of 26 seconds’ duration. A varia- tion of 10 seconds above or 12 seconds below is allowable. (c) Falling.—Examinee’s head is inclined 90° forward, resting his forehead on his upper fist, his fists being placed one above the other on his knees, which are brought close together. Turn to the right, five times in 10 seconds. On stopping, examinee raises his head and should fall to the right. This tests the vertical semicircular canals. Turn to the left, head forward 90°; on stopping, the examinee raises his head and should fall to the left. (d) Self-balancing test.—The applicant stands erect, without shoes, with heels and toes touching. He then flexes one knee to a right angle, being careful not to support it against the other leg, closes his eyes, and endeavors to maintain this position for 15 seconds. The test is then repeated on the other foot. The findings are recorded as “Steady,” “Fairly Steady,” “Unsteady,” or “Failed.” The appli- cant should be instructed that this is the equilibrium test. There is 183 1570-1572 CH. 11.—PHYSICAL EXAMINATIONS no objection to his assisting his balance by moving and bending back and forth. (e) Interpretation of findings.—Inability to pass the tests for equilibrium satisfactorily shall be cause for rejection. SECTION XXIV. IDENTIFICATION RECORDS Paragraph Identification Recorded 1570 How Recorded — 1571 Preparation of 1572 Use of Fingerprint Records — - - 1573 Apparatus 1574 Entries on Identification and Health Records 1576 Identification Tags 1577 Instructions for Making Identification Tags 1578 1570. Identification Record.—An identification record, consisting of fingerprints and personal description, will be made for all officers and men of the Navy and Marine Corps and forwarded to the Bureau of Navigation or to the major general commandant, as the case may be. 1571. How Recorded.—(a) In the case of all officers, fingerprints are required to be made upon entering the service, upon .appointment (enrollment) or commission, on Form N. Nav. 2 for naval officers and on NMC—Form 330 for marine officers. (b) In the case of enlisted men, fingerprints are required to be made at the time of first enlistment and forwarded on Form N. Nav. 2 or NMC—Form 330 to the Bureau of Navigation or major general commandant in the same envelope with the shipping articles and securely clipped thereto. (c) In the case of men reenlisting in the Naval Reserve or in the Navy, Form N. Nav. 379 should be used and similarly forwarded. (d) A space is provided on each discharge form that is awarded under honorable conditions for the rolled impressions of the right index finger of the man to whom it is issued. This impression is to be certified by the medical officer. (e) The rolled impression of the right index finger shall be made on the continuous-service certificate of a man discharged under honorable conditions and certified by the medical officer. (f) Whenever a service record of a man on first enlistment is dis- covered that does not contain the fingerprints of the man, impressions shall be taken and placed in the record and a copy of N. Nav. 2 or NMC—Form 330, properly filled out, and forwarded immediately. 1572. Preparation of.—(a) A sample identification record, pre- pared by an expert, with instructions, is furnished to each recruiting 184 SEC. XXTV.—IDENTIFICATION RECORDS 1573-1576 station, receiving ship, and vessel in commission. This sample represents the only satisfactory standard and no record should be forwarded that does not meet this standard. (b) Commanding officers should assure themselves that sufficient personnel on board are carefully instructed in the procedure required in making satisfactory fingerprints and that they familiarize them- selves with the instructions issued. They should be required to practice making imprints until they become proficient. (c) Detailed instructions are contained in the booklet, How to Obtain Good Fingerprints, issued by the Bureau of Navigation, and medical officers shall forward a request for this pamphlet to the Bureau of Navigation, Identification Section, if it is not on hand. 1573. Use of Fingerprint Records.—(a) Before the enlistment allowance is paid, a comparison of the fingerprint impression on the dis- charge or continuous-service certificate shall be made with a similar impression made by the man who presents the discharge or certifi- cate, in order that possible fraud may be prevented. (b) Whenever, in the opinion of the commanding officer, there is liability of fraud in the cashing of pay receipts by enlisted men, they shall be required to make simultaneous impressions of the four fingers of the right hand on the back of pay receipts at the time of cashing them. In case of fraud, the pay receipt in question should be forwarded for comparison with the imprints on file with the records in the Bureau of Navigation. (c) Safes and receptacles for money and valuable papers should be thoroughly cleaned and washed at least once a month. In case of theft or robbery latent fingerprints recently made are easily developed and identified. If the impression is on a dark surface, glass or metal, sprinkle with gray powder or aluminum dust and if on a surface of Tight color, sprinkle with graphite or powdered charcoal. Use a cameFs-hair brush or blow off the powder in order to bring out the print clearly. (d) The use of fingerprints is valuable in identifying dead bodies. In the case of a body recovered from water it is usually necessary to smooth out the skin on the bulb of the finger by injecting water with a hypodermic syringe. The fingerprint on the identification tag shall always be compared with prints taken from the body before considering the tag as conclusive evidence. 1574. Apparatus.—The apparatus for making fingerprints is sup- plied by the Bureau of Navigation, and by the major general com- mandant, Marine Corps, and not by the Bureau. Ink rollers and frames rendered unfit for use should be returned for reconditioning. 1576. Entries on the Indentification and Health Records.—(a) The entries on the front of each record should be complete in each detail. 185 1576 CH. 11.—PHYSICAL EXAMINATIONS On the line race should be entered the word white, negro, filipino, or as indicated. (b) The medical officer shall make a careful and systematic exam- ination of the man’s body, front and rear, on each side of the median line, separately commencing with the scalp and ending at the foot, and note and enter on the identification record and health record descriptive sheet all marks and scars of value for purposes of identification. (c) Record showing less than five marks in addition to vaccination scars, tattooing, loss of teeth, and deformities (which should like- wise be noted) cannot be relied upon in the effort to discover identity or to identify a person in suspected cases. Experience shows that as many as 10 or 15 marks may usually be found. (d) If no marks be found upon the recruit, the fact should be stated upon both the front and back figure outlines. If marks are found upon the front and none upon the rear, or vice versa, the entry. “No mark” should be made on the appropriate outline. (e) Identification record shall be made in permanent black ink. For preparation of descriptive sheets, follow instructions printed thereon. (f) Name.—Christian and middle names in full and surname should be recorded. The name should be written very plainly, or, preferably, typewritten or printed in plain gothic letters. (g) Marks on the outline-figure record should be made at points cor- responding to those occupied by the marks on the body of the recruit. This may readily be accomplished by drawing imaginary lines on the body of the recruit like the dotted lines on the record and placing the mark in the proper position on the record. As the dotted lines mark the boundaries of regions wrhich are used in the systematic arrangement of the records for purposes of identification, it is im- portant that each mark on the record should be placed in its proper position. (1) A pen picture is desired of all marks, showing their inclina- tion and general shape. In the case of tattoos this is optional. (2) A straglit line should be drawn from each mark to its descrip- tion on the right or left of the figure. When avoidable these lines should not cross each other. (3) When a description is common to a number of marks, it need not be repeated for each one, but the lines may converge to it, if they can do so without crossing others. (4) The sizes of all scars, moles, warts, birthmarks, etc., are to be given in inches or fractional parts thereof, except in the case of pin- head moles (abbreviation p. m.). (5) Pin-head moles are moles less than one-eighth of an inch in diameter. 186 SEC. XXIV.—identification records 1576 (6) Tattoo marks should invariably be noted and described in detail as they appear. In the case of devices composed of two or more figures, the component parts should be named, e. g., heart, CROSS, AND ANCHOR, not FAITH, HOPE, AND CHARITY; CLASPED HANDS not friendship; eagle, shield, crossed cannon, flags and arrows not American coat of arms. The same applies to all emblems, coats of arms, lodge pins, badges, etc. (7) Letters, initials, and words should be printed by hand in plain roman or gothic capitals, thus: j. h. m.; u. s. v.; i. x. l.; in god we trust, etc. (8) Details of costume, posture, and relationship to other devices should be given in the case of tattooed representations of men and women, e. g., clinging to a cross; man and woman em- bracing, HOUSES, LIGHTHOUSES, AND SHIP IN THE BACKGROUND; SAILOR STANDING BY A TOMBSTONE, WEEPING WILLOW OVERHEAD, CAP IN RIGHT HAND, WORDS “iN MEMORY OF MY MOTHER” ON STONE. (9) The size of tattoos need be given only in the case of dots, blotches, circles, lines, etc. 187 1578 SEC. XXIII.—AVIATION, INSTRUCTIONS (10) It is not necessary to state the color or kind of pigment used in the tattooing. (11) Do not crowd the description of tattoos between the arms of the figure and the edges of the card. (12) Indecent or obscene tattooing is cause for rejection, but the applicant should be given an opportunity to alter the design, in which event he may, if otherwise qualified, be accepted. (13) Do not write on the figure. The figure is to be used for the purpose of locating, by pen pictures, the different marks found on the body of the recruit. (14) Amputations and losses of parts of fingers and toes should be noted, showing the particular member injured and how much of it is gone. (15) The following abbreviations are authorized and will be under- stood in the sense indicated, viz: Amp., amputation; bl., blue; bmk., birthmark; bro., brown; d., depressed (except when following a dimension; than it stands for diameter); f, fat; fl., fleshy; h., hairy; m., mole; p., pitted; p. m., pin-head mole; r., raised; s., scar or smooth; v., vaccination; var., varicose veins or varicocele; w., wart. (16) All combinations of these abbreviations are admissible, as p. s. d., pitted scar one-half inch in diameter; s. 1., scar 1 inch long; f. p. s. 1 x an oval, flat, pitted scar, 1 inch long and % inch wide. (17) Abbreviations denoting shape are unnecessary, for the letter d, following a dimension, shows that the mark is circular. Two dimensions given indicate that the mark is oval or oblong, and when no letter follows the dimension it is understood that the mark or scar is linear. (18) When a linear mark or scar is otherwise than straight the length to be given is the shortest distance from one extreme to the other. (19) The letters T. M. should not be used as abbreviations for tattoo marks, as they are liable to be taken for tattooed letters on the person. 1577. Identification Tags.—Identification tags are prepared and worn in accordance with instructions issued by the Bureau of Navigation. 1578. Preparation of Identification Tags.—The identification tag for officers and enlisted men of the Navy consists of an oval plate of monel metal 1.25 by 1.50 inches, perforated at each end for suspension from the neck by a monel wire incased in a cotton sleeve. The tag will have on one side the etched fingerprint of the right index finger. 188 1578 SEC. XXIV.—IDENTIFICATION RECORDS On the other side the following information will be embossed by the graphotype machine: (a) Name. (b) Officer’s rank or man’s service number. (c) Type of blood, and if the man has received tetanus toxoid, the letter “T” with date (T 3/40) to so indicate. (d) At one end of the tag the letters “USN,” “USNR,” “USMC,” or “USMCR,” whichever may be appropriate will be placed. The etching of the tag shall be done by such member or members of the Hospital Corps as the medical officer may designate. The following articles are required: (1) The outfit for making a fingerprint on paper. (2) Gilsonite or powdered asphaltum. (3) Nitric acid, one part by volume; water, two parts by volume, in glass dish. A sufficient quantity of hydro- chloric acid should be added to this solution to facilitate the etching of the fingerprint. (4) Alcohol lamp with good flame or electric stove. (5) A device for holding the tag without touching the flat surfaces (not supplied, but device can be improvised by any carpenter’s mate). The steps in the preparation of the etchings are as follows: After collecting the various articles described above, take an ordinary “rolled” fingerprint on paper to show that the finger is clean, not too heavily inked, etc., and will make a good print. Make a “rolled” fingerprint (right index finger) on the metal tag in the usual manner. While ink is still fresh on the fingerprint, sprinkle it with finely powdered asphaltum. Some of this will mix with the ink and stick to the surface. The rest should be blown off. Now heat the tag slightly above the boiling point of water. Allow the tag to cool. Put it in the nitric acid solution for one-half hour. Remove, wash in water, and dry. Great care is to be exercised in the preparation of the tags, so as to avoid useless expense for tags spoiled in the process. The follow- ing cautions are to be noted: Remove all excess of ink from the finger, leaving a smooth, uniform coating. Press the finger lightly against the metal tag, avoiding to great pressure, as this will smear the impression. If the first impression with ink is not satisfactory, make it again 189 1578 CH. 11.—PHYSICAL EXAMINATIONS on a fresh tag. Tags that have been soiled with printer’s ink can be used again after thorough cleansing with gasoline. The cleansing must be thorough, as the least trace of ink left on the tag from a previous attempt will spoil the etching. (It is well to put aside the tags on which poor printing has been done and clean them up all at one time for use.) Be careful not to smudge the fingerprint. The next step is the application of the gilsonite or asphaltum. This should be fine enough to pass through a sieve having 100 meshes to the square inch. Sprinkle thickly on the wet surface. Remove what does not mix with and stick to the ink by tapping and blowing. The tag is now held with forceps over a flame or stove until the ink and asphaltum have melted together, forming sharp, glossy, black lines. If not enough heat is applied to completely melt the asphalt the action of the acid will be too powerful. Complete melting of the asphalt is indicated by the lines becoming glossy. If too much heat is applied the lines run together and are obliterated. The etching solution consists of concentrated nitric acid, one part by volume; water, two parts by volume plus a small quantity of hydrochloric acid. The solution may be placed in glass, china, or enameled ironware (if there are no nicks or cracks). A number of tags can be etched at once, but do not pile them one on top of the other. The name side should be down and the fingerprint side up while in the acid bath. This will prevent the lettering on the name side of the tag being removed by the acid. The etching process or acid bath should be watched and a tag lifted out from time to time to see how lively the action is. It can be moder- ated by adding water. Usually the process of etching requires one- half hour. The acid solution naturally weakens with use and should be renewed from time to time. If the corrosive action is low in beginning, concentrated hydrochloric acid (HC) may be added—1 part to every 30 of the nitric solution. If the name side of the tag is placed down in the acid bath, it is not necessary to replace any repellent on this side of the tag as the acid will not affect this lettering put on by the graphotype ma- chine. The fingerprint is etched with the fingerprint side up. The etching of the fingerprint is greatly facilitated by the addition of a small quantity of hydrochloric acid. The graphotype machine should be set so that the lettering on the tags is sufficiently deep to prevent the acid from eating away the lettering. The depth of the lettering on the tag can be regulated by the pressure device on the graphotype machine. 190 1594-1597 CH. 11.—PHYSICAL EXAMINATIONS SECTION XXV. CIVIL EMPLOYEES, PHYSICAL EXAMINATION OF Paragraph Provisions Governing Examinations 1594 When Required 1595 Form of Report 1596 Physical Examination Prior to Retirement for Physical Disability 1597 1594. Provisions Governing Examinations.—(a) The commandant of each navy yard or station shall recommend to the Civil Service Com- mission, through the district secretary, a medical officer, to be desig- nated a member of the labor board, for the purpose of conducting physical examinations and executing medical certificates free of charge for applicants for employment in positions under Groups I, II, HI, IV (a), and IV (6) of the Navy Yard Regulations. (b) The duties imposed above on medical officers are primarily for the protection of the Government, and therefore no fee shall be exacted for such examinations. In view of the liability under the Employees’ Compensation Act and the Civil Service Retirement Act, a careful execution of this work is enjoined. 1595. When Required.—Physical examinations of civil employees, in accordance with instructions issued by the United States Civil Service Commission, are required as follows: (1) Upon submitting application. (2) At time of reporting for duty or appointment. (3) Prior to retirement for physical disability. (4) For continuance beyond retirement age. 1596. Form of Report.—Reports of physical examinations will be submitted on such forms as may be indicated by the United States Civil Service Commission. 1597. Physical Examination Prior to Retirement for Physical Dis- ability.—The Act of May 29, 1930, as amended (U. S. Code, title 5, secs. 710-711), provides for retirement, under certain conditions, of employees of the classified civil service who become totally dis- abled for useful and efficient service by reason of disease or injury. No employee may be retired under this law unless examined by a medical officer of the United States, or a duly qualified physician or surgeon or board of physicians or surgeons designated by the Civil Service Commission for that purpose, and found to be disabled in the degree and in the manner specified therein. Certain classes of persons retired thereunder are required to undergo annual physical examina- tions. In accordance with the direction of the Secretary of the Navy medical officers shall make examinations of employees in the classified civil service for retirement. These examinations shall be made on 191 SEC. XXV. CIVIL EMPLOYEE EXAMINATIONS 1597 request of the commandant or commanding officer concerned in the cases of employees of the Navy Department, and on direct request of the Civil Service Commission in the cases of employees of other Federal activities. The examination and report will be made as indicated by the forms used. Note.—It will be understood that in no event will such medical officer be required to leave his station for the purpose of making the examination, as only in cases where the applicant is able to appear will a medical officer of the United States be requested to make an examination. CHAPTER 12 NAVAL HOSPITALS Paragraphs Section I. ESTABLISHMENT AND ORGANIZATION 1601-1606 H. ADMINISTRATION 1611-1626 m. ADMINISTRATIVE ASSISTANTS AND ADJUNCTS 1631-1663 IV. CLINICAL ADMINISTRATION AND FACILITIES 1661-1680 SECTION I. ESTABLISHMENT AND ORGANIZATION Paragraph Establishment 1601 Supervision 1602 Mission 1603 Command 1604 Organization 1606 Hospital Regulations 1606 1601. Establishment.—Naval hospitals, prior to March 4, 1913, were procured and erected as required by the Secretary of the Navy, under authority of section 4807, Revised Statutes. Since that date they may be constructed and extended by the Secretary of the Navy only after authorization by Congress (24 U. S. Code 14). 1602. Supervision.—Under the general supervision of the Secretary of the Navy, the Bureau of Medicine and Surgery is charged with the upkeep and operation of all naval hospitals (24 U. S. Code 15; art. 457, N. R.). 1603. Mission.—The mission of the naval hospital is: (1) Care of the sick and injured naval personnel with the object of their restoration to duty. (2) The disposition of those patients who require special treatment not satisfactorily available, or who are unfitted for retention in the naval service. (3) Treatment of other persons when authorized by competent authority. (4) Cooperation with military and civil authorities in all sanitary matters (par. 1612). 1604. Command.—Naval hospitals shall be commanded by naval medical officers (art. 170, N. R.). Should the officer regularly ordered to command a naval hospital be absent, disabled, relieved from duty, 193 1605-1611 CH. 12. NAVAL HOSPITALS or detached without relief, the command shall devolve upon the medi- cal officer next in rank present on the reservation and regularly attached to the hospital for duty. 1605. Organization.—(a) Definition.—A naval hospital is an integral unit of the naval establishment. As such it will conform, so far as its functions permit, with the established form of organization and administration employed in the naval service. The hospital organization must provide for both clinical and administrative func- tions. Since naval hospitals vary greatly in size, personnel, and facilities, a uniform or inflexible scheme of organization is impossible. The chart on the next page illustrates an organization applicable to a naval hospital. In hospitals of average size this organization may be modified as indicated by the dotted lines to provide for medical and surgical services to which other services are attached as depart- ments. In the smaller hospitals, due to lack of sufficient personnel and facilities, other arrangements will be necessary, even to the extent of assigning direct care of patients to the executive officer. It is an important duty of the commanding officer to effect an adequate, smoothly functioning organization (par. 1612 (a)). (b) Organization chart.—See following page. 1606. Hospital Begulations.—All orders and memoranda for the guidance of the staff and patients published by the commanding officer constitute the hospital regulations. Paragraph General Command Instructions 1611 The Commanding Officer—Specific Duties 1612 Limitations of Command Authority 1613 Executive Officer, General Duties 1621 The Officer of the Day 1624 Permanent Watches 1626 SECTION n. ADMINISTRATION 1611. General Command Instructions.—Instructions for the guid- ance of the commanding officer of a naval hospital necessarily must be general in character, leaving him the initiative to carry out the mission of the hospital in the most effective and economical manner. It must be borne in mind that the duties of the commanding officer embrace more than those of a military administrator. Discipline must be maintained but hospital rules and regulations governing the sick should be no more rigorous than necessary to provide effective administration. He is charged with the command and direction of the hospital for the purpose of effecting its mission. The commanding officer shall exact of all persons on the reservation compliance with Federal statutes, Navy Regulations and pertinent orders and instruc- tions of the Secretary of the Navy, the Bureau, and other competent authority. 194 SEC. II. ADMINISTRATION Neuro-Psych. Service Medical Service Laboratory Service Dental Service Nursing Service Clinical Out-patient Service TYPE ORGANIZATION CHART OF A NAVAL HOSPITAL E. E. N. & T. Service Urological Service Phy.-Ther. Service Surgical Service X-Ray Service Commanding Officer Executive Officer Officer of the Day Chief Master at Arms Hospital Corps Accounting Office Property Office Pharmacy Morale Activities Administrative Training Activities Personnel- Record Office Maintenance Department Commissary Disbursing Office Solid lines indicate an organization scheme for a large hospital. Broken lines indicate an organization scheme for a hospital of average size. Combinations and consolidations of the various administrative offices and activities and of the clinical services and departments will be effected by the commanding officer to meet requirements of small hospitals. 195 1612 CH. 12.—NAVAL HOSPITALS 1612. The Commanding Officer—Specific Duties.—(a) Organiza- tion scheme.—He shall maintain and direct an organization to ac- complish the mission of the hospital in accordance with the general scheme set forth in paragraph 1605. (b) Jurisdiction.—Subject to orders of higher competent authority he will exercise complete jurisdiction within the hospital reservation. Service of legal documents upon personnel on the hospital reservation by civil authority shall be in accordance with the provisions of ap- pendix C-13, Naval Courts and Boards, 1937. He shall require the maintenance of order within the reservation and obedience to Federal laws, including the penal laws of the State, Territory, or District wherein the hospital is located which have been adopted as Federal laws by section 289 of the United States Criminal Code (U. S. Code, Supp., title 18, sec. 468; art. 1515, N. R.). He will render necessary assistance or provide facilities for inspections, investigations, courts- martial, etc., held at the hospital on orders issued by competent naval authority. Services to patients and residents of the hospital reserva- tion and traffic therein shall be subject to such instructions as he may issue. (c) Cooperation with civil authorities.—He shall cooperate with the civil authorities in the control of contagious and infectious diseases and in matters of law enforcement. (d) Treatment of patients.—The commanding officer is respon- sible for the treatment of all patients. He shall require that he be kept informed of important developments. Surgical operations and special forms of treatment shall not be undertaken without his ap- proval. (e) Advice to next of kin.—He shall require prompt information regarding all patients whose condition is unsatisfactory and shall maintain a list of those whose condition may be serious, critical, or desperate. He shall keep the next of kin, or others who may have a proper interest, fully advised regarding such cases and in the event of death shall promptly notify them and obtain their instructions regarding shipment of remains or funeral arrangements desired; advising them of their rights as to burial in a national cemetery, or funeral expenses. (f) Assignment of personnel.—He shall formulate a policy regarding duty assignments of personnel which shall provide for rotation of duty for junior officers, nurses, and hospital corpsmen in order that professional experience shall be acquired in the various wards and services and that an equitable distribution of duty may be accomplished bearing in mind the mission of the hospital. 196 SEC. II.—administration 1612 (g) Training op staff personnel.—The commanding officer shall employ the facilities of the hospital for training of personnel of the medical department (par. 1652). (1) Training of specialists.—He shall provide for the instruction of assistants in the various specialties and shall bring to attention of the Bureau the names of medical department personnel showing evidence of proficiency in a specialty. (2) Basic courses for specialists.—He shall provide for basic training in all specialties in which the hospital affords sufficient clinical material for officers who may be ordered thereto for such training. (3) Training of interns.—He shall arrange assignments of officers serving internships at the hospital in such manner as to conform with civil requirements for such service. (4) Minimal surgical training.—He shall require that all medical officers of and below the rank of lieutenant commander shall be given such instruction as may be necessary to fit them to perform the usual surgical operations for emergencies which may be encountered at sea, such as intestinal obstruction, appendicitis, intestinal perforation, strangulated hernia, etc. (5) Conferences.—He shall, if circumstances permit, hold periodic con- ferences of the staff for the discussion of matters of professional and administrative interest. In order that professional interest of naval medical officers may be stimulated, he shall, when convenient, invite civilians, officers of the Navy and those of other public services whose experience and special attainments warrant, to address or otherwise participate in the hospital conferences. He shall seek to establish affiliation with civil professional activities, and to encourage members of the staff to avail themselves of privileges extended by local clinics and medical societies. He should extend to medical officers afloat or attached to other activities in the vicinity the privileges of attending conferences or clinics and availing themselves of the professional services of the hospital. (6) Hospital Corps instruction.—He shall make provision for in- struction of the staff hospital corpsmen in accordance with prescribed training courses and current instructions in Bureau circular letters. (7) Books.—He shall maintain an up-to-date professional library commensurate with the size and importance of the hospital. (8) Periodicals.—He shall request such publications as may be desired, by letter, annually, prior to January 31. The Bureau makes requisitions for all periodicals and determines annually those to be supplied to the various naval hospitals. (h) Military honors.—The commanding officer shall require that— 197 1612 CH. 12. NAVAL HOSPITALS (1) Personnel attached to the hospital be indoctrinated in matters of military courtesy. (2) Honors be rendered at colors. (3) In time of war, the hospital fly the Red Cross flag. This flag shall not be flown on the same staff as the national ensign but either from a separate staff or from a gaff or signal yard of the staff flying the national ensign. (1) Records and reports.—(1) The commanding officer is respon- sible for rendering of all official reports and returns and the preserva- tion of hospital records. He shall require that official records be made only upon official forms prescribed by the Navy Department or required by other Federal activities. Should other forms be con- sidered necessary the Bureau’s approval shall be obtained before adoption for hospital use. (2) Approval of health record entries.—Entries in health records must be approved by the commanding officer in every case involving misconduct. All other entries must also be approved by him or by an officer specifically delegated by him, who must be the executive officer or the chief of service charged with treatment of the patient. (3) Case records.—He shall exact punctilious compliance with instructions regarding the preparation of case records for each patient. For current requirements see Circular Letter I. (4) Preservation of records.—The commanding officer shall assure himself that the filing arrangements for correspondence, records, and reports are adequate and the filing system efficient. (j) Communications.—The commanding officer shall sign all hospital correspondence which shall be prepared in accordance with chapter 52, Navy Regulations, and arts. 75% and 76, Navy Regula- tions. Correspondence dealing with internal administration shall be forwarded to the Bureau direct (art. 2044 (9) and art. 1482, 4 (d), N. R.); but if involving military policy or the operation of some other unit, it shall be forwarded through the commandant (if the hospital is a unit of a navy yard) and the district commandant (art. 1482, 4 (e), N. R.). (k) Inspections.— (1) The commanding officer shall make, or cause to be made, such inspections as may be necessary to determine that the hospital is adequately equipped and manned, that it is functioning economically and efficiently, that all services, departments, and facili- ties are well managed and maintained and that compliance with Navy Regulations, orders and directives of the Bureau and hospital regulations is being enforced. (2) Inspections of personnel, both staff and patient, shall be held at stated times. 198 SEC. II.—ADMINISTRATION 1613 (3) Inspections of material, other than commissary stores, as to quantity, quality, and compliance with specifications shall be made on receipt. Periodic inspections shall also be made of up-keep, mainte- nance of minimum stocks, and adequacy of storage facilities for medical and surgical materials, as well as spare parts of all apparatus and machinery, and for compliance with policies of the Navy Department and the Bureau regarding periodic overhaul and replacement. (4) Inspection of commissary stores shall be made on receipt, as to quantity, quality, and compliance with specifications and contract agreements, and, periodically, as to preservation and adequacy of cold storage, chill rooms, and other food-storage facilities. (5) Inspection of buildings and grounds, exclusive of private quarters, shall be made weekly, but such inspections shall not be held on Sunday. (l) Safeguards for personnel and property.—The commanding officer shall provide necessary safeguards against fire, industrial and traffic hazards. He shall cause fire drill to be held at least once each week and shall assure himself that an effective fire bill is prepared and kept up-to-date, and that all personnel are indoctrinated regarding the sounding of alarms and the rescue of patients who are helpless, under restraint or confined in locked wards. He shall, when prac- ticable, forbid the placing of any but ambulant patients in buildings or wards that are not fireproof. When this is impracticable, he shall be assured that provision is made for quick opening of barred or locked windows and doors in event of fire or other emergency. Directions for procedure in such case shall be posted outside each locked ward or room. (m) Correction of defects.—The commanding officer shall, if he find personnel or facilities inadequate to permit accomplishment of the mission of the hospital, report the deficiency to the Bureau with appropriate recommendation for its correction. (n) Pecuniary transactions prohibited.—The commanding offi- cer shall prohibit any pecuniary dealings between patients and persons connected with the medical department except as may be required for the proper custody of valuables and effects and as authorized by competent authority (arts. 85 and 104, N. R.). (o) Slush funds prohibited.—The commanding officer shall pro- hibit unofficial or “slush” funds within the command. 1613. Limitations of Command Authority.—(a) Authority re- quired to order court martial.—Where authority is granted by the Secretary of the Navy, the commanding officer of a hospital is empowered to order summary courts martial or deck courts, and to assign such punishment as the commanding officer of a naval vessel 199 1621 CH. 12.—NAVAL HOSPITALS is authorized to inflict, on men attached to the hospital, whether on duty, or as patients (title 34, U. S. Code, sec. 1200, art. 26). Such punishment shall be recorded in the report book, in the journal of the officer-of-the-day, and in the service record of the individual. See Circular Letter I for commands currently authorized to order sum- mary and deck courts martial. (b) Limitation on recruiting.—The commanding officer, unless specifically authorized, shall not act as a recruiting officer. He may reenlist or extend the enlistments of members of the Hospital Corps under his command. (c) Discharges.—(1) Discharge jrom the hospital.—The com- manding officer shall not permit naval patients, other than super- numeraries, to be retained in hospital longer than is necessary to restore them to a condition of fitness for duty. He shall cause all naval patients who have been continuously under treatment for a period of 3 months, irrespective of place, to be brought before a board of medical survey for the purpose of determining the necessity for further treatment or recommending proper disposition. In deciding what constitutes a reasonable length of time for treatment he shall determine whether further retention in the service is unlikely to result in restitution of physical fitness for duty, and shall give due considera- tion to the medical history of the patient, his rank or rating, length of service, and all factors which establish his value to the service. Super- numerary patients shall not be discharged until restored to health or until maximum benefit from treatment has been achieved, except upon their own request or upon completion of the hospitalization directed by the Government agency by whose authority they were admitted. The commanding officer has authority to discharge super- numeraries for misconduct or for failure to cooperate in treatment. (2) Discharge jrom the Navy.—He shall not permit any person in the Navy to be discharged from the naval service for physical disability except upon the approved recommendation of a board of medical sur- vey. He shall, however, cause a medical survey to be held promptly in any case in which it is evident that the patient is permanently inca- pacitated for service or in which well recognized methods of treatment are incapable of restoring him to fitness for duty. 1621. Executive Officer, General Duties.—(a) Status and general duties.—The medical officer next in rank to the commanding officer, shall be the executive officer. His authority emanates from the com- manding officer. His duties in general are to have charge of the details in connection with the maintenance and operation of the hospital in all departments, including the care of patients. An order or directive issued by the executive officer shall be considered as having the ap- 200 SEC. II.—ADMINISTRATION 1621 proval of the commanding officer (arts. 182 and 932, N. R.). Accord- ingly, the executive officer shall keep himself fully informed regarding the policies of the commanding officer and all laws, Navy Regulations, and such orders, rules and instructions affecting the hospital as may have been issued by the Bureau or other competent authority. He shall keep the commanding officer fully advised concerning all matters of importance upon which he has taken action. (b) Specific duties of executive officer.—Unless otherwise directed by the commanding officer, the executive officer is charged with the specific duties listed below. (1) Organization.—The executive officer shall develop and main- tain a smoothly-operating organization of all services, departments, and facilities of the hospital. (2) Personnel.—He shall supervise the assignment of all officers of the hospital staff, nurses, hospital corpsmen, and civil employees. Detail of nurses shall be made through the chief nurse. (3) Discipline.— 1. He shall suppress disorders, correct abuses, and take all measures necessary to maintain discipline. 2. All infractions of law, Navy Regulations, and violations of discipline shall be promptly reported to the commanding officer for appropriate action. 8. All instances of commendable conduct exhibited and meri- torious acts performed by staff or patients shall be brought to the attention of the commanding officer as well as the names of mem- bers of the staff showing outstanding ability. (4) Supervision of patients.—He shall have general supervision of all patients. He shall keep himself informed and the commanding officer advised of their condition and shall exercise particular vigilance concerning such patients as may be considered to be in a serious, criti- cal, or desperate condition. He shall issue instructions for the guid- ance and control of officer and enlisted patients. In small hospitals he shall have immediate charge of treatment of such patients as the commanding officer may designate. (5) Liberty and leave.— 1. Liberty lists.—He shall direct the preparation of liberty lists and the issue of passes to enlisted men and employees to whom liberty may be granted. He shall prescribe the method for checking the departure and return of those granted liberty. 2. Leave.—He shall require all persons desiring leave to route leave requests through the chain of command and shall make recommendation concerning same to the commanding officer. 201 1621 CH. 12.—NAVAL HOSPITALS 3. Excuse from duty.—The executive officer shall receive all requests of officers to be absent from duty for short periods or from morning quarters. He shall act on such requests in the manner prescribed by the commanding officer. 4- Muster.—He shall make provision for daily muster of staff and patient personnel and report unauthorized absences to the commanding officer. (6) Uniform.—He shall promulgate the order for the uniform of the day for staff and patients and provide for inspection of uniform of liberty parties. (7) Provisions for security.—The executive officer shall make all necessary arrangements for safety of personnel and protection of property. 1. Guard.—The executive officer shall organize an adequate police system which shall include a master-at-arms detail and a station bill for the marine guard. If there be no marine guard attached to the hospital and the hospital reservation is not a unit of a naval reservation, he shall so organize the master-at-arms force that the grounds are adequately guarded. 2. Brig and locked patient spaces.—He shall maintain the secu- rity and fitness for their purposes of the brig and locked wards or rooms. 3. Traffic regulations.—He shall erect signs, provide safeguards, and promulgate such traffic regulations as may be necessary. 4. Industrial safety devices.—He shall report to the commanding officer absence of proper safety devices in shops, power plant, and elsewhere and shall, as soon as practicable, cause the installation and employment of such devices. 5. Fire drill.—He shall maintain an up-to-date fire bill, which shall include all requirements of paragraph 1612 (1). He shall prescribe the times at which the weekly fire drill shall be held and will, himself, take charge of all fire-fighting operations and fire drills. 6. Keys.—He shall make suitable arrangements for the safe custody of all hospital keys. 7. Safekeeping of valuables.—He shall cause moneys and valu- ables to be deposited with the disbursing officer for safekeeping, according to instructions in article 2167, Bureau of Supplies and Accounts Manual. If there be no disbursing officer attached to the hospital, the executive officer shall arrange for the safekeeping of money and valuables belonging to patients in such manner as the commanding officer may direct. 202 SEC. II. ADMINISTRATION 1621 8. Alcohol, narcotics, and poisons.—He shall require compliance with the instructions concerning the receipt, custody, and issue of alcohol, narcotics, and poisons contained in paragraphs 736 to 738 inclusive, of this manual. (8) Inspections.—The executive officer shall make necessary arrangements for all inspections and shall prepare schedules for all periodic inspections. He shall conduct, or designate an officer to conduct, such of these inspections as the commanding officer may direct. 1. Personnel inspections.—a. Officers.—He shall make such inspections as may be necessary to determine their efficiency in performance of duty and their compliance with uniform regula- tions. b. Enlisted men.—He shall inspect, or cause to be inspected, the clothing and outfits of all hospital corpsmen and be assured that each man has the required clothing, that uniforms are in good condition and comply with uniform regulations. 2. Materiel inspections.—a. He shall so plan materiel inspec- tions that he may be assured that requirements of paragraph 1612, (k), are being fully complied with. b. Commissary.—In addition to providing for inspections required by paragraph 1612 (k), he shall require that all meals be inspected by the officer-of-the-day and shall, at such times as he may elect, partake of the meals served to determine that food is properly prepared, of good quality, and sufficient in quantity. He shall, likewise, frequently inspect the special diets, their preparation and service, shall verify their adherence to diet pre- scriptions, and assure himself that they are appetizing, yet pre- pared with due regard to economy. c. Buildings and grounds.—On such days as the commanding officer does not inspect them, the executive officer shall make or cause to be made inspection of buildings and grounds and shall immediately bring to the attention of the commanding officer any unsatisfactory condition found. He shall inspect or require a report of inspection of condition of persons confined in the brig each day. (9) Morale.— 1. The executive officer shall endeavor to maintain a high level of morale of staff and patients. He shall arrange for and supervise proper facilities for recreation, entertainment, and athletics. See paragraphs 1645 to 1651, inclusive. 203 1624 CH. 12.—NAVAL HOSPITALS 2. Visitors.—He shall designate the hours when visitors may be received by patients. 3. Divine service and ministration.—He shall endeavor to provide an opportunity for those attached to the hospital to attend divine service and to obtain the services of a chaplain or other clergyman when patients express a desire for spiritual ministrations. Patients too ill to express a desire for spiritual ministrations shall be provided ministrations by a member of the faith professed by the patient. (10) Bulletin boards.—He shall have bulletin boards located in suit- able places where copies of all orders and notices issued by the com- manding officer and all general and special orders shall be posted. (11) Funeral arrangements.—He shall make all necessary arrange- ments for care of the dead. (12) Custody of prisoners.—He shall make arrangements, whenever practicable, to have court-martial prisoners under treatment guarded by the marine detachment of the hospital or by a special guard detailed for the purpose. He shall not organize an armed guard of hospital corpsmen unless it is impossible otherwise to guard such prisoners. 1624. The Officer-of-the-Day.—(a) Status.—The officer-of-the-day is the officer on duty as representative of the commanding officer, to whom he is responsible for compliance with orders and maintenance of good order and discipline. During the temporary absence of the commanding officer and the executive officer he is responsible for the efficient management of the hospital and has the authority necessary for enforcing compliance with their instructions. He shall render such routine reports as may be directed by the commanding officer or executive officer. In important matters he may at any time request advice from these officers or from senior watch officer or other senior officers available. (b) Tour of duty.—The tour of duty of each officer-of-the-day shall consist of 24 hours, beginning at 10 a. m. At this time the officer assigned as officer-of-the-day shall relieve his predecessor, receiving from him all special orders and instructions pertaining to his tour of duty. The officer-of-the-day shall remain on the hospital reservation during his tour of duty. The detailed and routine duties of the officer-of-the-day shall be such as may be prescribed by the commanding and executive officers. (c) Journal.—The officer-of-the-day shall keep a complete and succinct record of events during his tour of duty, in the journal of the officer-of-the-day provided for that purpose. This record shall include all entries required by the commanding officer. Upon the 204 SEC. II. ADMINISTRATION 1625 completion of his tour of duty the officer-of-the-day shall sign the journal and submit it to the commanding officer for approval. Any entries made by another officer, temporarily relieving the regular officer-of-the-day, shall be signed by the officer making such entries. The following are suggested as being of sufficient interest to be entered in the journal: All inspections; quality and quantity of meals; special ambulance trips; summary of all patients received and discharged; arrival and departure of personnel on leave; personnel reporting for duty or being detached; personnel absent without or over leave; confinement and release of offenders; meetings of all courts and boards; deaths; any unusual occurrences; and any event of which a record may be valuable. 1625. Permanent Watches.—(a) In addition to the officer-of-the- day the commanding officer shall cause to be established such other watches as may be necessary to care for patients or to police and guard the hospital property. These may include those listed below and such other details as may be considered necessary. (b) Senior watch.—At larger hospitals the commanding officer may establish a senior watch, consisting of officers not below the rank of lieutenant commander (generally excluding chiefs of services or heads of major departments) who shall act in an advisory capacity to the officer-of-the-day and whose tour of duty shall similarly be for 24 hours beginning at 10 a. m. (c) Master-at-arms.—The executive officer shall assign a chief pharmacist’s mate when practicable to serve as master-at-arms, and such additional assistants as may be necessary. The master-at-arms shall perform the duties prescribed in article 1264 Navy Regulations, except as they may be modified by the commanding officer in case of court-martial prisoners in custody of a marine guard. He shall have such duties in connection with administration of the hospital corpsmen as may be assigned by the executive officer and, unless otherwise provided, shall conduct the daily muster of these men. He shall make daily inspection of the fire-fighting apparatus and shall make report thereof to the executive officer; he shall also keep a record of the dates on which fire extinguishers are due for overhaul. He shall accompany the commanding officer on routine inspections. Police and other tasks for which he shall be responsible will be assigned by the executive officer. (d) Marine guard.—A marine guard shall be maintained when- ever practicable to perform guard duty on the hospital reservation. If no marine guard is assigned for duty at the hospital, the executive officer shall organize and establish such guard as may be necessary, under the charge of the master-at-arms. 205 1631-1632 CH. 12.—NAVAL HOSPITALS (e) Chief pharmacist’s mate-of-the-day.—A watch shall be established in larger hospitals, to provide continuous presence of a responsible chief pharmacist’s mate. This watch shall include all chief pharmacist’s mates attached to the hospital who shall serve thereon in rotation. The master-at-arms, or other person designated, shall keep the bill of the chief pharmacist’s mate’s watch up-to-date and submit it to the executive officer for approval. The duties of the chief pharmacist mate-of-the-day shall be those prescribed by the commanding officer and the executive officer. SECTION III. ADMINISTRATIVE ASSISTANTS AND ADJUNCTS Paragraph Administrative Officers 1631 Maintenance Officer 1632 Accounting Officer 1633 Property Officer 1634 Commissary Officer 1635 Special Messes 1636 Personnel-Record Officer 1637 Disbursing Officer 1638 Additional Administrative Facilities 1639 The Pharmacy 1640 Morale Activities 1645 Ship’s Service Store 1646 Library 1647 Recreation and Athletics 1648 Occupational Therapy 1649 American Red Cross 1650 Morale Regulations, Bureau of Navigation 1651 Training 1652 Civil Employees 1653 1631. Administrative Officers.—For transaction of hospital business, preparation of correspondence, records, reports and returns, and the orderly filing of documents, there shall be established in large naval hospitals the various offices and activities shown under administra- tive on the organization chart (par. 1605). In succeeding paragraphs are outlined the tasks assigned to officers charged with the adminis- tration of these offices and activities. In small hospitals such com- binations of offices or activities shall be effected by the commanding officer as may be necessary to accomplish the tasks assigned with the personnel available. 1632. Maintenance Officer.—This officer shall be a commissioned or warrant officer whose duties will include the care and upkeep of buildings and grounds, power plant, ambulance service, and super- vision of civil employees (except clerical and commissary), and such other duty as may be assigned. He shall see that the hospital ceme- 206 SEC. m.—ADMINISTRATIVE ASSISTANTS 1633-1634 tery is appropriately maintained and that the graves of service per- sonnel therein are properly marked. See paragraph 3059 for proce- dure for obtaining headstones. 1633. Accounting Officer.—This officer shall be a commissioned or warrant officer. He shall— (1) Be the assistant to the commanding and executive officers in financial and property matters. (2) Be responsible for the accounting records and keep the com- manding officer informed relative to the status of allotments, expen- ditures, etc. Keep the land and buildings, the equipment, and the supplies ledgers and be responsible for their accuracy. (3) Supervise the preparation of requisitions, public vouchers, pay rolls, invoices, requests for allotments, surveys, annual estimate, and advanced year’s estimates of expenditures, and all other forms and reports pertaining to financial matters. (4) Submit to the commanding officer, via the executive officer at the end of each month, a report on the condition of allotments, and a statement of the balances available, or prospective over obligations, if any, with reasons therefor. (5) Keep himself informed of the laws, regulations, and instruc- tions governing the preparation and submission of accounting records and reports and keep the books of account and financial records of the hospital. 1634. Property Officer.—This officer shall be a commissioned or warrant officer subordinate to the accounting officer. He shall—(1) Be custodian of all stores and equipment belonging to the hospital, exercising personal and careful supervision over them and the eco- nomical use and expenditure thereof, reporting any deficiencies to th© accounting officer. (2) Receipt for, issue, and account for all stores (except commis- sary stores) and equipment. (3) Maintain the proper records of equipment issued to the several services and facilities of the hospital, obtain and retain in file custody receipts therefor, and report any deficiency in property charged to these activities by the accounting officer. (4) Take an actual inventory of stores (except commissary stores) on hand at the end of each quarter and report to the accounting officer any differences in the amounts as shown on the books and as determined by actual inventory. (5) Correlate the inventories from the various activities of the hospital submitted by the heads of the activities as of June 30, each year, and prepare the annual inventory for submission to the Bureau. (6) Be responsible for management and accounting of the phar- 207 1635 CH. 12. NAVAL HOSPITALS macy unless the commanding officer shall specifically except this responsibility from his assigned tasks. (7) When detached or relieved he shall make a complete inventory of all equipment and supplies (except commissary stores) and transfer them to his successor. 1635. Commissary Officer.—This officer shall be a chief pharmacist or pharmacist, who shall— (1) Be responsible for all commissary stores and provisions, and for all equipment pertaining to the commissary. (2) Be in charge of all personnel assigned to commissary activities. (3) Upon receipt of stores and provisions verify their weights, con- dition, compliance with specifications and contract requirements; be punctilious in complying with hospital regulations concerning inspec- tion of commissary stores and in event of any items being unsatis- factory notify the executive officer or officer-of-the-day. (4) Exercise strict supervision over upkeep, cleanliness and food handling in galleys, mess halls, store room, diet kitchens (unless the latter be in charge of the Nurse Corps) and all other commissary activities. (5) Be responsible for all meals, giving unremitting attention to the preparation and service of food and exacting constant attention to economy and cleanliness. (6) Supervise the issue of all commissary stores used at the hos- pital. The daily issue of stores shall be made in accordance with menus prepared in advance and approved by the executive officer, based on personnel to be subsisted and requirements of approved special-diet lists. Individual rations will be inspected to determine that they are adequate but not excessive. (7) Directly supervise messing facilities and issue special articles of diets, rations, or subsistence in kind upon presentation of accom- plished diet sheets or other requisition as may be authorized by the commanding officer. (8) Permit no special mess to be set up without specific authority of the commanding officer. (9) Comply with ail regulations and instructions concerning special messes listed in paragraph 1636 so far as they apply to the commissary. (10) Prepare or supervise the preparation of daily receipt and expenditure vouchers for the preceding day, submit them to the com- manding officer, via the executive officer, and post them, or cause them to be posted in the commissary ledger. (11) Take an acutal inventory of stores and provisions on hand at the end of each month and report in detail to the commanding officer, via the executive officer, any discrepancies between amounts as shown 208 SEC. III.—ADMINISTRATIVE ASSISTANTS 1636 on the books and those found by actual inventory; certify a copy of the inventory to the property and accounting officers as a permanent hospital record. (12) Keep himself informed of regulations and instructions governing the procurement, inspection, storage, and issue of provisions and the proper method of obtaining provisions on contract. Keep a complete file of Navy Department provision specifications for reference in inspections. (13) When detached or otherwise relieved from duty, make a com- plete inventory of all commissary stores, provisions, and equipment under his charge and transfer custody thereof to his successor. Details of a typical naval hospital commissary organization are shown in the Hospital Corps Manual. 1636, Special Messes.—(a) The commanding officer may authorize separate messing facilities which shall be issued rations or subsistence in kind from the commissary department. (b) Rations issued to these messes shall be identical with the ration served in the general mess hall. No distinction in quantity or quality shall be made in favor of any mess when issued subsistence in kind. The quantities issued shall be computed on the basis of the number to be served. (c) Government property required for the establishment and main- tenance of messes shall be charged to the custody of the commissary officer. If the nurses’ mess is located within the nurses’ quarters, custody of Government property for the nurses’ mess shall be assigned to the chief nurse. (d) The commissary employees assigned to special-mess duty shall be supervised by the commissary officer. (e) The privileges of the messes are limited to service personnel attached to the hospital and their guests, civil employees, and duly accredited Red Cross representatives. (f) The charge for meals shall be at the rate of 25 cents per meal for those who are not entitled to subsistence in kind. This charge shall be paid by all personnel for meals served their guests. At the end of the month or earlier, if necessary, the commanding officer shall furnish the cognizant disbursing officer a letter directing by name and amount the charges for meals to be checked against the accounts of personnel indebted to the Government for meals. A copy of this checkage letter shall be delivered to the accounting officer. The amounts so checked shall be credited to the naval hospital fund. (g) Officers may be assigned to or withdrawn from the duty-officers’ mess only upon written application to the commanding officer. 209 1637-1645 CH. 12.—NAVAL HOSPITALS 1637. The Personnel-Record Officer.—This officer shall be a com- missioned or warrant officer. He shall— (1) Be responsible for the personnel-record office. (2) Have custody of the general files of the hospital and be respon- sible for the proper filing of all personnel records and correspondence. (3) Have custody of service records, health records, case papers, and all correspondence and other documents pertaining to naval personnel whether on duty or in a patient status. (4) Be responsible for the preparation of personnel returns required by the Bureau, and by other bureaus of the Navy Department or by other governmental departments. (5) Keep himself informed of the laws, regulations, and instructions governing the maintenance, preparation, and submission of personnel reports. (6) Be responsible and make all arrangements for funerals and dis- position of remains of the dead, when so directed by the executive officer. 1638. The Disbursing Officer.—The duties of this officer are specified by the Bureau of Supplies and Accounts Manual. Pay of civil em- ployees, equipment and supplies required by a disbursing officer are chargeable to the Bureau of Supplies and Accounts funds (par. 3048). 1639. Additional Administrative Facilities.—There are in addition other necessary facilities which, in function, may be chiefly clinical or may be maintained for both patients and staff, but the management of which pertains to the administrative rather than the clinical aspect of hospital management. These are listed in the following paragraphs. 1640. The Pharmacy.—As noted in paragraph 1634 the ultimate responsibility for the management of the pharmacy Tests, usually, upon the property officer. A pharmacist or chief pharmacist’s mate shall be detailed for the immediate supervision of its maintenance and operation. The necessary number of additional pharmacist’s mates shall be detailed by the executive officer for instruction and to act as assistants. No prescription shall be filled except on order of a medical or dental officer. All prescriptions shall be numbered, filed, and properly safe-guarded. Instructions concerning the custody and issue of alcohol, narcotics, and poisons shall be scrupulously obeyed. Pre- scriptions for narcotics shall be filed separately and given a distinct series of numbers preceded by the letter N. See paragraphs 736 to 738, inclusive, for instructions governing custody and issue of alcohol, narcotics, and poisons. 1645. Morale Activities.—These activities and the method of their administration will vary according to the size and location of the hos- pital. In smaller hospitals direct supervision may be exercised by the 210 seo. m.—administrative assistants 1646-1648 executive officer; in larger institutions, or to meet local needs, the commanding officer may delegate their supervision in whole or in part to commissioned or warrant officers designated as morale or welfare officer, athletic officer, ship’s service officer, etc. These activities shall be created and rules established for their administration, when considered desirable, by the commanding officer and when so created the maintenance of their proper functioning shall be a duty of the executive officer. 1646. Ship’s Service Store.—This store may be established in ac- cordance with the provisions of article 1442 (7) Navy Regulations. The activities of this store shall be conducted in accordance with regulations issued by the commanding officer based on article 1442, Navy Regulations, and instructions issued by the Bureau of Naviga- tion (Bureau of Navigation, Regulations for Ship’s Service Depart- ment, March 15, 1930). The profits of this store shall be expended for the welfare of the personnel in such a manner as the commanding officer may direct. Under existing instructions the sale of alcoholic liquors is prohibited. See appendix D, Circular Letter I. 1647. Library.—(a) The professional library.—The books re- ferred to in paragraph 1612 are obtained from the medical supply depots on requisition to the Bureau, and are charged against funds allotted to the hospital. (b) The general library.—(1) A limited list of new books of gen- eral interest is shipped quarterly and without request to most naval hos- pitals. Such books are not charged against allotments made to the districts or to the hospitals. Books not automatically supplied may be requested by letter addressed to the Chief of the Bureau of Naviga- tion. (2) See Chapter VI, Bureau of Navigation Manual, for regulations governing library records, quarterly reports, inventory, surveys, and reconditioning of books. (3) In certain cases the Bureau of Navigation has authorized the employment of civilian librarians. Correspondence relating to such librarians, including resignations, requests for appointment, etc., shall be forwarded to the Bureau of Navigation via the Bureau. In the case of certain smaller hospitals, the Bureau of Navigation, at the request of the commanding officer, has detailed librarians for part- time duty. If no civilian librarian is authorized, the commanding officer shall make necessary provision for the management and care of the library. 1648. Recreation and Athletics.—(a) The commanding officer shall provide for such exhibitions of moving pictures and other entertain- ment, athletic events, etc., as he considers proper and shall assign 211 1649-1652 GH. 12.—NAVAL HOSPITALS necessary rooms, or ground space for the purpose as well as storage space for athletic gear and other paraphernalia required. (b) Allotments are granted by the Bureau of Navigation from the appropriation recreation for enlisted men to the commandant of naval districts for the maintenance of welfare activities of the district. Allotments to naval hospitals are included in the allotments granted to the commandant of districts to an indicated amount. These funds may be expended at the discretion of the commanding officer for the recreation, amusement, comfort, contentment, and health of the Navy. Correspondence in regard to such allotments should be addressed to the Bureau of Navigation via the commandant of the district and the Bureau. 1649. Occupational Therapy.—This activity may be set up by the commanding officer if a useful purpose may be served thereby, and if funds and personnel are available. Its duties may include all types of training or employment given in hospitals, whether for actual thera- peutic purposes, or as jireliminary work toward a vocation. 1650. American Red Cross.—See appendix C for the function of the American Red Cross as it relates to naval activities. 1651. Morale Regulations, Bureau of Navigation.—Bureau of Navi- gation Manual, part E, chapter 7, should be consulted for informa- tion and regulations pertaining to morale, athletics, motion pictures, music, dramatics, education, libraries, social hygiene, Red Cross ac- tivities, etc. 1652. Training.—(a) A secondary mission of a naval hospital is to instruct Medical Department personnel in their professional duties (par. 1603). The commanding officer is directed to provide training for the staff (par. 1612). Chiefs of services or officers in charge of departments shall use the clinical material and facilities available to instruct and indoctrinate junior officers and hospital corpsmen. Nurses shall likewise use the material available to them to instruct hospital corpsmen in nursing and to indoctrinate junior nurses in naval practice and ward management. (b) Educational officer.—The commanding officer shall desig- nate a commissioned or warrant officer to supervise the instruction of hospital corpsmen in the subjects required by training courses pre- scribed by Bureau of Navigation. This officer shall prepare a curric- ulum and submit it, together with the names of hospital corpsmen required to take the courses, to the executive officer for approval. (c) Special training.—Such provision as the commanding officer may consider necessary shall be made for instruction of special groups, such as indoctrination courses for internes or classes for applicants for entrance to the Naval Academy. 212 SEC. IV.—CLINICAL ADMINISTRATION 1653-1663 1653. Civil Employees.—Regulations pertaining to civil employees in naval hospitals are incorporated in Navy Department and Civil Service regulations and instructions which are abstracted and quoted for information and compliance in circular letter C, appendix D, of this manual. Paragraph Organization 1661 Regulations 1662 Chiefs of Services 1663 Heads of Departments 1664 Ward Medical Officers 1665 Junior Medical Officers 1666 Nursing Service 1670 The Chief Nurse_ 1671 Nurses 1672 Hospital Corpsmen 1673 Patients 1674 Disposition of Patients 1677 Supernumerary Patients 1678 Clinical Facilities. 1680 SECTION IV. CLINICAL ADMINISTRATION AND FACILITIES 1661. Organization.—The type organization chart in paragraph 1605 indicates the usual organization of clinical activities of a naval hos- pital. That paragraph also describes modifications to be applied to fit the organization as charted to smaller hospitals. In every hospital, when existing conditions permit, there shall be created at least the two major services—medical and surgical. As indicated in the alter- native arrangement on the organization chart, the linking of other services and facilities therewith, or combinations of facilities, shall be accomplished in such manner as the commanding officer may deter- mine as best fitting local conditions. 1662. Regulations.—The executive officer shall prepare, or cause to be prepared, rules and regulations governing the general and routine administration of services and facilities for approval by the command- ing officer and have them posted in the activities concerned. In addi- tion, each chief of service, head of department or facility and ward medical officer shall issue, subject to approval of the executive officer, such instructions as are necessary to meet the special needs of his activity. 1663. Chiefs of Services.—These officers shall be the senior officers attached to the services. They shall—(1) Supervise and, when necessary, direct the treatment of all patients in wards assigned to their services; (2) keep the commanding officer and executive officer advised of the status of patients, particularly of those in serious, critical, or desperate condition; (3) hold themselves in readiness for 213 1664-1665 CH. 12. NAVAL HOSPITALS consultation at all times; (4) arrange conferences which may be necessary with chiefs of other services; (5) make appropriate recom- mendation to the executive officer if, for any reason, facilities of the hospital appear inadequate to properly care for a patient under their charge; (6) formulate rules, subject to approval by the executive officer, to provide prompt and efficient service to the entire hospital by all laboratories and clinical facilities under their supervision; (7) require that all records and reports be accurate, kept up-to-date and promptly completed on discharge of patient from wards under their supervision; and (8) certify the final approval of such of these records as may be directed by the commanding officer (par. 1612 (i)). Chiefs of technical services shall be governed by paragraph 1664, except that rules, schedules, etc., shall be submitted directly to the executive officer for approval. 1664. Heads of Departments.—These shall be the medical officers in charge of laboratories, treatment rooms, and other clinical facilities not constituting services, which may be organized for administrative purpose according to the alternative scheme indicated on the type or- ganization chart in paragraph 1605, or any suitable modification thereof. These officers shall be charged with the custody of technical apparatus, appliances and equipment pertaining to their departments and shall exercise careful supervision over its use or operation by all subordinates. They shall carefully instruct all personnel assigned to their departments as assistants or for instruction, as to technique and materials to be used, safeguards and precautions to be employed and, if proper, the manner of preparing reports. They shall formulate rules, after consultation with the chiefs of service, for the preparation of patients for treatments to be given or tests to be performed, and shall prepare schedules for the reporting of patients or submission of material for examination. They shall cooperate with the chiefs of services in the development of an efficient, smoothly operating plan for the thorough, prompt, and economical clinical study of all import- ant cases, or special treatments to be given by their departments. They shall render reports of all treatments given, examinations made or tests performed, on the prescribed forms. They shall keep careful records of all work accomplished in their departments. 1665. Ward Medical Officers.—(a) The medical officers in charge of wards shall have full administrative authority over and responsibil- ity for their wards, under the supervision of their chief of service. They shall be responsible for the neatness of the wards and appurtenances thereto under their charge. They shall exercise personal supervision over the sick, being attentive to their welfare and comfort. They shall require nurses and hospital corpsmen to be considerate and attentive 214 sec. iv.—clinical administration 1666-1671 in the care of all patients and punctilious in the administration of medicines. They shall be responsible for the proper keeping of all ward books, records, and forms. They shall see that all ward property is carefully used and properly accounted for. They shall sign the morning reports of sick and report to the proper authority all patients who, in their opinion, are fit for duty, for convalescent detail, or who should be surveyed. They shall verify the property list when relieving another officer in charge of the ward. They shall require compliance with all instructions or orders regarding custody, issue, and administration of alcohol, narcotics, and poisons in the wards under their charge. (b) They shall visit the sick at such hours as may be prescribed and whenever necessary. They shall consult with the chief of service regarding patients under their charge when necessary and keep him fully advised regarding all patients in their wards. In emergency, the commanding officer, executive officer, or any other available officer, may be called in consultation. They shall accompany the command- ing or executive officers when they make inspections of the ward and invite their attention to matters of professional or administrative interest. They shall inform the officer-of-the-day before they leave the hospital of the condition of patients under their charge who may need special attention during their absence. (c) They shall familiarize themselves with instructions and orders regarding procedures to be followed in case of fire. In the event of fire, they shall supervise the removal of helpless and bedridden patients from the wards under their charge, using any personnel available. 1666. Junior Medical Officers.—(a) Such officers when not serving as ward medical officers shall perform such duties as may be assigned by the commanding officer (b) Watch officers.—All junior medical officers, except interns, shall be detailed for duty as officer-of-the-day, being governed by such instructions as may be issued by the executive officer and approved by the commanding officer. (c) Interns.—Junior officers serving internships at the hospital shall stand watches, attend such lectures and meetings and perform such duties as the commanding officer may prescribe. 1670. Nursing Service.—The type organization plan, paragraph 1605, shows the nursing organization as a service in large and average size naval hospitals. Under the direction of the commanding officer and executive officer it is supervised by the chief nurse. 1671. The Chief Nurse.—(a) General duties.—The title the chief nurse shall be applied to the senior chief nurse assigned to duty at the hospital. She shall perform, subject to adaptation to the naval 215 1671 CH. 12. NAVAL HOSPITALS service, the functions of a superintendent of nurses in a civilian hospital. She shall exercise general supervision of the nursing service, shall keep herself advised of policies of the commanding officer in relation there- with and shall supervise the execution of all orders, regulations, and instructions of the executive officer affecting the nursing service. She is responsible for maintenance of order among nurses. She shall re- quire obedience to orders and report violations of discipline. She may, in case of neglect of duty, failure to obey orders, or flagrant breach of discipline, temporarily relieve a nurse, reporting her action immediately to the executive officer. She shall be assigned adequate office space for transaction of the business of the nursing service. When absent from duty by reason of leave, sickness, or other cause, the nurse next junior to her shall perform her assigned duties. (b) Specific duties of the chief nurse.—(1) Assignment of nurses.—The chief nurse shall prepare all detail lists and arrange working schedules for all nurses attached to the hospital and submit them to the executive officer for approval. She shall exercise care in arranging schedules so that they provide an equitable distribution of duty. (2) Inspections.—The chief nurse shall inspect or cause to be in- spected at least twice each day all parts of the hospital in which nurses are employed. She shall accompany the commanding officer on all routine inspections of the hospital and such other inspections as he may direct. (3) Illness of nurses.—She shall make prompt report to the execu- tive officer of the illness of any nurse which may require relief from duty. (4) Training.— 1. Conferences.—The chief nurse shall arrange, subject to approval of the executive officer, conferences of nurses for the discussion of professional problems. 2. Instruction of nurses serving probationary period.—She shall instruct, or supervise the instruction of nurses serving proba- tionary periods and others who may have recently reported for duty, in naval and hospital regulations applying to the Nurse Corps. This instruction shall include a careful explanation of the content of chapter IV of this manual and of such other subjects as may be necessary to prepare nurses for examination at the end of probationary period. 3. Instruction of hospital corpsmen.—She shall make provision for the instruction of hospital corpsmen in nursing and shall, if 216 SEC. IV.—CLINICAL ADMINISTRATION 1672 so directed, conduct examinations in this subject and report the results to the executive officer. (5) Linen room.—She shall have charge of the linen room and shall keep, or cause to be kept, a careful record of all linen received, issued, sent to and returned from the laundry. She shall see that all linen issued is properly marked. (6) Reports and records.—The chief nurse shall have custody of nurses’ records and shall prepare the required reports concerning the nursing service for approval by the commanding officer. She shall prepare and maintain up-to-date records, including the following— 1. Nurses’ health records; except that, when a nurse is on the sick list her health record shall be in custody of the medical officer in charge of her treatment. 2. Nurses’ folders, in which shall be filed copies of orders, authority for leave, information slips, fitness reports, and other data of which record shall be made. This folder shall show the name and designation, name and address of next of kin, and dates of reporting, transfer, or discharge. S. A day book in which shall be entered the detail of each nurse for the day, nature of the duty, hours on duty, etc. 4. A correct inventory of Government property in the nurses’ quarters. (7) Nurses' mess.—Ii this is maintained in the nurses’ quarters, the chief nurse shall assume supervision thereof and shall be charged with the custody of all mess gear, utensils, and other Government property issued to the mess. She shall submit requisitions for provisions at times specified by the executive officer and shall be responsible for the economical operation of the mess. (8) Morale.—She shall make appropriate recommendation to the executive officer regarding proper maintenance of the nurses’ quarters, provision of recreational facilities, and other matters which contribute to the health, contentment, and general welfare of the nurses attached to the hospital. 1672. Nurses.—(a) Status.—The term nurses as used in this paragraph includes nurses and all chief nurses junior to the chief nurse. All nurses shall be under the immediate supervision of the chief of the nurse service in accordance with executive instructions provided for that service (par. 1662). (b) Right to communicate with the commanding officer.— Article 182 (10), Navy Regulations, applies to nurses. Applications 217 1672 CH. 12.—NAVAL HOSPITALS to communicate with the commanding officer on official matters shall be made to the executive officer via the chief nurse. He shall inves- tigate the matter to be discussed and shall express his approval or disapproval. (c) Assignment to duty.—Nurses shall be assigned to duty by the executive officer on recommendation of the chief nurse. (1) Special assignments.—Nurses assigned to special details, as technicians, charge of linen room, etc., shall perform such assigned duties when approved by the commanding officer. (2) Ward duties.—Nurses on duty in wards shall have the necessary authority over patients and hospital corpsmen for purposes of direct care of the sick and of ward work, and shall be responsible for their conduct, attention to duty, and practical instruction in the details assigned to them (art. 1649 (5), N. R.). In case of neglect of duty, inattention to instructions, or insubordinate conduct on the part of the hospital corpsmen, the nurse shall report the matter to the ward medical officer or, in his absence, to the officer-of-the-day. (3) Absence from post of duty.—A ward nurse shall not absent her- self from her post of duty without being properly relieved, or shall she be called away from her station and duty except for urgent reasons. (4) Inspections with medical officer.—The nurse on duty shall always, unless excused, accompany any officer officially visiting the part of the hospital under her charge. (5) Ward keys.—The ward nurse is responsible for all keys under her charge. When leaving the ward such keys must be transferred to the nurse relieving her, or to the senior hospital corpsman in the ward, who shall be held responsible for them and for the maintenance of discipline during the absence of the nurse. (6) Alcohol, narcotics, and poisons.—Nurses shall see that all nar- cotics and liquors issued to the ward are properly labeled and kept under lock and key when not in actual use. Nurses shall be espe- cially careful with regard to poisons, and shall see that they are prop- erly labeled and that the instructions concerning the care of poisons and the use of poison containers are faithfully enforced. (7) Valuables of patients.—Nurses shall see that the money and valuables of patients who so request are safeguarded in accordance with instructions of the executive officer. This shall always be done in cases where the patient’s condition is such as to render him unfit to safeguard his possessions. A list of such money and valuables shall be made and filed for future reference. (8) Confined or restricted patients.—The ward nurse shall be notified when a patient is to be confined in the brig or is to be restricted to the ward or hospital. When a patient is confined in the brig or is 218 SEC. IV.—CLINICAL ADMINISTRATION 1673 absent without leave for over 24 hours she shall have all his clothing and belongings collected, make a list of the same, and turn a copy of the list and the property over to the master-at-arms. When a patient leaves the hospital she shall see that he turns in all ward linen and wearing apparel issued to him. (9) Ward records, books, forms, and reports.—The ward nurse shall be responsible for the proper keeping of the prescribed ward records, books, forms, and reports. See Circular Letter I for current require- ments. (10) Night duty.—No nurse shall be required to perform continuous night duty exceeding a month, unless required by some special exigency of the service, and no nurse shall ordinarily be called upon for night duty more frequently than 1 month out of every 3. In tropical stations the periods of night duty should be of shorter dura- tion. Except in emergency, a nurse relieved from night duty shall have a free day before assignment to regular day duty. In hospitals having an active service, a nurse assigned to a special detail may be excused from night duty on the recommendation of the chief nurse, but ordinarily a nurse must take routine assignment in these duties. (11) Responsibility of night nurse.—The night nurse shall be informed of all emergencies arising in the wards and is held responsible for giving timely information to the officer-of-the-day. All orders relative to treatment during the night shall be given to her, and she shall be responsible for compliance with such orders. Before going off duty she shall see that the prescribed morning routine is in opera- tion and shall leave a written report of any incident worthy of note occurring during her tour of duty. (12) Nurse as night supervisor.—In hospitals where a chief or a senior nurse is assigned as night supervisor, she shall make rounds of all wards and shall arrange for the relief of nurses and hospital corps- men during the night lunch hour and shall be responsible for the morning report submitted to the chief nurse. (13) Hospital corpsman as ward nurse.—The senior ward hospital corpsman, in the absence of a ward nurse, shall serve in a similar capacity, and shall be subject to all the regulations pertaining to such duty. 1673. Hospital Corpsmen.—(a) Duties.—Enlisted men of the Hospital Corps shall perform such duty as the commanding officer may direct. They shall familiarize themselves with orders and instructions in relation to the work of the wards, offices, or special details to which they may be assigned by the executive officer. They shall also thoroughly familiarize themselves with their stations and 219 1674-1677 CH. 12.—NAVAL HOSPITALS duties in connection with fire drill, with all regulations for safeguarding patients and Government property, and the maintenance of order. (b) Command.—While actually on watch, hospital corpsmen are under the immediate command of the officer in charge of the service, department, ward, office, or activity to which they are assigned for duty. When not on watch they are under immediate command of the executive officer, represented, for this purpose, by the master-at- arms, unless the organization of the hospital shall vest the immediate command of the hospital corpsmen off watch in some other officer. (c) Special duties.— (1) Master-at-arms. See paragraph 1625 (c). (2) Mate-of-the-day watch. See paragraph 1625 (e). 1674. Patients.—(a) Duties.—For administrative purposes pa- tients are attached to the naval hospital and come under the immediate supervision of the medical officer in charge of their ward. They shall be required to comply with all lawful orders and instructions governing their conduct and treatment. (b) Convalescent patients.—Convalescent service patients may, under article 1192, Navy Regulations, be detailed for light duty as a part of their course of treatment. Such details should be made only when it is evident that no physical injury would be caused thereby. 1677. Disposition of patients.—(a) Discharged to duty.—Officers and enlisted men shall be discharged to duty promptly upon recovery and shall be transferred in accordance with the provisions of the Bureau of Navigation Manual (D-7017). (b) Transfer to another naval hospital.—In case a patient under treatment at a naval hospital desires transfer to another naval hospital for continuance of treatment, a request for such transfer shall be submitted by the patient to the Bureau of Navigation via the commanding officer, and the Bureau. The commanding officer shall, in forwarding such request, state diagnosis and probable length of time before the man will be available for duty. The patient should be informed that the transfer will be approved only upon condition that he agrees to pay the expenses of transportation. Transportation at the expense of the Government will be only upon the approved recommendation of a board of medical survey. Upon approval of the request, orders for transfer are issued by the Bureau of Navigation (Bureau of Navigation Manual, D-7017). (c) Patients ill 3 months.—Patients, other than supernumeraries, shall not be retained in a hospital longer than is necessary to restore them to a duty status, and those who have been under treatment for 3 months irrespective of place shall be brought before a board of medical survey in order that further treatment or other disposition 220 SEC. IV.—CLINICAL ADMINISTRATION 1678 may be authorized. (See par. 1613 and Bureau of Navigation Manual, D-9116.) (d) Patients in need of further treatment at expiration of enlist- ment shall be so reported, by letter, to the Bureau of Navigation, and retained in the hospital for treatment for the convenience of the Government. (e) Patients permanently incapacitated.—(1) See paragraph 1613. (2) In case of expiration of enlistment of any man who is being treated for an injury or disease incurred in line of duty, whose con- dition is such that reenlistment would be impossible, a medical sur- vey shall be held in order that he may be discharged for physical disability instead of being discharged on account of expiration of enlistment. Discharge for physical disability is necessary to give men injured or diseased in line of duty the benefits of preference in civil-service appointments, eligibility for hospitalization under the Veterans’ Administration, and for pensions. 1678. Supernumerary Patients.—(a) All persons not on the active list of the Navy or Marine Corps are to be considered supernu- meraries when admitted to a naval hospital for treatment. (b) There are several classes of supernumeraries eligible for treat- ment in naval hospitals for various reasons. These classes, the authorization for their admission and the compensation for their treatment are itemized in Circular Letter F, appendix D of this manual. (c) While Veterans’ Administration beneficiaries are officially classed as supernumeraries, they shall, in other than official reports and correspondence, be designated veterans and not supernumer- aries. In reporting United States Veterans’ Administration patients on statistical returns the abbreviation VAP shall be used. (d) Medical records of supernumeraries shall be kept and dis- posed of in accordance with instructions contained in chapter 14, paragraph 2207. The medical records of Veterans’ Administration patients shall be prepared and disposed of according to instructions issued by the Veterans’ Administration. (e) Supernumeraries under treatment shall be required to conform to the regulations governing the internal administration of the hospital. Assignment of Veterans’ Administration patients to work- ing details should be in accordance with instructions from the Vet- erans’ Administration or its local representatives. It is assumed, however, that these patients will be available for such work as they may be able to do in maintaining the order and cleanliness of the part of the hospital they occupy. Restrictive or punitive measures 221 1680 CH. 12.—NAVAL HOSPITALS applied to veterans shall conform as nearly as possible to the in- structions issued by the Veterans’ Administration. 1680. Clinical Facilities.—(a) Operating rooms.—The chief of a service shall be responsible for the operating and accessory treatment rooms of that service. All operating rooms and their appliances shall be kept in readiness for immediate use. Each operating room shall be provided with an operation book in which shall be recorded all data regarding each operation. The chief of service, or the head of the department shall issue necessary instructions to nurses and hospital corpsmen regarding procedures and technique and shall properly train assistants and others assigned for instruction in opera- tive surgery. Reference should be made to paragraphs 1663 and 1664. (b) Other clinical facilities.—X-ray rooms, electrocardiograph rooms, basal metabolism rooms, special diet kitchens, laboratories, physical therapy rooms, etc., vary widely in accordance with the size and activity of naval hospitals. Regulations for their manage- ment and operation will likewise vary according to the organization scheme set up for the various hospitals. The commanding officer shall cause to be formulated all necessary rules for their economical maintenance, safeguarding of patients, operators and instruments, apparatus, and machines; limitations as to personnel permitted to operate instruments, apparatus, and machines; instruction to be given by officers or others in charge, etc. Paragraphs 1662, 1663, and 1664 contain further instructions to officers charged with super- vision of clinical facilities. 222 CHAPTER 13 SPECIAL HOSPITALS Paragraphs Section I. THE ARMY AND NAVY GENERAL HOSPITAL 2101-2111 n. HOSPITALS FOR PULMONARY TUBERCULOSIS- 2121-2122 in. THE UNITED STATES NAVAL HOME 2142-2143 IV. HOSPITALS FOR THE INSANE 2151-2160 V. OTHER GOVERNMENT HOSPITALS 2170-2173 VI. HOSPITALS FOR MALIGNANT DISEASE 2176-2178 SECTION I. THE ARMY AND NAVY GENERAL HOSPITAL Paragraph Establishment 2101 Organization 2102 Administration and Function 2103 Persons Eligible for Treatment 2104 Authority for Admission 2105 Admission of Retired Personnel 2106 Admission of Ex-service Men 2107 Papers Required for Admission. 2108 Types of Cases Treated 2109 Length of Treatment 2110 Charges for Treatment 2111 2101. Establishment.—An Army and Navy Hospital at Hot Springs, Ark., was established by an act of June 30, 1882. All patients were made subject to the rules and articles for the government of the armies of the United States by an act of March 3, 1909. 2102. Organization.—The organization of the hospital shall con- sist of one medical officer of the Army, who shall command it, and such other medical officers of the Army and Navy as may be neces- sary, to be detailed by the Secretary of War or the Secretary of the Navy, respectively. (Executive order of August 25, 1892.) 2103. Administration and Function.—The hospital is under the direction of the Secretary of War. While equipped to care for all types of medical and surgical conditions (except insanity and pul- monary tuberculosis), this hospital is to be utilized by the Navy chiefly in connection with those types of diseases and injuries for which the Hot Springs mineral waters have been found to be of special benefit. Venereal cases are not admitted, except chronic cases of at least 1 years duration. 2104. Persons Eligible for Treatment.—The following classes of patients may be admitted: 223 2105-2107 CH. 13.—SPECIAL HOSPITALS (1) Officers, nurses, commissioned warrant officers, warrant officers, and enlisted men of the Navy and the Marine Corps on the active lists and midshipmen of the United States Naval Academy. (2) Beneficiaries of the United States Veterans' Administration to the extent of the beds allotted to that agency by the Surgeon General, United States Army, from time to time. (3) Officers, nurses, commissioned warrant officers, warrant officers, and enlisted men of the Navy and the Marine Corps on the retired lists or the equivalent thereof. (4) Members of the Naval Reserve and Marine Corps Reserve who are entitled to treatment in naval hospitals. (5) Honorably discharged officers, nurses, commissioned warrant officers, warrant officers, midshipmen, and enlisted men of the Navy and the Marine Corps (including National Guard forces, Naval Mili- tia, volunteers and drafted or selected men in the service of the United States). 2105. Authority for Admission.—The Chief of the Bureau may grant authority for admission to the Army and Navy General Hos- pital, Hot Springs, Ark., to all persons in the Navy or Marine Corps, when on an active-duty status, on the report of a board of medical survey or, when that is impracticable, on the certificate of a naval medical officer, clearly stating the applicant’s disability. If a naval medical officer be not available, a certificate from the attending physician will be considered. 2106. Admission of Retired Personnel.—Retired personnel (includ- ing enlisted men transferred to the Fleet Reserves after 16 or more years of naval service) of the Navy and Marine Corps should apply direct to the Surgeon General, United States Army, for admission to the Army and Navy General Hospital, Hot Springs, Ark. (Consult par. 2107 (b).) 2107. Admission of Ex-service Personnel.—(a) Honorably dis- charged ex-service personnel may be admitted to this hospital, when vacant beds are available, upon permits issued by the Surgeon General of the Army, from whom blank forms of application can be obtained. (b) The application forms must be properly filled in, giving all necessary information in relation to the applicant, and be certified to by a practicing physician, stating the nature of the disability and the probable period required for hospital treatment. Permits issued thereunder are not valid after 21 days from their date. Patients admitted under this authority may be discharged from the hospital by the commanding officer at any time he may deem proper. 224 SEC. I.—ARMY AND NAVY GENERAL HOSPITAL 2108-2110 (c) Applicants should not go to Hot Springs expecting admission to this hospital until permits have been issued. Expenses to and from the hospital must be defrayed by the patient. 2108. Papers Required for Admission.—Upon admission to the hos- pital the patient shall present for the information of the hospital authorities the following papers relating to his case: (1) Order for admission. (2) Copy of report of medical survey (if recommended by a board of medi- cal survey). (3) Health record (if patient is on active list). (4) Copy of hospital ticket (if transferred from a ship or station). (5) A statement of patient’s condition (if admitted upon certificate of a civilian physician). 2109. Types of Cases Treated.—(a) Relief may reasonably be ex- pected at the Hot Springs in the following conditions: The various forms of rheumatism, including muscular and articular conditions, after the acute inflammatory stage has passed; neuralgia and neu- ritis and metallic poisoning of a chronic nature; paralysis not of central origin; the earliest stages of locomotor ataxia and any other chronic degenerative change of nervous origin (insanity excepted); chronic nephritis and cardiorenal diseases (the early stages only); chronic skin diseases, especially the squamous varieties; arterioscle- rosis; neurasthenic conditions, due to overwork, and other condi- tions accompanied by high blood pressure; certain metabolic diseases, such as gout, diabetes, obesity, etc.; chronic gastro-intestinal diseases which have not responded to continued hospitalization at other places (gastric neuroses, post dysenteric colitis, chronic intestinal stasis, etc.). (b) Admission to this hospital of all such cases, regardless of their severity, is not, however, contemplated. Its facilities wall not be extended to mild and transient cases which should yield to ordinary treatment, but are reserved for those of a serious and obstinate char- acter which, through resisting ordinary methods of relief, promise a rapid and permanent recovery from the use of the waters of the springs. 2110. length of Treatment.—The physical condition of an officer or enlisted man on the active list under treatment at this hospital will be reported from time to time by the commanding officer of the hos- pital, with his opinion as to length of treatment necessary and with his recommendations to The Adjutant General of the Army for the information of the Secretary of War, who will determine when the treatment shall be discontinued and what further action shall be taken. Ordinarily officers on the active list will not remain under treatment longer than 3 months. In the case of an officer who may 225 2111-2122 CH. 13.—SPECIAL HOSPITALS have been retained under treatment 6 months a full history of the case and its prognosis will be reported to The Adjutant General of the Army by the commanding officer of the hospital. 2111. Charges for Treatment.—(a) For officers and enlisted men of the Navy and Marine Corps on the active list, and for those officers and enlisted men on the retired list (including enlisted men transferred to the Fleet Reserve after 16 or more years of naval service) whose admission to the Army and Navy General Hospital has been author- ized by the Bureau under the act of January 19, 1929, the Surgeon General of the Army will bill the Bureau at the rate of $3.75 per day per patient. The accounts of all officers, active and retired, will be checked for hospital ration in the same manner as when in a naval hospital. (b) For retired officers who are admitted on authorization of the Surgeon General of the Army (par. 2106), subsistence charges of $1.50 per day will be collected by the hospital. SECTION II. HOSPITALS FOR PULMONARY TUBERCULOSIS Paragraph Fitzsimons General Hospital 2121 Disposition of Cases of Pulmonary Tuberculosis 2122 2121. Fitzsimons General Hospital.—The Bureau has made arrange- ments with the Surgeon General of the Army to receive a limited number of naval cases of pulmonary tuberculosis for treatment in Fitzsimons General Hospital at Denver, Colo. (a) Character of cases to be transferred.—It is desired in general that only officers, midshipmen, nurses, and those members of the enlisted personnel whose total service is such that they are eligible for transfer to the Fleet Reserve or Fleet Marine Corps Reserve, and whose cases are unusual and seem not to be doing well under local conditions, in whom the diagnosis is confirmed by positive sputum, be recommended for transfer to Fitszimons General Hospital. Fur- thermore, only those who give promise of deriving positive benefit from the prevailing climatic influences should be so transferred. (b) Commanding officer to be notified.—It is directed that when patients are to be transferred to the Fitzsimons General Hospital the commanding officer be informed by a timely dispatch giving (1) the number of patients, (2) their names and ranks or ratings, (3) whether or not they are stretcher cases, (4) the date and hour of departure en route, and (5) the probable date and hour of arrival at Denver, Colo. 2122. Disposition of Cases of Pulmonary Tuberculosis, (a) All cases of pulmonary tuberculosis shall be transferred to the nearest naval hospital for treatment and further disposition. As it is the 226 SEC. II. HOSPITALS FOR PULMONARY TUBERCULOSIS 2122 policy of the Department not to return to a duty status either officers or enlisted men in whose cases a diagnosis of pulmonary tuberculosis has been established, commanding officers of naval hospitals shall have such cases surveyed and disposition recommended as follows (art. 1141 (3) N. R.): (b) Officers.—(1) Officers may be surveyed and recommended for transfer to Fitzsimons General Hospital, where they will be retained under treatment for not longer than 6 months. Medical surveys shall be held in accordance with paragraph 3423. (2) Officers whose transfer to Fitzsimons General Hospital is not contemplated should be surveyed with recommendation that they appear before a retiring board. (3) Recommendation to appear before a retiring board must not be delayed in order to afford an officer the opportunity to become due for promotion. (See sec. 956, naval courts and boards, 1937.) (c) Midshipmen.—(1) Midshipmen will be surveyed, and, when deemed advisable and they so desire, their transfer to Fitzsimons General Hospital may be recommended. If not sooner discharged, a medical survey shall be held at the expiration of 6 months’ treatment. (2) Where transfer to Fitzsimons Hospital is inadvisable or is not desired, midshipmen will be surveyed after a sufficient period of treatment and recommendation made that they be discharged from the service. (d) Enlisted personnel (other than those eligible for transfer to the Fleet Reserve or Fleet Marine Corps Reserve).—(1) Tuberculosis patients received by a naval hospital, in whom a diagnosis is estab- lished by definite x-ray and laboratory findings, shall immediately be brought before a board of medical survey if they desire and their condition warrants and permits transfer to a Veterans’ Administration facility. The survey board shall make a statement as to the line of duty status of the disease and shall recommend discharge from the naval service if the patient is eligible for transfer to a Veterans’ Administration facility. The board also shall make recommendation as to the advisability of retention as a supernumerary until arrange- ments have been completed for the transfer to a Veterans’ Administra- tion facility. (2) Patients who do not desire such transfer may be recommended for further treatment in the naval hospital, with a view either to educating the individual to care for himself or to bring about an arrest of the infection, after which discharge from the service by medical survey will be accomplished, with recommendation (if de- sired by the patient) for further retention as a supernumerary until claim for pension shall have been acted on. If pension is granted, 227 2142 CH. 13.—SPECIAL HOSPITALS they then become eligible for treatment in any naval hospital on forfeiture of pension while hospitalized (sec. 4813, R. S.). (3) Patients ineligible for transfer to a Veterans' Administration facility may be recommended for further treatment as in subpara- graph (2) above, with subsequent survey for discharge from the service. (4) Application for domiciliary or hospital care in Veterans’ Ad- ministration facilities will be made on Veterans' Administration form, copies of which are obtainable on request from any facility or regional office of the Veterans’ Administration. (5) When executed by the applicant, the form is to be forwarded to the manager of the nearest Veterans’ Administration facility. The said manager will determine eligibility of the applicant and necessity for domiciliary or hospital care, and will make the necessary arrange- ments for admission, including notice to the applicant. If a bed is not available in the facility to which the application was sent, the form will be forwarded therefrom to the nearest facility having suitable accommodations, and the applicant will be notified of such forwarding of application, with instructions to await advice from the manager of the facility to which the application was transmitted. (6) An applicant must be granted prior authority from the man- ager of the facility accepting his admission before he shall report to or return from a Veterans’ Administration facility. Transportation, including Pullman accommodations when necessary, meal and lodging requests, and expenses of an attendant when required in the judg- ment of the manager, will be supplied by the Veterans’ Administra- tion to enable the patient to proceed to a facility for hospital treat- ment of a disease or injury incurred, or aggravated in line of duty in the active military or naval service; and to accomplish return there- from to the place from which he proceeded to hospital, upon comple- tion of treatment and regular discharge from the facility. (7) Cases not requiring or desiring further treatment shall be sur- veyed and their discharges recommended. Paragraph Persons Eligible for Admission 2142 Procedure for Admission 2143 SECTION III. THE UNITED STATES NAVAL HOME 2142. Persons Eligible for Admission.—(a) Officers of the Navy or Marine Corps may be admitted to the benefits of the Naval Home by permission of the Secretary of the Navy. (b) Enlisted men of the Navy or Marine Corps may be admitted to the benefits of the Naval Home by authority of the Bureau of Navigation under the following classifications: 228 SEC. IV. HOSPITALS FOR THE INSANE 2143-2151 (1) Class C4).—Discharged enlisted men of the Navy or Marine Corps who have served in the Mexican War, the Civil War, the war with Spain, the Philippine insurrection, the World War, or any other service where the armed forces of the United States have been em- ployed and their lives hazarded in military operations and who are, by reason of wounds, sickness, old age, or other disability, unable to support themselves by manual labor. (2) Class (B).—Discharged enlisted men of the Navy or Marine Corps who become disqualified for further service by wounds, or in- juries received, or by disease contracted in the service in the line of duty, and who are unable to support themselves by manual labor. (3) Class (C).—Retired enlisted men of the Navy or Marine Corps unable to support themselves by manual labor. 2143. Procedure for Admission.—(a) Application for admission to the Naval Home should be in duplicate and addressed to “The Gov- ernor, United States Naval Home, Philadelphia, Pa.” Blank forms may be obtained from the governor of the Naval Home or from the Bureau of Navigation, Navy Department, Washington, D. C. (b) Applicants for admission to the Naval Home should furnish the information required on the application form issued by the Bureau of Navigation. (c) Applicants must produce a certificate from a medical officer of the Navy, or if such officer be not available, an attested certificate from a reputable physician, setting forth the nature of their dis- ability and the fact that they are not able to support themselves by manual labor. (d) Transportation is not furnished to the Naval Home except in destitute cases. Paragraph Insane Patients, Where Transferred 2151 Recommendation for Attendants to Accompany Insane Patients 2152 Records to be Obtained Prior to Transfer 2153 Persons Eligible for Admission to St. Elizabeths Hospital 2155 Records Required for Admission to St. Elizabeths Hospital 2156 Receipt for the Person and Personal Effects 2157 Disposition of Patients in St. Elizabeths Hospital 2158 Death of Patient at St. Elizabeths Hospital 2159 Discharge of Insane Patients by Medical Survey 2160 SECTION IV. HOSPITALS FOR THE INSANE 2151. Insane Patients, Where Transferred.—(a) Whenever practi- cable, patients giving evidence of being insane shall be transferred to a naval hospital for treatment and determination of their mental condition. 229 2152-2155 CH. 13.—SPECIAL HOSPITALS (b) Patients under treatment for mental disease in naval hospitals in the United States who require commitment to an institution for the care of the insane, or who require prolonged observation to establish diagnosis, will be transferred upon approved recommenda- tion of a board of medical survey to the United States Naval Hos- pital, Washington, D. C., on the Atlantic coast, or to the United States Naval Hospital, Mare Island, Calif., on the Pacific coast. 2152. Recommendation for Attendants to Accompany Insane Patients.—Boards of medical survey concerned with recommending the transfer of insane to hospital should consider the practicability in each individual case of having the patient transferred under the charge of an officer or a responsible chief pharmacist’s mate, with other attendants, if necessary. Statement as to necessity for such detail shall be incorporated in the recommendation of the board for transfer. 2153. Records to be Obtained Prior to Transfer.—Medical officers having charge of an insane patient, prior to recommending transfer to a hospital for the insane, shall endeavor to obtain an accurate family and personal history of the patient and to secure statements relative to the case from any institution for the insane of which the patient may have been an inmate. Any such statement shall be appended to the report of medical survey. 2155. Persons Eligible for Admission to St. Elizabeths Hospital, District of Columbia.—(a) Section 4843, R. S. provides— The superintendent, upon the order of the Secretary of War, of the Secretary of the Navy, and of the Secretary of the Treasury, respectively, shall receive, and keep in custody until they are cured, or removed by the same authority which ordered their reception, insane persons of the following descriptions: First. Insane persons belonging to the Army, Navy, Marine Corps, and Revenue-Cutter Service. Second. * * * Third. Men who, while in the service of the United States, in the Army, Navy, or Marine Corps, have been admitted to the hospital, and have been thereafter discharged from it on the supposition that they have recovered their reason, and have, within three years after such discharge, become again insane from causes existing at the time of such discharge, and have no adequate means of support. Fourth. Indigent insane persons who have been in either of the said services and been discharged therefrom on account of disability arising from such insanity. Fifth. Indigent insane persons who have become insane within three years after their discharge from such service, for causes which arose during and were produced by said service. (b) Retired personnel of the Navy and Marine Corps and enlisted men of the Fleet Reserve and Fleet Marine Corps Reserve, trans- ferred thereto after 16 or more years of naval service, may be com- mitted to St. Elizabeths Hospital by the Navy Department. 230 SEC. IV. HOSPITALS FOR THE INSANE 2156-2159 2156. Records Required for Admission to St. Elizabeths Hospital.— For the information of the superintendent of St. Elizabeths Hospital the following records shall accompany each patient upon his admission to the hospital: (1) Order for admission. (2) Copy of report of medical survey. (3) Copy of hospital ticket. (4) Health record, to be given to the naval medical officer on duty at St. Elizabeths Hospital, who will make a concise record of the case and upon completion of the record will forward it to the commanding officer, United States Naval Hospital, Washington, D. C., for disposition (par. 2216). (5) Copy of Department of Interior form. (Procurable from the Bureau.) 2157. Receipt for the Person and Personal Effects.—Upon the admission of a patient into St. Elizabeths Hospital the hospital authori- ties will furnish the medical officer or attendant delivering such patient with a receipt for the person and personal effects of the patient. This receipt shall be forwarded without delay to the Bureau for the permanent files of the Bureau. 2158. Disposition of Patients in St. Elizabeths Hospital.—(a) Com- missioned and warrant officers.—(1) Commissioned and warrant officers under treatment in St. Elizabeths Hospital shall be returned to a duty status only upon the approved recommendation of a board of medical survey. (2) As soon as it becomes definitely established that a commis- sioned or warrant officer under treatment in St. Elizabeths Hospital is permanently incapacitated for active service, he shall be surveyed and recommendation made that he appear before a retiring board. (b) Enlisted personnel.—Before disposition is made of enlisted men of the Navy or Marine Corps under treatment in St. Elizabeths Hospital, a medical survey shall be held. If they are found definitely insane, recommendation for disposition shall be made, as follows: (1) Men who are able to care for themselves, and who will not be a menace to themselves or to the community, will be discharged from the service and from treatment at St. Elizabeths Hospital. (2) When it is deemed advisable, patients in St. Elizabeths Hospital may be discharged from the service and delivered into the custody of the next of kin upon written request and receipt. (3) Patients who require permanent or prolonged treatment will be discharged from the service and retained in St. Elizabeths Hospital. 2159. Death of Patient at St. Elizabeths Hospital.—The official death report shall be prepared and signed by the medical officer assigned to 231 2160-2170 CH. 13.—SPECIAL HOSPITALS duty in connection with the patients from the Navy and Marine Corps in St. Elizabeths Hospital, and shall be approved and forwarded to the Bureau by the commanding officer, United States Naval Hos- pital, Washington, D. C. 2160. Discharge of Insane Patients by Medical Survey.—(a) Boards of medical survey recommending the discharge of harmless insane, able to care for themselves or to be cared for by friends or their families, shall enter on the report of medical survey the statement “Not a menace to himself or the community.” (b) Insane patients entitled to treatment under the Vet- erans’ Administration.—The survey board shall make a statement as to the line of duty status of the disease and shall recommend discharge from the naval service if the patient is eligible for transfer to a Veterans’ Administration facility. The board also shall make recommendation as to the advisability of retention as a supernumerary until arrangements have been completed for the transfer to a Veterans’ Administration facility. For procedure see paragraph 2122 (d). Paragraph Admission of Naval Patients to Other Government Hospitals 2170 Army Hospitals 2171 Public Health Service Hospitals 2172 Veterans’ Administration Facilities 2173 SECTION V. OTHER GOVERNMENT HOSPITALS 2170. Admission of Naval Patients to Other Government Hospitals.— (a) Under provisions of an act of January 19, 1929, the Bureau is authorized to provide for the care and treatment, in Government hospitals other than naval, of officers and enlisted men of the Navy and Marine Corps, active and retired, and of members of the Naval Reserve or Marine Corps Reserve entitled to treatment in naval hospitals. Such hospitalization, however, is subject to three con- ditions: First, the authorization of the Bureau; second, the unavail- ability of appropriate naval hospital facilities; and, third, the consent of the authorities of other Government hospitals concerned. (b) The treatment of naval pensioners in Government hospitals other than naval is not authorized under this act. The classes of personnel to whom the act applies are limited to: (1) Officers and enlisted men of the Navy and Marine Corps on the active or retired list. (2) Officers and enlisted men of the Naval Reserve and Marine Corps Reserve while employed on active duty. (3) Transferred members of the Fleet Reserve and Fleet Marine Corps Reserve, whether on active duty, in an inactive status, or on the retired list of the regular Navy. 232 SEC. V.—OTHER GOVERNMENT HOSPITALS 2171 (c) The routine admission of active duty personnel to other Government hospitals, in the absence of naval hospital facilities, may be authorized by commanding officers or other competent naval authorities (except as noted in par. 2173, relating to Veterans’ Ad- ministration facilities), in accordance with paragraph 3161. Special- ized treatment, however, will be governed by paragraphs 2105, 2121 et seq., and 3163. (d) Requests for treatment for retired officers and retired enlisted men and transferred members of the Fleet Reserve (inactive) and Fleet Marine Corps Reserve (inactive) in other Government hospitals will be submitted to the Bureau for prior consideration. If practi- cable, such personnel should report to a naval hospital or naval medical officer for examination, and the hospital or medical officer will then submit report to the Bureau covering diagnosis and present condition, with recommendation as to the character of hospitaliza- tion required and statement as to whether appropriate naval hospital facilities are available. If a naval hospital or naval medical officer is not available for this examination, a certificate from the attending physician will be considered. In any case, the Bureau may validate only those expenses incurred on and subsequent to the date of authori- zation. (e) No transportation expenses may be paid for retired or inactive personnel under this act. 2171. Army Hospitals.—(a) Navy Regulations (art. 1189 (6)) specify that in the absence of naval hospital facilities, the hospitals of the United States Army or of the United States Public Health Service, where available, shall be utilized for the hospitalization of the person- nel of the Navy and Marine Corps. (b) Officers and enlisted men of the Navy and Marine Corps on the active list will be admitted to any Army hospital on the request of their immediate commanding officers, and they may be admitted on their own request, their commanding officers not being present, if in the opinion of the medical officer in command of the hospital or the surgeon of the station such admission is necessary (art. 1204 (5), N. R.). (c) Bills covering the cost of hospitalization in Army hospitals of naval personnel on the active list will be submitted by the War Department directly to the Bureau for settlement. (d) Retired officers and enlisted men of the regular Navy and Marine Corps and enlisted men of the Navy and Marine Corps transferred to the Fleet Reserve after 16 or more years of service, may be admitted to any Army hospital on their own request subject to the approval of the medical officer in command of the hospital or 233 2172-2173 CH. 13.—SPECIAL HOSPITALS the surgeon of the station (art. 1204 (6), N. R.). When retired officers are so admitted, the Army hospital subsistence charge will be collected by the hospital from the individual concerned. If, however, admission has been authorized or approved by the Surgeon General of the Navy, the hospital charges will be billed by the War Depart- ment to this Bureau and the pay of the officer will be checked for subsistence in the same manner as when admitted to a naval hospital. 2172. Public Health Service Hospitals.—(a) In the absence of available naval hospital facilities, the hospitals of the Public Health Service (sometimes known as marine hospitals) are to be utilized for the care of naval personnel on the active list in the same manner that Army hospitals are so utilized, the Bureau being billed for all hospital charges. (b) Retired personnel (including enlisted men transferred to the Fleet Reserve after 16 or more years of service) may not be admitted to Public Health Service hospitals except on the prior authority of this Bureau (par. 2170). 2173. Veterans’ Administration Facilities.—(a) Personnel on the active list.—(1) Officers and enlisted men of the Navy and Marine Corps on the active list, and members of the Naval Reserve and Marine Corps Reserve when on active duty status, may be admitted to Veterans’ Administration facilities upon authority from the Medical Director, Veterans’ Administration, Washington, D. C., or upon re- quest made by their immediate commanding officers upon the manager of a facility in the regional area in which the immediate commanding officer is stationed, in accordance with the following procedure: The immediate commanding officer will furnish such manager all information necessary in making such request, including the nature of the disease or injury, the name and address of the patient’s next of kin, and instructions concerning disposition of the patient upon discharge from hospital. The manager of the facility so contacted will, if the facility is equipped to render the type of treatment required and a bed is available therein, accept the application. If the facility first so contacted is not equipped to render the type of treatment required or has no available bed, the manager will promptly refer the request of the immediate commanding officer to the nearest suitable Veterans’ Administration facility, asking that the request be handled thereat and the immediate commanding officer be advised. The latter will be informed of such reference of his request by the manager first contacted. Emergency requests will be given preferential attention. If a bed is not available, the immediate commanding officer will be promptly so informed and will be further advised that his request has been filed, and will be honored as soon as a bed is available. If hospitalization can be effected, it will be authorized by transmittal of the upper part of Veterans’ Administration Form 2557, admission card, to the immediate commanding officer for presentation by the patient upon his arrival at the facility accepting him. 234 2176 SEC. VI.—HOSPITALS FOR MALIGNANT DISEASE (2) For Navy personnel on active duty all transportation, including attendants, if necessary, incident to admission to and discharge from Veterans’ Administration facilities will be supplied by the Navy Department. At a sufficient time in advance of contemplated dis- charge of a Navy patient from a facility, the manager will directly notify the proper naval authority (as shown on the back of Form 2557) of the impending discharge, and will request transportation to be forwarded for the patient’s return travel. If an attendant or attendants will be required to accompany the patient upon discharge, the manager will so state in his communication requesting the for- warding of return transportation. (b) Retired personnel.—(1) Retired personnel (including enlisted men transferred to the Fleet Reserve or Fleet Marine Corps Reserve after 16 or more years of service) may be admitted to Veterans’ Administration facilities as naval patients under an act of January 19, 1929 (par. 2170) on request of the Bureau and approval by the Medical Director, Veterans’ Administration, in which case hospital charges will be billed to the Bureau for settlement. (2) The above classes of personnel also may be admitted to Vet- erans’ Administration facilities as patients of the Veterans’ Admin- istration, provided that a part, at least, of their active service was war service. Application should be made directly to the Veterans’ Administration facility in which hospitalization is desired. Trans- portation expenses to and from the facility will be at the expense of the applicant. (c) Ex-service personnel.—(1) Under the regulations of the Veterans’ Administration provision is made for hospitalization or domiciliary care, in the facilities of that Administration, of naval personnel honorably discharged by reason of physical disabilities incurred or aggravated in line of duty during peace time enlistments. Included are those in need of hospital treatment for such diseases and injuries and those suffering with permanent disabilities, or tuberculosis, or neuropsychiatric ailments which incapacitate them from earning a living and who have no adequate means of support. (2) The procedure for transfer to a Veterans’ Administration facility is set forth in paragraph 2122 (d). SECTION VI. HOSPITALS FOR MALIGNANT DISEASE Paragraph Naval Hospital, Brooklyn, N. Y 2176 Naval Hospital, San Diego, Calif 2177 Transfer of Patients, Requirements 2178 2176. Naval Hospital, Brooklyn, N. Y.—This hospital is the regular treatment hospital for malignant cases in the Navy, serving ships 235 2177-2178 CH. 13.—SPECIAL HOSPITALS and stations on the Atlantic coast and the ninth naval district. The advantages of treatment at this hospital may be summarized as follows: (1) Every malignant case or a suspicious case of malignancy is seen in consultation with the staff of Memorial Hospital within 24 hours after admission. Treatment in each case is outlined by the chief of service and carried out under his direct supervision. (2) The Memorial Hospital has a large and outstanding staff of specialists devoting full time to the treatment of cancer. (3) The services of any or all of the above specialists are available to naval patients without charge. Charges are made only when actual operative work requiring hospitalization at the Memorial Hospital becomes necessary. (4) Radium from a Government deposit at Memorial Hospital is available in the element pack, as plaques, and as gold-filtered radon seeds. There is no charge for the preparation or administration of radium unless, as previously stated, actual operative work is involved. (5) All malignant cases in the naval hospital are under the daily supervision of one medical officer who has been trained in the manage- ment of this type of disease. Patients returning for periodic examina- tions are first seen at the naval hospital and then taken to Memorial for final examination by the staff physician who originally planned the patient’s treatment. 2177. Naval Hospital, San Diego, Calif.—This hospital serves as the concentration point for malignant cases on the West coast, having facilities and contacts which make available the latest and best advice and apparatus necessary for the treatment of malignancy. 2178. Transfer of Patients, Requirements.—A slide and a portion of the tissue should be forwarded with each patient transferred. If no biopsy has been done, a statement to that effect should accompany the patient. In view of the importance of early diagnosis, dispatch request for prior approval of report of medical survey is suggested, to expedite transfer. 236 CHAPTER 14 Paragraphs Section I. OPENING, CUSTODY, TRANSFER, AND TERMINATION.. 2201-2217 n. NAME AND RANK, RATE, OR OTHER DESIGNATION.. 2251-2253 IH. THE DESCRIPTIVE SHEET 2261-2263 IV. THE MEDICAL HISTORY SHEETS 2281-2290 V. THE MEDICAL ABSTRACT 2301 VI. THE DENTAL RECORD 2311-2319 VH. SPECIAL DUTY ABSTRACT 2331 VIH. THE SYPHILITIC ABSTRACT.. 2350 HEALTH RECORDS SECTION I. OPENING, CUSTODY, TRANSFER, AND TERMINATION Paragraph Navy Regulations 2201 Officers 2202 Reserve Officers 2203 Midshipmen 2204 Nurses 2205 Enlisted Personnel 2206 Supernumeraries 2207 Custody 2208 Health Records to be Examined Upon Receipt 2209 Health Record Lost, etc 2210 Disposition 2211 Expeditionary Forces 2212 Transfer of Patients 2213 Record of Receipt and Disposition 2214 Subject to Inspection 2215 Insane Patients 2216 Medical History Sheet's Forwarded Annually... 2217 2201. Navy Regulations.—(1) General (art. 138, N. R.); (2) cus- tody and disposition (arts. 1163 and 1195 (1), N. R.); (3) upon enlist- ment (art. 1201, N. R.); (4) health record to accompany patient to hospital (art. 1142 (2), N. R.); (5) transfer to other than a naval hospital (art. 1143, N. R.); (6) commanding officer to inspect health records (art. 1322 (2), N. R.). 2202. Officers.—(a) Appointment.—A health record shall be opened (issued) for each officer (commissioned or warrant), appointed from civil life, by the president of the board of medical examiners, or a member designated by him, but upon appointment of an enlisted 237 2202 CH. 14.—HEALTH RECORDS man to warrant rank or a warrant officer to commissioned rank, a new descriptive sheet (physical examination sheet) shall be made out and inserted as the top sheet. The health record shall be retained with current medical history sheets and abstract. Appropriate notation shall be made upon the cover. No part of the health record shall be forwarded to the Bureau at this time. (b) Promotion.—Upon physical examination for promotion of a commissioned officer to the next higher rank, or of a warrant officer to chief warrant, a new descriptive sheet (physical examination sheet) shall be completely filled in by the president of the board of medical examiners, or a member designated by him, at the time the candidate is found physically qualified. The health record shall be retained with notation on the outside cover of the new rank, and the new descrip- tive sheet inserted as the top sheet. The old descriptive sheet shall be closed and retained in the health record for further comparison and reference (par. 2217). When promotion is effected notation shall be made on the cover of the health record, on the abstract, and on the current medical sheet to show date of promotion and rank. No part of the health record shall be forwarded to the Bureau at this time. (c) Retirement.—Upon retirement of an officer (commissioned or warrant) the health record shall be closed with appropriate notation under termination of health record, including date, place, and reason (physical disability, age, etc.). The abstract shall likewise be terminated and the health record shall then be forwarded to the Bureau (par. 1525). (d) Resignation, death, desertion, etc.—The health record shall be closed with appropriate notation under termination of health record on the current medical history sheet and abstract and for- warded to the Bureau (par. 1525). (e) Retired officers on active duty.—When a retired officer (commissioned or warrant) is ordered to active duty prepare a new descriptive sheet and request health record cover and abstracts from the Bureau (par. 1525). Upon return to inactive status, the health record shall be closed with appropriate notation under termination of health record on current medical history sheet and abstract and forwarded to the Bureau. (f) Temporary rank.—In case of promotion to temporary ad- vanced rank, appropriate notation shall be made in the abstract and on the current medical history sheet, giving date, place, and new rank. The new rank shall also be placed on the cover. Upon revert- ing to former rank the same procedure shall be followed. Should permanent commission be received in the new advanced rank proceed as directed in paragraph 2202 (b). 238 2203-2205 SEC. I. OPENING, CUSTODY, ETC. 2203. Reserve Officers.—(a) Appointment, reappointment.—A health record shall be opened (issued) upon appointment as a commis- sioned or warrant officer in the Naval Reserve, and shall be retained in the custody of the commandant of the district in which appointed, and shall accompany the officer on all active duty. In the case of officers of the Marine Corps Reserve, health records shall be retained in the custody of the Reserve area commander. In cases of reappoint- ment the same procedure shall be carried out as in paragraph 2202 (e). (b) Promotion and transfer of class.—Same as for promotion in the regular service. Proceed as directed in paragraph 2202 (b). (c) Termination of service.—Upon expiration of appointment, transfer to honorary retired list, death, desertion, etc., proceed as outlined in paragraph 2202 (d). 2204. Midshipmen.—(a) Appointment.—A health record shall be opened by the president of the board of medical examiners, or a member designated by him, and shall be continued intact until termination of service as midshipman. (b) Commissioned as ensign.—WRen commissioned as ensign appropriate notation shall be made on the cover, a new descriptive sheet (physical examination sheet) completed and the medical and dental abstracts retained. The balance of the health record (old descriptive sheet, medical history sheets, and record of vision and hearing) shall be closed by appropriate notation and forwarded to the Bureau. (c) Resignation, death, etc.—Proceed as directed in paragraph 2202 (d). (d) Graduation without commission as ensign.—Proceed as directed in paragraph 2202 (c). 2205. Nurses.—(a) Opening, custody, transfer.—When a regu- lar or reserve nurse first reports for duty a health record shall be opened by the medical examiner. It shall be continued throughout her service and shall be retained in the custody of the chief nurse, whose duty it shall be to forward the health record direct to the chief nurse of the station to which transferred. The envelope containing the health record shall be marked Nurse Corps in the lower left- hand corner. (b) Transfer from reserve to regular.—When a reserve nurse is appointed in the regular service the same health record shall be continued, appropriate notations being made on the cover, current medical-history sheet, and abstract. (c) Termination of service.—Upon resignation, discharge, or retirement, enter the facts under termination of health record and on the current medical-history sheet and abstract, and forward 239 2206 CH. 14.—HEALTH RECORDS health record to the Bureau (office of the Superintendent of Nurse Corps). 2206. Enlisted personnel.—(a) Enlistment.—Upon enlistment a complete health record shall be opened by the medical examiner. In the case of a person having physical disabilities which have been waived and who has been enlisted by authority of the Navy Depart- ment, the physical condition of such person must be fully described in his health record in order that no improper claims for pension may be allowed. Medical officers shall record all minor defects noted at time of enlistment. (b) Reenlistment.—Upon immediate reenlistment a new de- scriptive sheet (physical examination sheet only) shall be made out by the medical officer. The cover and abstracts of previous enlistment shall be retained. The original service abstract shall contain entries (red ink) as noted on cover of health record for each reenlistment. The descriptive sheet of previous enlistment closed by appropriate notation together with the medical history sheets shall be forwarded to the Bureau. When the individual does not reenlist immediately, the health record shall be closed and forwarded in its entirety to the Bureau. Upon delayed reenlistment, a new examination sheet only shall be prepared by the medical officer and the cover and abstracts of previous enlistment shall be requested from the Bureau. Entries shall be made on cover and service abstract indicating reenlistment. (c) Extension of enlistment.—The same procedure shall be used as in immediate reenlistment (subpar. (b)). The physical examination shall be made on the day of expiration of current en- listment, or immediately prior thereto, and the findings shall be en- tered on a new descriptive sheet. (d) Termination of service.—Upon expiration of enlistment, death, desertion, etc., the health record shall be closed by appro- priate notation under termination of health record and on the abstract and forwarded to the Bureau. (e) Temporary rank.—When an enlisted man is given an acting or temporary appointment as a warrant or commissioned officer the following notation shall be made on the cover, the medical abstracts, dental record, and the medical history sheet of the current health record: Place and date. “Received temporary (acting) appoint- ment as (state rank) this date.” Entries of similar character shall be made upon revocation. Upon expiration of enlistment after revo- cation of such temporary rank the health record shall be closed in the usual manner. Should permanent commission be received proceed as directed in paragraph 2202 (b). 240 SEC. I.—OPENING, CUSTODY, ETC. 2207 (f) Reserve.—Same as for the regular service, except that health records shall be in the custody of the commandant of the district in which carried, and shall accompany the individual on all active duty. If transferred to the regular service to serve the unexpired portion of enlistment, appropriate notation shall be made on the current medical history sheet and the abstract and the health record continued. Health records of enlisted personnel of the Marine Corps Reserve shall be in the custody of the Reserve area commander. (g) Transfer to Fleet Reserve.—When an enlisted man of the regular service is transferred to the Fleet Reserve a new descrip- tive sheet (physical examination sheet) shall be opened. The descriptive sheet of previous enlistment closed and with the medical history sheets shall be forwarded to the Bureau. The abstracts shall be retained. The health record shall be marked Fleet Reserve on the cover and forwarded to the commandant of the naval district to which the man will be attached. Entry shall also be made on the medical history sheet as to whether the individual is fit for all duties, class A; limited duties, class B; or no duty, class C. (h) Stragglers.—Health records of stragglers shall be requested from their regular ship or station and, until its receipt, any medical history shall be entered on loose leaves for subsequent insertion in the record. (i) Surrender or apprehension of deserters.—Upon surrender or apprehension of a deserter, the health record shall be requested from the Bureau by letter, giving name in full, rate, and date and place of birth. In case the health record is not on file in the Bureau, a request should be made to the place of desertion. 2207. Supernumeraries.—(a) When a patient is discharged by- reason of expiration of enlistment and retained as a supernumerary for further treatment and disposition, the health record shall be closed and forwarded to the Bureau. Health records shall not be opened for patients admitted to the sick list as supernumeraries, but medi- cal history sheets shall be used and continued until the termination of the case, when, except in the case of ex-service personnel, they shall be filed at the hospital. Medical sheets and death reports of ex-naval personnel shall be forwarded to the Bureau. The top sheet should show the full name, status (i. e., former rank or rate if re- tired, or ex-service, etc.), and the place and date of birth. In the case of retired officers or enlisted men, it is important that opinion be incorporated in the record as to whether or not the disability is traceable to service on the active list. (b) Army personnel.—In all cases of United States Army per- sonnel admitted for treatment at a naval hospital, the following 241 2208-2211 CH. 14.—HEALTH RECORDS reports shall be prepared: (1) Medical history sheet; (2) Form 52, Medical Department, United States Army; (3) Special letter to the Bureau, giving name, rate, organization, diagnosis, dates of admis- sion and discharge. As soon as a case is discharged to duty or other- wise disposed of, the medical history sheets, together with Form 52 (Medical Department, United States Army), shall be forwarded to The Adjutant General, United States Army. (c) Veterans' Administration patients.—Medical histories and death reports in the case of Veterans' Administration patients shall not be forwarded to the Bureau, upon completion of the case, but direct to the Veterans’ Administration (district manager). 2208. Custody.—The health record of each officer and enlisted man shall be retained in the custody of the medical officer of the ship or station to which the individual is attached. Health records of all personnel shall be checked at definite intervals of time, at least quarterly. 2209. Health Records To Be Examined Upon Receipt.—Whenever a health record is received, the medical officer shall examine it care- fully, correct all errors, supply any omissions, and, if necessary, communicate with the medical officer of the previous ship or station for additional data. All such corrections shall be made in red ink, dated, and signed by the officer making the entry. 2210. Health Record lost, etc.—In case of loss or destruction of a health record, the medical officer shall at once notify the Bureau, giving name in full, rank or rate, and date and place of birth. A complete new health record shall then be opened. Should the missing record be recovered, any additional information or entries in the new record shall be inserted in the old record. The Bureau does not issue duplicate health records. 2211. Disposition.—(a) Individual transferred.—Upon transfer of an officer or enlisted man, the health record shall be forwarded, via official channels, to the ship or station to which ordered except as noted in paragraph (d). (b) Officers unassigned, etc.—In the case of officers unassigned, ordered to duty where there is no medical officer, granted sick leave, or other contingency where a proper destination is not obvious, the health record shall be forwarded to the Bureau with an explanatory letter. (c) Officer ordered before a board.—When notified that an officer is ordered to appear before a board involving a physical exami- nation, the medical officer having custody of the health record shall forward it to the president of the board, via the commanding officer or direct, as the circumstances may require. 242 SEC. I. OPENING, CUSTODY, ETC. 2212-2213 (d) Officers ordered to Washington, D. C., and vicinity.— Health records of officers of the Navy and the Marine Corps ordered to duty in the Navy Department, Marine Corps Headquarters, Naval Observatory, Army War College, Army Industrial College, Naval Research Laboratory, Arlington Radio Station, and Radio Material School, Anacostia, D. C., shall be forwarded to the com- manding officer, Naval Dispensary, Navy Department, Washing- ton, D. C. 2212. Expeditionary Forces.—In the event of an expedition for dis- tant service, where it is inadvisable to take health records, entries should be made on medical history sheets, to be subsequently inserted into the proper health records. When embarked on an Army trans- port, health records shall, when practicable, be forwarded with the individuals, and, if not available, medical history sheets shall be used and inserted, subsequently, in the health record. 2213. Transfer of Patients.—(a) To a naval hospital.—When a patient is transferred to a naval hospital, he shall invariably be accom- panied by a hospital ticket and his health record. (b) To other than a naval hospital.—(1) Within the United States or its possessions.—When a patient is transferred to any hospital other than a United States naval hospital the health record shall be retained at, and the case continued by, a naval activity until the patient is sent to another naval activity for further treatment or is discharged from the sick list. A note of the removal to such a hospital shall be made in the health record, but no Form F card (see par. 2405) or disposition by transfer (T) on the sick list (see par. 2404) shall be made. Transactions on the sick list and preparation of Form F cards occur in these cases only when custody of the health record and responsibility for the patient change. The senior medical officer of the activity having custody of the health record shall communicate, through his commanding officer, with the hospital, keeping himself advised of the patient’s condition, entering all available information in his health record, and furnishing to the Navy Department infor- mation required by article 1203, Navy Regulations. WRen the transfer is temporary and the patient is expected to return to the transferring naval activity, the health record may be retained at that activity. When the stay at the hospital is to be prolonged, or when the patient is not expected to return to the transferring naval activity, the health record shall be retained at that activity only if it is within, or operating from a port in, the same naval district. When, in such cases, the transferring activity and the hospital are in different naval districts, or when a ship sails to a port outside of the district, the responsibility for the patient and custody of the health record shall be 243 2214-2216 CH. 14.—HEALTH RECORDS changed, by transfer, (T) to the headquarters of the district within which the hospital is located, and a Form F card forwarded showing that disposition. The district headquarters shall take up the case by readmission (RA) and continue it until some disposition is made (pars. 2404 and 2407-2415). (#) Foreign hospitals.—Removal to a foreign hospital shall be noted in a patient’s health record, but this shall not be considered as a trans- fer of the sick list (T). The health record shall be retained and con- tinued on board the ship until the patient returns to duty, is trans- ferred to another naval activity, or until the ship leaves port. On departure of the ship from the foreign port the responsibility for, and custody of health records of, patients left behind shall be changed by transfer on the sick list (T) to any other United States naval vessel remaining in the port. (See par. 2407-2415.) The medical officer of this ship is then responsible for continuing the case as directed below. If, on departure of the ship, there is no other United States naval vessel left in the port, the medical officer shall forward, through the commanding officer, to the consul, the health records of all patients who are left behind. The record shall state in each instance that it is to accompany the patient if he is sent to the United States, or to be forwarded to the commanding officer of the next United States naval vessel arriving in port. On arrival of a ship in a foreign port, her medical officer shall take charge of all such cases and shall continue their health records. He shall interest himself in their welfare, report their progress to his commanding officer, and suggest any measures that he may consider necessary for their benefit. (c) Patients received for transportation.—The medical officer of a ship shall, when patients are received for transportation, continue their health records as readmissions, and account for them as sick of the ship. 2214. Record of Receipt and Disposition.—All medical officers having custody of health records shall keep a record of the receipt and disposition of such records. This record shall be retained as a part of the permanent medical department files of the ship, station, or hospital. 2215. Subject to Inspection.—Health records of officers and en- listed men shall be subject to inspection at any time by the com- manding officer or the fleet surgeon, otherwise they are to be con- sidered confidential. 2216. Insane Patients.—The service record and all other records pertaining to an insane patient, except the health record which will accompany the patient, shall be retained at the naval hospital from which he was transferred to an institution for the insane. (This 244 SEC. II. NAME, RANK, RATE, ETC. 2217-2251 paragraph concerns the naval hospital at Washington, D. C., with reference to insane patients cared for in St. Elizabeths Hospital.) Insane patients who have been transferred from a naval hospital to an institution for the insane shall be carried as still attached to the naval hospital and shall be accounted for by ratings on the reverse side of N. Nav. 25 and navigation roster reports. These patients shall be retained under the cognizance of the naval hospital until they are surveyed and discharged from the Navy or final disposition is made. These patients shall be shown on all hospital and naviga- tion reports under the heading of Patients in St. Elizabeths Hos- pital, but their number shall be omitted from the compilation of the total number of sick days of the naval hospital proper. These patients shall be accounted for on Bureau forms, as follows: Upon the transfer of the patient to the institution for the insane a Form F card shall be rendered as in the case of any other transfer and upon return of insane patients to the naval hospitals for final disposition they shall be taken up as readmissions and final disposition reported in the usual manner. A separate set of statistical reports shall be rendered for this class of patients under the caption of Patients in St. Elizabeths Hospital. These patients while in the hospital for the insane shall not be included in the returns of the naval hospital proper. (M. & S. file No. 128586 (121), March 16, 1923.) 2217. Medical History Sheets Forwarded Annually.—(a) Offi- cers.—Upon completion of the annual physical examination each year, the descriptive sheet of prior rank, if promoted since the last annual physical examination, and all medical history sheets containing entries shall be detached from the health record and forwarded to the Bureau attached to the report of annual physical examination. In each case the sheets shall be numbered consecutively. The top sheet shall contain the full name, rank, and date and place of birth. Should an officer be on the sick list at this time, the medical history shall not be forwarded until the case is closed. (b) Nurses.—Same as in the case of officers except that the med- ical history sheets shall be forwarded to the Bureau (office of the Superintendent of Nurse Corps). SECTION II. NAME AND RANK, RATE, OR OTHER DESIGNATION Paragraph Names 2251 Ranks and Rates 2252 Advance in Rating 2253 2251. Names.—The whole name (Christian, middle, and surname) shall be entered on the cover, descriptive sheets, and abstracts, to 245 2252-2261 CH. 14.—HEALTH RECORDS correspond with that on the service record and to be legibly written out (without abbreviations) and correctly spelled, preference being given to the original spelling of foreign names. The surname (in capital letters) shall precede and be underlined. 2252. Ranks and Rates.—When practicable, the ranks and rates of officers and enlisted men shall be spelled out in full on all records and reports, but where sufficient space is not provided abbreviations shall be used in accordance with instructions provided in Circular Letter R in appendix D of this manual. 2253. Advance in Rating.—When an enlisted man is advanced in rating, the medical officer should be furnished with a proper order by the commanding officer, and shall enter the new rate on the cover of the man’s health record. SECTION III. THE DESCRIPTIVE SHEET Paragraph Instructions 2261 Marks and Scars 2262 Waivers 2263 2261. Instructions.—The descriptive sheet shall be typewritten if possible and completely filled in at the time of the examination, except for the place and date of enlistment, appointment, or promo- tion, when these are not yet determined. As soon as enlistment, appointment, or promotion is determined, the descriptive sheet shall be completed. The total amount of previous service shall be entered, and the branch or branches in which performed, e. g., USA—4 years, USMC —8 years, USN—3%a years. All diseases, injuries, and operations prior to entering the Navy, according to the individual’s statement, shall be noted with the date of each, e. g., Pneumonia—1905, Appendectomy—1911, etc. These notations shall be made on the first medical history sheet. Under place of birth, enter the city, town, or village and the State, or the country (when foreign born). Enter the color of the eyes in accordance with the chart issued with the test set. Enter the color of the hair as flaxen, sandy (yellow-red), auburn (red-brown), brown (light, medium, or dark), black, gray, etc. When the hair is curly, woolly, very thin (or bald), this should also be noted. Complexion shall be as accurately stated as possible, as pallid, sallow, fair (only when decidedly clear), ruddy, florid, dark (tawny, 246 SEC. IV.—MEDICAL HISTORY SHEETS 2262-2282 sunburnt, or tanned), very dark (swarthy or dusky), mulatto, Negro, etc. State whether color perception is good, bad, or feeble (state color in which deficient). 2262. Marks and Scars.—Note marks and scars and any prominent physical characteristics, not inconsistent with bodily vigor or not in such degree as to constitute cause for rejection, e. g., leanness or the reverse; hirsuteness; slight asymmetry of body or limbs; knock- knees or bowlegs; flat feet or low arches; peculiarities of the teeth or genitalia; slight varicocele; relaxed inguinal rings, etc. Any marks and scars noted subsequent to the original examination shall be entered on the back of the descriptive sheet and dated and signed by the medical officer making the entry. Entries of marks and scars shall be made in accordance with instructions in paragraph 1576 (g). 2263. Waivers.—The date and nature of any waiver of physical disability shall be entered on the health record. (See par. 1407 for instructions to be followed when a waiver is requested.) SECTION IV. THE MEDICAL HISTORY SHEETS Paragraph Navy Regulations „ 2281 General Instructions for Entries . 2282 Minor Affections, etc 2283 Examples of Entries. _ 2284 Other Entries 2285 Erroneous Entries 2286 Venereal Disease , 2287 Sickness on Leave, etc 2288 Misconduct , 2289 Patients in Custody of Civil Authorities 2290 2281. Navy Regulations.—(1) Information for selection boards (art. 1195 (2) (3), N. R.). (2) Examination before transfer (art. 1143 (2), N. R.). (3) Transfer to other than a United States naval hospital (art. 1143 (1) (3), N. R.). (4) Patients received for trans- portation (art. 1162, N. R.). (5) Entries only by medical officers (art. 1200, N. R.). (6) Entry upon enlistment and transfer (art. 1201, N. R.). (7) Line of duty and misconduct (arts. 137 (10), 554, and 1196, N. R.). (8) Injuries to be investigated (art. 1844, N. R.). (9) Where official medical record is incomplete (art. 1845, N. R.). 2282. General Instructions for Entries—(a) Entries shall be type- written when practicable, but must be signed by the medical officer by whom or for whom they were made. As the medical history should be continuous, care shall be taken to number each page con- 247 2283 CH. 14. HEALTH RECORDS secutively and to enter the name in full, with rank or rate and ship or station, on each sheet upon which entries are made. Daily entries are not required but entires will be made as may be indicated (at least once each week), giving concisely all essential details concern- ing diagnosis, origin, symptoms, course, and treatment. All facts concerning the origin of the disease or injury shall be noted, and, if a conflicting opinion be subsequently expressed by the same or some other medical officer, the reason for such change must be fully stated. Injuries and poisonings shall be classified in accordance with the in- structions in paragraph 2416 (d). The entries for each case from ad- mission (A, ACD, or RA) to disposition (D, T, C, DD, R, or IS), shall be complete in regard to place, dates, number of sick days, diagnoses of all disabilities for which treated, signature of medical officer, and approval (when entries are not made by the senior medical officer). Continuance or absence of disability will be stated when the patient is discharged to duty, transfer, leave, or from the service. The purpose of the health record is obvious and elementary. It is to supply for future contingencies a succinct recital of events from which a clear reconstruction of the situation can be formed in the mind of the reader, a story so plain, so complete, yet without verbosity, that anyone can readily understand why such a diagnosis was made, why a particular method of treatment was followed, or a specific operation was necessary. The record need not be voluminous, but it should be thorough, clearly phrased, and complete in its data of a particular case. Both the patient and the Government will profit by faithful com- pliance with current regulations, instructions, and the requirements of modem medicine. (b) The senior medical officer shall approve the entries made in health records on the ship or station or enter his reasons for disapproval. (c) Entries shall be made on the medical history sheet when an individual is admitted to the sick list or, as a note, when he applies for any ailment not requiring admission to the sick list (if such ailment has a possible bearing on a future claim for pension). (d) The names of medical officers making entries shall be typed or printed under their signatures. (e) No forms, reports, photographs, or other papers shall be attached to or inserted in a health record. 2283. Minor Affections, Etc.—Minor affections and dental opera- tions, not requiring admission to the sick list, shall be indicated by a note on the medical history sheet (2282 (c)). 248 SEC. IV.—MEDICAL HISTORY SHEETS 2284 2284. Examples of Entries.—For ordinary cases the following examples indicate the data required (par. 2404): U. S. S. Yorktown. A.—June 10, 1938: Tonsillitis, acute (818). Not due to misconduct. Exposure on watch. Mild attack. Routine treatment. D2.—June 12, 1926: To duty. Well. C. D. Browne, Lt. (MO, U. S. Navy. Approved. C. A. Jones, Comdr. (MO, U. S. Navy. N U. S. S. Brooklyn. O June 19, 1938: Contusion, over left tibia, struck leg against ladder tread T during ship drills. Injury slight. Dressing applied. Placed on binnacle E list. No complications. A. A. Blank, Lt. Comdr. (MO, U. S. Navy. U. S. S. Yorktown. A.—June 10, 1938: Catarrhal fever, acute (801). Not due to own misconduct. Exposure while on watch. Temperature 101, pulse 90, respirations 22. Moderate general malaise. Lungs clear. Bed rest and routine treatment. June 12, 1938: Temperature normal. Patient feeling well except for pain in region of frontal sinuses. Given ephedrine nasal sprays, t. i. d. C*.—June 13, 1938: Frontal pain continues. The patient has recovered from the general symptoms of catarrhal fever. Diagnosis changed, this date, by reason of complication, to: ACD.—June 13, 1938: Sinusitis, frontal (535). Not due to own misconduct. Pain is persistent and moderately severe. Ephedrine nasal spray q 3 hrs., A. P. C. capsules gr. v. q 3 hrs. June 15, 1938: Pain continues but is much improved. Dg.—June 16, 1938: To duty. Well. C. D. Browne, Lt. (MO, U. S. Navy. Approved. C. A. Jones, Comdr. (MC), U. S. Navy. U. S. S. Arizona. RA.—September 20, 1938: Tonsillitis, chronic (540). Not due to own miscon- duct. Existed two years prior to enlistment, according to’ patient’s signed statement below, signed copy of which has been forwarded to the Bureau of Medicine and Surgery. (Patient’s signed statement.) It is not believed that this condition has been aggravated by naval serv- ice. Usual history and symptoms. Patient desires operation. Ti.—September 21, 1938: Transferred to the U. S. Naval Hospital, San Diego, Calif. A. B. Smith, Lt. (j.g.)(MC), U. S. Navy. Approved. C. A. Jones, Comdr. (MC), U. S. Navy. 249 2285 CH. 14.—HEALTH RECORDS Naval Hospital, San Diego, Calif. RA.—September 21, 1938: Tonsillitis, chronic (540). Not due to own miscon- duct. Existed prior to enlistment. See previous entry. September 25, 1938: Tonsillectomy under local anesthesia. No compli- cations. October 2, 1938: Tonsillar fossae clear. Placed on liberty list. October 6, 1938: Tonsillar fossae healed. To return to duty tomorrow. Ci8.—October 7, 1938: Diagnosis changed because of intercurrent injury to: A.—October 7, 1938: Submersion, nonfatal (2554). Key letter “G.” Result of own misconduct. Patient is not at present able to comprehend the above adverse entry. (1) Within command. (2) Not work. (3) Man’s own negligence. (4) While returning from liberty intoxicated, walked off hospital boat landing into water. This occurred at about 08:30 this date. He was rescued by other patients and resuscitated after prolonged, arti- ficial respiration. Treated for shock and acute alcoholism. Condition improved under external heat and stimulation. October 8, 1938: Much improved. Article 1196, N. R., complied with. Patient submitted the following statement in rebuttal to the commanding officer for transmittal to the Navy Department for decision. (Patient’s signed statement.) D2.—October 9, 1938: Patient has recovered from the effects of his submersion. To duty. Well. E. F. Andr, Lt. Comdr. (MC), U. S. Navy. Approved. G. W. Phelpson, Capt. (MC), U. S. Navy. 2285. Other Entries.—Entries shall invariably be made in the fol- lowing instances: (1) Officers.—All physical examinations, including findings and recommendations of boards for promotion or retirement, and defects noted on the annual physical examination. All examinations for special duty (aviation, etc.). (2) Reserve.—All physical examinations of both officers and en- listed personnel including reporting for, and release from, active duty. (3) Enlisted personnel.—All physical examinations, such as pre- liminary examination for warrant rank (art. D-6202 (2), Bu. Nav. Manual), examination for appointment to warrant rank (arts. D- 6203 (3) and D-6204 (1), Bu. Nav. Manual), appointment to the Naval Academy Preparatory School (art. D-6103 (1) (c), Bu. Nav. Manual), entrance to the Naval Academy (art. D-6107 (1) (c), Bu. Nav. Manual), examinations for discharge, reenlistment, extension of enlistment, transfer, change of rating, special duties (aviation, diving, submarine service, etc.), and all other physical examinations should be noted 250 SEC. IV. MEDICAL HISTORY SHEETS 2286-2289 on the medical history sheet and on the abstract for special quali- fications when indicated. (4) Boards of medical survey.—Brief entry of findings and recom- mendations (par. 3423). (5) Serological tests.—All serological and other diagnostic tests. (6) Identification tag.—Whenever an identification tag is made and issued to an enlisted man, an entry of the fact, signed by the man and witnessed by a medical officer, shall be made in his health record. 2286.—Erroneous Entries (decision of the Judge Advocate General, dated December 27, 1921; 28478-237: 1.) In the event that the facts in a particular case show that the entry in question is erroneous, said entry may not be stricken from the records but an additional entry shall be made showing wherein and to what extent the original entry is in error. An entry in a public record, whether correct or erroneous, thereby becomes a fact which may not be destroyed, but if in error such additional entry or entries may be made, and in fact should be made, as are necessary to show the nature of the error sought to be corrected. 2287. Venereal Disease.—(a) All infections of a venereal nature shall be regularly admitted to the sick list if only for record. (b) Syphilis.—Medical officers when admitting a patient to the sick list with a diagnosis of syphilis shall assure themselves that there are other signs and symptoms of the disease beyond a positive serum test. The policy of the Bureau is not to approve a diagnosis of syphilis solely on a positive serum test unless repeated and con- firmed. 2288. Sickness on Leave, Etc.—When any person in the Navy or Marine Corps has been injured or has contracted disease, and, on account of the absence of a naval medical officer or for any other reason, the facts have not been entered in his health record, the medical officer having custody of his health record shall endeavor to ascertain the facts in the case and make the requisite entries (art. 1844, N. R.). 2289. Misconduct.—(a) In accordance with article 1196, Navy Regulations, the medical officer is required to enter in the health record whether a disease or injury is or is not due to the patient’s own misconduct, when a patient is admitted to the sick list. A discussion of misconduct status appears in chapter 16. Medical officers are also referred to chapter 9, naval courts and boards. (b) In order to avoid unnecessary correspondence and delay, when- ever it is considered necessary to submit the case to the Judge Advo- 251 2290-2301 CH. 14.—HEALTH RECORDS cate General of the Navy for determination of the misconduct status, the following data shall be forwarded: 1. Certified copy of all medical history contained in the current medica record. 2. Original signed statement of the individual in rebuttal. 3. Opinion of medical and commanding officers. 4. Any other pertinent facts. 2290. Patients in Custody of Civil Authorities.—When, for any reason, an enlisted man undergoing treatment at a naval hospital is held in the custody of the civil authorities, every effort shall be made to ascertain how long he will be held before disposition of the civil case and before he will be available for return to the hospital or dis- charge from the Navy. If it is evident the man will be held by the civil authorities for a period in excess of 2 weeks he shall be trans- ferred, in accordance with instructions of the Bureau of Navigation, to the nearest receiving ship or receiving station, together with a complete record of the case. Complete information regarding the case and the need for further hospitalization shall be given on pages 9-10 of his service record, and a letter setting forth all the facts of the case shall be forwarded both to the Bureau of Navigation and the receiving ship or receiving station to which the transfer is made. The current medical history shall be closed as to duty (D) after making appropriate entry as to the reason therefor. This procedure prevents charging the health of the Navy with sick days not actually incurred as the result of service conditions. Paragraph Instructions 2301 SECTION V. THE MEDICAL ABSTRACT 2301. Instructions.—(a) Cowpox vaccinations shall in each instance be entered on the abstract sheet and signed by a medical officer. The result shall be recorded as failure, primary reaction, acceler- ated REACTION, or IMMUNITY REACTION (par. 2605). (b) Typhoid inoculations shall in each instance be entered on the abstract sheet and signed by a medical officer. When a severe reac- tion is produced the fact should be noted. (c) Medical abstract sheets should afford a chronological record of places of duty and of the medical history. Each medical officer is responsible for the completeness of the entries therein when they leave his custody. (d) The abstract sheets are continuous and a part of the health record. With the exception of the dental record, when required, the abstracts shall not be removed from the health record. Upon termi- 252 SEC. VI.—DENTAL RECORD 2311-2312 nation of service the health record in its entirety shall be forwarded to the Bureau. Paragraph Preparation of Dental Records 2311 Record of Dental Examinations 2312 Record of Dental Operations 2313 Entry of Dental Treatments 2314 Continuation of Dental Record 2315 Form K, Dental 2316 Classification of Teeth 2317 Markings on Dental Charts 2318 Classification of Filling Materials 2319 SECTION VI. THE DENTAL RECORD 2311. Preparation of Dental Record.—The dental record sheet shall be inserted in the health record upon the completion of recruit train- ing, or upon graduation in the case of midshipman, and shall thereafter be handled as other abstract sheets. This sheet shall be prepared when each officer and man is first examined or treated by a dental officer and each dental officer who examines or treats an officer or enlisted man shall be responsible for the completeness of the dental record when it leaves his custody. 2312. Record of Dental Examinations.—(a) Upon the arrival of an officer or enlisted man upon a ship or station his health record shall be sent to the dental officer, who shall, as soon as practicable, examine such officer or man and arrange for any needed dental treatments. Upon the completion of such examination and treatments (when needed) the appropriate entries shall be made in the dental record and signed by the dental officer, and returned to the medical officer having custody of the health record. (b) Health records for all patients sent to another ship or station for dental treatment shall accompany such patients. When such treat- ments are completed, or terminated for any other reason, the record shall be returned to the medical officer charged with its custody. (c) Every person shall be examined by a dental officer as soon as practicable after entering the service, and record of the first dental examination shall be made on the upper chart of the dental record, in conformity with the existing instructions on this subject. This chart shall be signed and dated by the examining dental officer. (d) When a body has been subjected to conditions which cause decomposition of tissue, the dental record may become the only means 253 2313-2317 CH. 14. HEALTH RECORDS -of arriving at a positive identification. It is therefore important that the original charted record and subsequent entries for restora- tions and treatments be in conformity with the existing instructions on this subject, and unquestionably accurate. The upper chart of the dental record is particularly valuable for the purpose of identifica- tion when decomposition has destroyed other means; any peculiarities or unusual conditions should be concisely recorded under remarks. The following are examples of such peculiarities and unusual condi- tions: Gingival erosion, any abnormality of occlusion, occlusal abra- sion, pigmented enamel, fractures of enamel or teeth, abnormal spaces between teeth, rotation of teeth that can be definitely discerned, how- ever slight, irregularity of alignment of teeth, giving teeth involved with abnormal inclination or position. The above is of particular importance when only sound teeth are present, and, when this condi- tion exists, a notation to that effect should be entered and a careful examination made to record any abnormalities present, however slight. Entries to the above effect shall be made under remarks at any time abnormalities are observed, so that it may be a record of existing conditions and of value for the purpose of identification. 2313. Record of Dental Operations.—Dental operations and restora- tions, as rendered, shall be charted in accordance with instructions, on the lower chart. Authorized abbreviations covering the opera- tion performed should be entered on the dental record in the desig- nated spaces as well as data relating to prosthetic replacements. 2314. Entry of Dental Treatments.—No entries of dental treatments shall ordinarily be made on the medical history sheets, except those incident to the treatment of a patient while on the sick list. How- ever, notes of unusual dental conditions or treatments, which may be of medical interest, may be made on the medical history sheets. 2315. Continuation of Dental Record.—The original dental records shall be used and recharted as required, upon promotion of an officer, appointment to officer’s rank, reenlistment or extension of enlistment. (See par. 2318.) 2316. Form K (Dental).—Dental officers will retain memoranda of all dental treatments in order to make monthly reports to the Bureau, using for this purpose Form K (Dental). 2317. Classification of Teeth.—For the purpose of recording opera- tions and treatments of teeth and the keeping of dental records, the following classification of the teeth and surfaces will be used: 254 SEC. VI.—DENTAL RECORD 2318 (1) Classification of teeth.— 1. Right superior third molar. 17. Right inferior third molar. 2. Right superior second molar. 18. Right inferior second molar. 3. Right superior first molar. 19. Right inferior first molar. 4. Right superior second bicuspid. 20. Right inferior second bicuspid. 5. Right superior first bicuspid. 21. Right inferior first bicuspid. 6. Right superior cuspid. 22. Right inferior cuspid. 7. Right superior lateral incisor. 23. Right inferior lateral incisor. 8. Right superior central incisor. 24. Right inferior central incisor. 9. Left superior central incisor. 25. Left inferior central incisor. 10. Left superior lateral incisor. 26. Left inferior lateral incisor. 11. Left superior cuspid. 27. Left inferior cuspid. 12. Left superior first bicuspid. 28. Left inferior first bicuspid. 13. Left superior second bicuspid. 29. Left inferior second bicuspid. 14. Left superior first molar. 30. Left inferior first molar. 15. Left superior second molar. 31. Left inferior second molar. 16. Left superior third molar. 32. Left inferior third molar. (2) Classification of surfaces.— E. External. M. Mesial. I. Internal. D. Distal. 0. Occlusal. Examples: The classification of cavities is effected by the use of the initial letter of the surface. 25-E would indicate a simple cavity on the external, or labial, surface of the left inferior central incisor, 30-EIO would indicate a compound cavity of the extemo-interno- occlusal surface of the left inferior first molar. 2318. Markings on Dental Charts.—(a) An endeavor has been made to unify the markings of the dental charts so that the following con- ditions can be readily noted from the diagrams: Dental restorations originally present and in good condition; dental treatment needed; dental treatment completed; present dental condition. This will prove of value to the operator for ready reference and will establish identification where other means may be absent. Dental officers will therefore be governed by the following instructions: (1) The upper chart of the dental record shall be used for a record of the first dental examination. On all upper charts markings in red will be made to indicate dental restorations present and in good condition; markings in black to indicate the need of dental attention, as caries present, etc. By the use of the system of differential markings given below, written entries and abbreviations will be unnecessary in recording dental examinations. (2) The lower charts on dental records are to be used for recording all subsequent operations, which are to be entered as they are completed; all such entries to be made in black. A com- parison of the black entries in the upper chart with those in the lower 255 2318 CH. 14. HEALTH RECORDS chart will give, at a glance, the dental condition then present, locate cavities remaining unfilled and other dental conditions which need attention, and indicate plainly cavities which have been filled. (3) All entries of restorations or treatments shall be dated and signed by the dental officer concerned. (b) The following differential markings on dental charts shall be used to indicate the accompanying conditions: (1) In red on the upper chart to indicate dental restorations in good condition, or teeth missing: 1. X.—Over roots of all teeth missing. This classification to include those previously extracted, unerupted, or replaced by dummies on a bridge or plate. 2. Amalgam fillings in good condition.—Outlined and blocked in. 8. Cement fillings (tempo- rary, permanent, or synthetic).—Outlined only. 4- Gold surfaces.— Outlined, with one or more horizontal lines in the outline. 5. Gold fillings or inlays.—Outlined and gold indicated as above. Note.—All fillings, of whatever material, to be entered as designated (not more than one entry for a filling), charted on surface showing greatest filling exposure, and extended to the other surfaces involved where the chart permits. 6. Gold crowns.—Outlined and gold indicated on both aspects. 7. Porcelain facing or tooth.—Outlined and porcelain indicated by plain surface. 8. All porcelain crowns.—Outlined on both aspects and post indicated by line. 9. Richmond crown.—Outlined, facing plain, back gold, post indicated. 10. Bridges.—Entire bridge to be indicated by a continuous outline for each aspect, porcelain facings plain, gold surfaces indicated by diagonal lines, posts in position. Note.—Dental treatment performed by other than naval dental surgeons, sub- sequent to the first dental examination, should be charted in red on the upper chart. To distinguish it from conditions found on the first examination, it should also be noted by appropriate abbreviations in the spaces for written entries, under the date of discovery and followed in each instance by abbreviation for the word “civilian” in parentheses. For example: 8—M—Gold (Civ.), 18 to 21— Bridge (Civ.), 30—Gold Crown (Civ.). (2) In black on upper charts to indicate need for dental attention. 1. All cavities or fillings needing renewal.—Outlined and blocked in. 2. Cavities or diseased conditions developing or noted subsequently to first examination.—Blocked in when detected, with a red line around them to signify discovery subsequent to first examination. S. Need for extraction.—Indicated by double black lines through both outlines of the tooth. 4- Impacted teeth.—Both outlines in- cluded in an oval. 5. Abscess present.—Circle over root or roots involved; date of occurrence to be noted by an entry on reverse side of the sheet. 6. Fistula.—Short straight line ending in a small circle, in position. 7. Pyorrhea.—Parallel lines under tooth or teeth 256 2319-2331 SEC. VII. SPECIAL DUTY ABSTRACT involved. 8. Pathological area shown by x-ray.—Outline roots involved; written abbreviation under restoration or treatment will indicate date of exposure. (3) The following designations on lower charts; all entries in black: 1. Cavities filled (any material).—Outlined and blocked in. 2. X over roots of a tooth extracted.—Indicates all roots removed, unless otherwise noted on reverse side of the record. 8. Root canals with uncompleted treatment.—A line or lines under tooth involved, in relative position. 4- Root canals filled.—A line or lines over tooth involved; number and direction of lines corresponding to canals filled. 5. Root amputation.—Small triangle over root involved. 2319. Classification of Filling Materials.—The following classifica- tion of filling materials and abbreviations will be used: Am Amalgam. Cem. T Cement, temporary (employed in securing treatments). Cem. P Cement, oxyphosphate. Cem. S Cement, silicate. Gp Temporary stopping (gutta-percha, etc.). Ster. D Sterile dressing. F. C Formocresol treatment inserted. R. C. T Phenol treatment inserted. Root canal treatment. Ag N03 Silver nitrate treatment. Sed Sedative or mild antiseptic dressing, any medicament. R. F. (2) Root canals filled; number of canals filled in the tooth indicated in parentheses. Ex Extraction of tooth or roots; one extraction indicating all roots removed unless otherwise noted. Ab Abscess present. Ab. L Abscess lanced. P. E Pulp extirpation L. An Local or infiltration anesthesia used during operation. Sc Dental prophylaxis. C. An Conductive anesthesia used during operation. X ray O. K X-ray film or plate showing normal condition. X-ray area X-ray film or plate showing abnormal condition, with root canals apparently unfilled. Note.—Other procedures should be written in full. EXAMPLES 12-R. F. (2)-Mo.-Am. 8-P. E.-L. An.-Ster. D.- Gp. l-Mo.-Am. 18-Ex.-C. An. 22-X-ray area. 5-F. C.-Cem. T. 15-P. E.-Sed.-Gp. 23-X ray-O. K. SECTION VII. SPECIAL DUTY ABSTRACT 2331. Instructions.—In cases of physical examinations necessitat- ing refractions, the medical officer shall enter the findings of such 257 2350 CH. 14. HEALTH RECORDS examinations of the eyes on the special abstract provided for such record of refraction. Such entries shall appear over the signature of the medical officer. In the cases of special physical examinations for aviation, submarine, diving, etc., the result of such examination, together with any disqualifying defects or waivers pertaining thereto, shall be entered in the special duty abstract provided for this purpose, in accordance with instructions noted thereon. Entries shall also be noted on the medical history sheet. Such entries shall appear over the signature of the medical officer. SECTION VIII. THE SYPHILITIC ABSTRACT 2350. Instructions.—(a) A syphilitic abstract shall be filled out, and inserted next to the last page of the health record, for each person who develops the disease or any of its complications or sequelae. All entries on the syphilitic abstract are intended for the information of the medical officers under whose care the case may come. To this end care must be used to insure accuracy and completeness. Each medical officer, under whom the case may come, shall be responsible for the continuance of the abstract. The syphilitic abstract does not replace any part of the health record or medical history, but is in addition thereto. All data entered on the abstract shall also be en- tered in full on medical history sheets. The syphilitic abstract shall not be placed in the health records of men in whom the diagnosis of syphilis has not been made. (b) Whenever a diagnosis of syphilis is made, it is the duty of the medical officer to carefully and fully explain to the patient the nature of the infection and that prolonged treatment is necessary to effect a cure. The patient shall then be instructed to sign the statement in the abstract; if he declines to do so, an entry to that effect shall be made. With regard to statements in rebuttal, medical officers shall be guided by instructions contained in paragraph 5, article 1196, Navy Regulations, 1920, and paragraph 2289 of this manual. 258 CHAPTER 15 Paragraphs Section 1. INSTRUCTIONS 2401-2420 II. NOMENCLATURE OF DIAGNOSTIC TITLES... See appendix A. m. NOMENCLATURE OF SURGICAL OPERATIONS See appendix A. IV. NOMENCLATURE OF NATURE AND CAUSE OF VIOLENCE See appendix A. DIAGNOSTIC NOMENCLATURE SECTION I. INSTRUCTIONS Paragraph General Instructions 2401 Choice of Titles 2402 Abbreviations for Taking up and Disposing of Cases on the Sick List 2403 Interpretation and Usage of Terms 2404 Form F Card. Individual Statistical Report of Patient 2405 Form F. Abstract of Patients 2406 Form F Card and Monthly Form F. When, and by Whom, Prepared 2407 Venereal Diseases, Class XII 2408 Diagnosis Undetermined 2409 Disabilities Existing Prior to Entry into the Naval Service 2410 Disabilities Arising While in Desertion Status 2411 Injuries, Class XXV 2412 Poisonings, Class XXVI 2413 Key Letters 2414 Specialty Letters 2415 Injuries and Poisonings, Method of Reporting 2416 Designation of Aviation Personnel 2417 Nomenclature of Surgical Operations 2418 Nomenclature of Nature and Cause of Violence 2419 Itemized Nomenclature. Appendix A 2420 2401. General Instructions.—(a) General plan.—The following nomenclature has been compiled to meet the needs of the United States Navy. Diseases and conditions are grouped in various anatom- ical, epidemiological, and miscellaneous classes. Injuries and poison- ings each have their own class. (b) Diagnosis numbers and class numbers.—The last two digits of a diagnosis number identify it as a title within the class indicated by the one or two preceding digits. When appearing elsewhere than in a diagnosis number, classes are indicated by roman numerals. These roman numerals are for grouping and for statistical use and need not accompany diagnosis numbers. 259 2402 CH. 15.—DIAGNOSTIC NOMENCLATURE (c) Methods of listing titles; significance of print styles.— Itemized diagnostic titles are given in two parts in appendix A: first, by classes, Section II, A; and second, by alphabetical arrangement, Section II, B. All titles appear in full in each part. The listing by classes is for numerical cataloging and for convenience of reference to related titles. Although it is essentially numerical, certain titles are repeated for ease of reference in alphabetical order within the classes. In the fisting by classes, instructions and explanatory re- marks are given with the titles only in their numerical positions; when a title appears in its numerical position the verbatim portion is given in bold face type; all titles which are repeated for reference are printed in capitals and are followed, rather than preceded, by their numbers; and, titles which are out of alphabetical order are indented. Through- out Section II print styles are used as follows: bold face or capitals for wording to be used verbatim; ordinary print for instructions specifically influencing additional wording of the titles; and, italics for explanatory remarks. (d) Wording of titles.—Wording not specifically required shall not be included as a part of the diagnostic title. 2402. Choice of Titles.—(a) Symptomatic diagnoses.—A number of symptomatic diagnoses are necessarily included. Whenever possible the title chosen shall be that of the underlying disability rather than a secondary manifestation. When, at first, it is necessary to assign a symptomatic diagnosis, that diagnosis shall, if possible later, be changed by reason of error to that of the underlying disabil- ity: e. g., headache (2131), changed to glioma, brain (2312), cardiac ARRHYTHMIA, HEART BLOCK (227), changed to CORONARY HEART DISEASE, arteriosclerotic (237). In order to accomplish this it is not neces- sary for the patient to have been continuously on the sick list. If a patient has been discharged from the sick fist with a symptomatic diagnosis the underlying nature of which is ascertained later, he shall be again taken up under the symptomatic diagnosis and the diagnosis changed by reason of error to that of the underlying disability, even though no further sick days are involved. (b)—XY, Other diseases of this class.—For elasticity in the use of the nomenclature, definite clinical entities having generally accepted titles not included in this nomenclature may be reported under—XY, other diseases of this class, state title. With three exceptions, one such title is provided for each class. This title shall not be used for disabilities which can be reported correctly under any other title appearing in the nomenclature. In the case of poisonings, title numbers 2601 and 2603 render an XY unnecessary. No XY titles are provided for venereal diseases, class XII; or injuries, class XXV. If a 260 SEC. I.—INSTRUCTIONS—TITLES 2402 venereal disease or an injury occurs which is not covered by a title provided in these classes, the Bureau shall be advised of the circum- stances and instructions requested as to the diagnostic title to be used. (c) Diagnosis undetermined.—For further elasticity in the use of the nomenclature, the title diagnosis undetermined is provided under three headings: Diseases and conditions (2122); Injuries (2518); and Poisonings (2600). For further instructions see paragraph 2409. (d) Malingering (2139) is to be used when a patient claims to be ill or unduly exaggerates a disability, and the medical officer is of the opinion that there is only a slight or no actual disability. (e) No disease (2143) is to be used for individuals who, for any reason, must be carried on the medical department returns for rations, as suspects, or as contacts, who do not claim to be and are not regarded as sick. Although undue sick days under this title are to be avoided, it shall be used when applicable. The binnacle list shall not be used as an alternative. When the title no disease is used, the reason or condition for its use shall be recorded as follows: no disease (mental observation); no disease (spinal puncture); etc. WTien a person is admitted to the sick list under no disease and is later discovered to have, or have had, a disability of sufficient gravity to have caused his admission to the sick list at that time, the diagnosis shall be changed by reason of error to that of the disability. WTien a person is admitted to the sick list under the title of a dis- ability and is later discovered not to have, nor to have had, a dis- ability of sufficient gravity to have caused his admission to the sick list at that time, the diagnosis shall be changed by reason of error to no disease. When changing from diagnosis undetermined to no disease it shall be by reason of established. (f) Precedence op titles.—No case shall be carried on the sick list simultaneously with more than one diagnosis. WTien two or more disabilities exist, the first admission shall be for an infectious disease, the graver disability, or a primary disability rather than a complica- tion. In the case of injuries where the title injuries, multiple, extreme (2542) does not apply, the graver injury shall be given preference for the first admission. It sometimes happens that swelling obscures a graver injury, for example a fracture, and the case is taken up as contusion or sprain. In such a case, when the fracture is discovered, the diagnosis shall be changed by reason of error to the fracture. (g) Prompt changes to new titles.—When sequelae, complica- tions, or intercurrent disabilities occur in cases already on the sick 261 2403-2404 ch. is.—diagnostic nomenclature list, a change of diagnosis shall be made as soon as possible so that each disability may be charged with its proper number of sick days. (h) Subsequent discovery of error.—When a patient is dis- charged from the sick list under any diagnosis which is later dis- covered to be erroneous, he shall be readmitted with the erroneous diagnosis and his diagnosis changed by reason of error to the correct title. This procedure shall be followed even though no further sick days are involved. 2403. Abbreviations for Taking Up and Disposing of Cases on the Sick List.—The following abbreviations shall be used for entries on form F cards and on the left margins of medical history sheets: (a) Methods of taking up on sick list.— Admitted (new admission) A. Admitted contributory disability ACD. Readmitted RA. Remaining (from previous year) —. (b) Methods of disposition on sick list.— Duty D. Diagnosis changed C. Died DD. Invalided from service IS. Ran (deserted) Ran. Transferred T. Continued (to next year) —. 2404. Interpretation and Usage of Terms.—(a) Admitted.—All new admissions for disabilities which have developed or been incurred since entry into the service and which bear no relation to a disability for which the patient has been previously taken up on the sick list shall be taken up as admitted (A). Separate, distinct, and new occurrences of disabilities for which a patient has been previously taken up on the sick list and from which there has been a complete recovery, shall be taken up as admissions, A. (b) Admitted contributory disability.—All first admissions on account of complications or sequelae, including final disabilities, shall be taken up as admitted contributory disability (ACD), e. g.: contracture, cicatrix, etc., in the case of injuries; broncho-pneumonia complicating measles, etc.; also reactions, diseases, and injuries result- ing from diagnostic procedure and treatment, including: no disease (spinal puncture); burn from a hot water bottle; poisoning, thera- peutic; malaria, induced, etc. No case shall be taken up as ACD unless there has been a previous admission to the sick fist for the disability of which the complication, sequela, or dependent disability is a result. Such a complication, sequela, or dependent disability shall be taken up as admitted (A) 262 8E0. I.—INSTRUCTIONS—TERMS 2404 (or, if existing prior to entry into the service, as readmitted (RA), and a note made on line 14 of the form F card and in the health record as follows: “No previous admission for underlying (name of underlying disability) which is not now present.” (See par. 2408 (b) (3).) If, however, the primary disability is present with the complication and has not been previously reported, the case shall be first taken up under the primary disability and changed to the complication as ACD. (See par. 2408 (b) (2).) (c) Readmitted.—(1) Each taking up on the sick list under the same diagnostic title for a disability definitely a continuation or recur- rence of one for which previously taken up shall be readmitted (RA). A subsequent new and independent occurrence of the same disability shall be taken up as admitted (A), as provided for in sub- paragraph (a), above. (2) Every person who is taken up on the sick list because of a dis- ability which is considered to have existed prior to entry into the naval service, shall be taken up as readmitted (RA). (See par. 2410.) (3) When a patient is received from transfer, he shall be taken up as readmitted (RA), with the disability under which transferred. (4) The established diagnosis in a case first taken up under diag- nosis undetermined shall be reported as readmitted (RA). (See par. 2409.) (5) The corrected diagnosis following a change of diagnosis by reason of error shall be reported as readmitted (RA). (See subpar. (f), example (1), below.) (6) In cases of injuries where more than one injury title resulting from the same violence is required to properly record such multiple injuries, only the title of the gravest injury shall be reported as admitted (A), others which are deemed necessary being reported as readmitted (RA). (7) Every person who is taken up on the sick list because of a dis- ability considered to have been incurred in desertion status shall be taken up as readmitted (RA). (See par. 2411.) (8) Persons returning from sick leave shall be taken up as readmit- ted (RA), under the same disability for which granted sick leave and properly disposed of from the sick list even though for record only, inasmuch as they are in a modified sickness, not a leave, status. (See par. 2407 (m).) (9) In three types of readmissions, the date and place of a previous admission is required on line 14 of the form F card. For these cases see paragraph 2405 (b), line 14. 263 2404 CH. 15.—DIAGNOSTIC NOMENCLATURE (d) Remaining.—All cases remaining on the sick list on January 1, from the previous year, shall be taken up as remaining, “—.” (See par. 2405 (c).) (e) Duty.—All cases restored to duty or transferred to the Naval or Marine Corps Reserve shall be disposed of as discharged to duty (D). Patients granted leave of absence to begin upon discharge from treatment, shall be disposed of as to duty (D). Patients discharged from the service by reason of expiration of enlistment and retained in the hospital as supernumeraries, shall be disposed of as to duty (D). (f) Diagnosis changed.—A diagnosis may be changed by reason of: (1) Error. (2) Concurrent disability which exists on admission or develops prior to current readmission for present illness and excludes recurrent disability. (3) Inter current disability which develops during present illness subsequent to present admission or current readmission and excludes recurrent disability. (4) Recurrent disability, one which has continued or recurred and with which the patient has previously been carried on the sick list. (5) Complication. (6) Sequela. (7) Diagnosis established, used only when changing from diagnosis UNDETERMINED. Examples (numbered as above).—(1) A case is admitted with a diagnosis of tuberculosis which is later determined to be bron- chitis, chronic. Discharged from diagnosis of tuberculosis by C, reason—error, and readmitted (RA), with bronchitis, chronic. (2) A patient has been admitted for tonsillitis, acute, and, following recovery, the diagnosis is changed to pterygium. Discharged from tonsillitis, acute, by C, reason—concurrent disease, and admitted (A), with pterygium. (3) and (4) A patient under treatment for tuberculosis receives an injury. Discharged from tuberculosis by C, reason—intercurrent injury, and admitted (A), with the injury. When recovered from the injury, discharged from the injury by C, reason—recurrent disease, and readmitted (RA), with tuberculosis. If the patient dies, or is discharged from the service by reason of the tuberculosis, while still on the sick list for the unhealed injury, the diagnosis shall be changed back to tuberculosis, as above, to show that termination of service was on account of tuberculosis and not because of the intercurrent injury. (5) and (6) A patient is under treatment for scarlet fever which becomes complicated with otitis, media, which, in turn, is followed by deafness. Discharged from scarlet fever by C, reason—complication, taken up with 264 SEC. 1.—INSTRUCTIONS—FORM F CARD 2405 OTITIS, MEDIA, by ACD, DISCHARGED from OTITIS, MEDIA, by C, reason—sequela, and taken up with deafness by ACD (par. 2284). (g) Died.—In case of death the patient shall be disposed of as died—(DD). Should death result from a disability other than that with which the patient is carried on the sick list, the case should be disposed of by C, properly taken up with the direct cause of death, and immediately disposed of by DD. (h) Invalided from service.—In case of termination of service of an officer or nurse by retirement for physical disability, of a mid- shipman or aviation cadet for physical disability, or of an enlisted man through an approved recommendation of a board of medical survey, the patient shall be disposed of as invalided from service— (IS). Only the place from which the actual discharge from the service takes place shall use this disposition. An officer or nurse granted leave at the expiration of which he or she is to be placed on the retired list, shall be disposed of by IS on the date this leave begins. A hos- pital, station, or ship may survey a man and recommend his discharge from the service, but if the actual discharge takes place on a receiving ship or other station, such hospital, station, or ship shall show the disposition of the case as transferred (T), and at the place to which transferred the case shall be readmitted (RA) and disposed of by IS on the date of actual discharge from the service. The diagnosis under which disposed of in the health record and on the form F card shall always agree with the condition for which the patient is invalided from the service. (i) Ran.—In case of termination of service through desertion while on the sick list, the patient shall be disposed of as deserted (Ran). The record shall be closed out, when officially declared a deserter, as of the actual date of running. Patients returning before the expiration of 10 days shall be continued on the sick list without interruption. For patients returning after the expiration of 10 days see subparagraph (c) (7) above, and paragraph 2411. (j) Transferred.—In case of disposition of a patient to another ship, station, or hospital, he shall be disposed of as transferred (T). The same disposition shall be used to indicate the disposition of an officer, midshipman, aviation cadet, or nurse sent on sick leave. (k) Continued.—All cases present on the sick list on December 31, unless discharged that date, shall be disposed of, i. e., closed out for the year,.as continued—“—,” to the next year. (See par. 2405 (c).) 2405. Form F Card. Individual Statistical Report of Patient.— The form F card serves to advise the Bureau of each admission to, change of status on, and discharge from, the sick list of each patient. It is an essential part of the vital statistics of the Navy. 265 2405 CH. 15.—DIAGNOSTIC NOMENCLATURE (a) When prepared and forwarded.—(1) A form F card shall be opened in duplicate each time a person is taken up (A, RA, ACD, “—,” see par. 2403) on the sick list, even though taken up for record only (e. g., cases admitted and discharged to duty on the same date, cases returning from sick leave for disposition, etc.). Each card is retained until completed by disposition (D, C, DD, IS, Ran, T, “—”) of the patient. The data for its preparation shall be obtained from the health record and from the nomenclature, appendix A. (2) In the case of active-duty ‘personnel the originals of form F cards shall be closed out and forwarded direct to the Bureau as promptly as possible upon disposition of patients. They shall be sent under separate cover, not with any other correspondence. The duplicates shall be retained for office files and for preparation of monthly form F except as in paragraph 2407. At the end of the year, for statistical purposes, all cases continuing on the sick list are closed out as continued to the next year and their cards sent to the Bureau. They are picked up on new cards for the new year (par. 2405 (c)). (3) In the case of supernumeraries the procedure is the same as for active duty personnel except that the originals are not sent to the Bureau unless requested. (b) Instructions for numbered lines.— Line 1.—Surname and Christian name in full. Rank or rate. Line 2.—Total service, Navy and Marine Corps. All service as a com- missioned officer, commissioned warrant officer, warrant officer, aviation cadet, midshipman, enlisted man, and active reserve shall be used in computing total service. Odd days of less than 1 month shall be dropped. Aviation status at time of taking up (see par. 2417). Line S.—Name of State or country if foreign born. Date of birth using num erals (1-13-38). Race—White, Negro, Amer. Indian, Filipino, Samoan, Cha- morro, Chinese, Japanese, etc. Line 4.—For patients received from transfer (indicate origin), change of diagnosis, etc. State date of present enlistment (use numerals, month first). Hospitals, only, will indicate by the word “Staff” when the patient is a member of the hospital staff. When admitted direct to a naval hospital by orders of the Bureau of Navigation, or from home awaiting discharge or retirement, so indi- cate. When received from sick leave, so indicate. If the patient is a straggler or in desertion status, so indicate. When a case is taken up from a change of diagnosis on the preceding form F card, enter the phrase “Change of diagnosis.” Line 5.—Diagnostic title (see nomenclature). In taking up a case received from transfer, particular care should be exercised to see that the diagnosis agrees with that under which transferred. Line 6.—Diagnosis number (see nomenclature). Key letter (par. 2414). Specialty letter (par. 2415.) Line 7.—Abbreviation indicating method of present taking up under diagnostic title given on line 5 (par. 2403). Date of present taking up, using numerals. 266 SEO. I.—INSTRUCTIONS—FORM F CARD 2405 Indicate whether the disability existed prior to entry into the naval service— (EPTE)—(state “yes” or “no”). If yes, the case should be taken up as read- mitted (RA), in the first space on this line and line 13 on the reverse side of the card should be filled in. Line 8.—Abbreviation indicating method of present disposition from the title given on line 5 (par. 2403). Date of present disposition, using numerals. Number of sick days, i. e., number of days accounted for on the present form F card by the dates on lines 7 and 8. In computing the number of sick days, the day of admission shall be considered a day of duty and the day of discharge a day of absence; count the latter but not the former. In case there is a series of form F cards for a continuous stay on the sick list, the same rule applies, thus pre- venting the days of taking up or disposition from being counted twice. No sick days shall be counted for cases taken up and disposed of on the same calendar day. In reporting the sick days of cases remaining from the preceding year, the first day of the current calendar year shall be counted as shown in paragraph 2405 (c). The number of sick days shown on this line shall be increased by one in eastward crossings of the international date line (180th meridian) and decreased by one in westward crossings, and a note of such gain or loss made on line 14. Line 9.—For cases disposed as transferred (T), on line 8. The name of the place to which transferred shall be stated; in case of transfer to sick leave, etc., so state. In case of intermediate transfer, the name of the naval vessel to which actually sent for transportation shall be given, not the place to which ultimate transfer is to be made. If such transfer is by commercial transportation or Army transport, the words “via commercial transportation” or “via Army transport” shall be inserted after the name of the station or hospital to which the patient is to report. Line 10.—Name of ship or station preparing the card except as in paragraph 2407. Active-duty passengers admitted to the sick list shall be reported on line 10 as patients of that ship. Line 11.—To be filled in only when the present card has been closed out by a diagnosis changed (C), on line 8. Enter the new diagnosis and its number and the reason for the change (par. 2404 (f)). Line 12.—To be filled in only when the case is taken up as an admitted con- tributory disability (ACD), on line 7. State the previous diagnosis, and its number, of which this disability is a complication or sequela. Line 18.—To be filled in only when the disability existed prior to entry into the naval service as shown by the answer “Yes” on line 7. State if previously taken up under the same diagnosis title and the date thereof. Line 14-.—Miscellaneous data essential to complete the report. These shall include circumstances of occurrence for every admission for injury or poisoning (see par. 2416) and for a readmission only when it follows transfer of the original admission. In the following types of readmissions RA, the date and place of original admission is required on line 14, except when the readmission follows receipt from transfer T: (1) For every readmission for a dis- ability definitely a continuation or recurrence of one for which pre- viously taken up; (2) for an injury or poisoning taken up as read- mitted (RA), under any injury or poisoning title resulting from the 267 2405 CH. 15.—DIAGNOSTIC NOMENCLATURE same violence or poisoning (see par. 2404 (c) (6) and 2416 (b)); (3) for all venereal diseases taken up as readmitted (RA), the date and place first taken up for the present infection (whether under another venereal title or diagnosis undetermined). (See par. 2408 (d).) The space under line 14 shall be used for such additional remarks as are required or considered necessary to clarify the case. (c) Cases continuing at the end of one year and remaining at the beginning of the next.—All cases present on December 31, unless discharged that date, shall have their form F cards closed out as continued to the next year. They are picked up on new cards for the new year as remaining. Two form F cards are required for each such case. On the card for the year just ended, a dash, “—,” indicating continued, shall be entered under “disposition” on line 8 as of the last day of the year, and the number of sick days from the date of present taking up (on line 7) to and including December 31. On the card for the ensuing year, a dash. “—,” indicating remaining shall be entered under “taken up” as on line 7, followed by the date taken up in the previous year and, when finally disposed of, only the sick days for the current calendar year, including January 1. Examples for use in forwarding form F cards: Taken up as— Date Dispo- sition Date Sick days Forwarded 1 A 8-23-35 D 8-28-35 5 Aug. 28,1935 2 RA 12-20-37 — 12-31-37 11 Dec. 31,1937 3 12-20-37 D 1-10-38 10 Jan. 10,1938 Examples 2 and 3 indicate the method of recording a continued case. (d) Only completed cards to be forwarded.—If there is no health record to which reference can be made for the completion of a form F card, the information necessary to complete the card shall be obtained from the service record, if available; otherwise from the patient, if possible. An incomplete form F card shall not be sent to the Bureau unless the data are unobtainable, in which event the card shall be accompanied by a letter directing attention to the incomplete record and stating the reason therefor. (e) Form F cards to be initialed.—Before each original form F card is forwarded to the Bureau, it shall be initialed in the lower right-hand corner by a medical officer, if practicable the one handling the case, exceDt at hospitals and training stations where this duty 268 SEC. I.—INSTRUCTIONS—FORM F ABSTRACT 2406 may be delegated as necessary, and, when there is no medical officer, by the member of the medical department responsible. (f) Further instructions.—For further instructions see para- graph 2407. 2406. Form F—Abstract of Patients.—(a) General instructions.— This form shall be prepared and forwarded to the Bureau monthly and when a ship, station, or hospital is placed out of commission. It shall include all personnel of the active list (including personnel of the retired list or reserve on active duty) of the Navy, Marine Corps, and Nurse Corps disposed of from the first to the last day of the month, inclusive. The date of disposition on line 8, of each form F card indicates the month in which a case shall be reported on this form. Form F for the month of December shall also include all cases continued to the next year. The data for preparation of Form F shall be obtained from the duplicate form F cards kept for that purpose. (b) When no cases have been disposed of.—This form shall be submitted monthly whether or not there were any cases disposed of. (c) Alphabetical listing.—The names shall be entered in strictly alphabetical order, using additional sheets when necessary. The record shall be continuous without unnecessary spacing. (d) Form.—The form shall be typewritten, tho original ribbon copy being forwarded to the Bureau and a duplicate copy retained for the files of the office of origin. A copy shall also be forwarded to the senior fleet or squadron surgeon when serving in fleet or squadron. (e) Supernumerary patients as defined in the manual of the Medical Department, shall not be fisted on Form F. (f) Constitution of “average complement”.—Each reporting activity (par. 2407 (a)) shall include all personnel on duty at, or on detached duty from, that activity, and in addition: (1) For tenders and other ships of the fleet, the crews of all attached craft which carry no medical department personnel (commissioned or enlisted); (2) for yards and stations (other than district headquarters), crews of all yard craft (including submarines) attached; (3) for naval district headquarters, all persons under the jurisdiction of the district who are directly responsible to it or who are on duty away from medical department personnel, including crews of district craft which have no medical department personnel; (4) for central recruiting stations, all personnel under their jurisdiction. (g) Calculation. Average complement shall be computed by dividing the total number of daily rations issued and commuted dur- ing the month or fraction of month embraced in this report, by the number of days of the period embraced in the report. To this are 269 2407 CH. 15.—DIAGNOSTIC NOMENCLATURE added the average number of officers and nurses (to whom rations are not allowed) and average numbers of such persons as indicated in subparagraph (f) above, for whom data on daily rations cannot be obtained. (Number of rations issued and commuted may be obtained from the supply officer.) Ships, stations, and yards shall not include in their average complements officers, nurses, and men attached (on duty or as patients) to a naval hospital. Naval hospitals shall give as an average complement officers, nurses, and men attached (on duty or as patients) to the hospital. (h) Further instructions.—For further instructions with refer- ence to Form F, see paragraph 2407. 2407. Form F Card and Monthly Form F. When, and By Whom, Prepared.—(a) Form F cards and monthly Form F required PROM ALL SHIPS, STATIONS, HOSPITALS, AND EXPEDITIONARY GROUPS.— When there are medical department personnel (commissioned or enlisted), form F cards and monthly Form F shall be prepared, as directed in paragraphs 2405 and 2406. (b) Illness of naval personnel on leave or on duty away from medical department personnel.—When illness or injury of such persons comes to the attention of any member of the medical department, it shall be the duty of the latter to prepare and forward form F cards in accordance with instructions contained in paragraphs 2405 and 2407, with especial reference to paragraph 2407 (c), below. (c) Personnel temporarily away from command.—When a member of the personnel of a ship or station temporarily away from his command is admitted direct and carried on the sick list by the medical department of another ship, station, or hospital, the case will be taken up there as a readmitted (RA), and a form F card prepared showing admitted (A), at and transferred (T), from his regular station to that at which carried on the sick list; line 10 will show the forwarding as well as the regular station, e. g., “U. S. S. Utah, by Naval Hospital, Chelsea, Mass.” The original of this A and T card shall be sent direct to the Bureau and the duplicate shall be sent to the ship or station which appears on line 10. Personnel detached from a ship or station and proceeding to a new ship or station who are admitted to the sick list by the medical department of a ship (except when being transported, see par. 2405, fines 9 and 10), station, or hospital while in route, will be taken up as readmitted (RA). A form F card shall be prepared showing admitted (A) at and transferred (T), from the ship or station to which they are to report, to the ship, station, or hospital at which placed on the sick fist, fine 10 to show the name of the forwarding station as well as that of the ship or station for which the original is forwarded (and to which the duplicate is sent). Line 10 of 270 sec. i.—instructions—preparation of forms f 2407 the form F card shall read likewise if a ship or dispensary acts as an intermediary and transfers the caso to a naval hospital or other place for treatment. The form F card duplicate shall be forwarded to the ship or station to which the patient was attached, or was proceeding, at the time of his admission to the sick list, for inclusion with the statis- tical returns made by that station. This procedure credits the proper command with the original admission. When no sick days are involved, the case shall not be carried on the medical department returns of the ship or station acting as intermediary but shall be shown as transferred from the regular station to the hospital by the inter- mediary. (d) Yard craft.—These shall be considered a part of, and included with, the yard or station to which attached, when preparing form F cards and monthly Form F. (e) Ships of the fleet which have no medical department personnel.—These shall be considered a part of, and included with, the ship to which attached, when preparing form F cards and monthly Form F. (f) Submarines.—In the preparation of form F cards and monthly Form F for submarine personnel, the procedure shall be the same as in subparagraph (a), (d), or (e), above, with the exception that line 10 of the form F card shall also carry the name of the submarine. Example: Submarine Base, New London (U. S. S. S-80). (g) District craft which have no medical department per- sonnel.—Personnel of these craft shall be considered, in regard to form F card and monthly Form F procedure, as on duty at their district headquarters, and line 10 of the form F card shall carry the name of the district. When cared for by the medical department personnel of other activities, the form F card procedure shall be as in subparagraph (c), above. District headquarters shall maintain files of duplicate form F cards for these personnel and shall submit monthly Form F covering them. (h) Personnel on recruiting duty.—These personnel shall be considered, in regard to form F card and monthly Form F procedure, as on duty at the central recruiting station under whose jurisdiction they come, and line 10 of the form F card shall carry the name of the central recruiting station. When cared for by the medical department personnel of other activities, the form F card procedure shall be as in subparagraph (c), above. Central recruiting stations shall maintain files of duplicate form F cards for all persons under their jurisdiction and shall submit monthly Form F covering them. Monthly Form F is not required from other than central recruiting stations. 271 2407 CH. 15.—DIAGNOSTIC NOMENCLATURE (1) Isolated, independent, or detached duty away from medi- cal department personnel.—(1) If the person is under the direct jurisdiction of a ship, station, or naval district, he shall be considered, in regard to form F card and monthly Form F procedure, as on duty there, and line 10 of the form F card shall carry the name of that activity. When cared for by the medical department personnel of other activities, the form F card procedure shall be as in subparagraph (c), above. Ships, stations, and districts shall maintain files of dupli- cate form F cards for such persons under their jurisdiction and shall submit monthly Form F covering them. (2) If the person is under the direct jurisdiction of the Navy Depart- ment or of a Bureau, the original of the form F card showing first taking up and disposition shall be sent to the Bureau and its dupli- cate retained by the reporting activity but not included on the monthly Form F of the reporting activity. Line 10 shall carry the name of the authority under whose jurisdiction the person comes, the place of duty in parentheses, and the name of the reporting activity. (j) Naval districts.—The medical departments of naval distirct headquarters shall maintain files of duplicate form F cards and sub- mit monthly Form F for their headquarters personnel and for persons under their jurisdiction who are either responsible directly to them or who are on duty away from medical department personnel. (See pars. 2406 (f) and 2407 (a), (g), and (i).) (k) Sickness while on leave.—WFen sickness or injury occurs while on leave, a form F card shall be prepared and forwarded by the activity to which the person is attached, when aware of the cir- cumstances, unless cared for as in subparagraph (c), above. If the person returns to his ship or station and continues on the sick list under the same diagnosis, he shall be continued on the same form F card until disposed of (par. 2403). (l) Death while on leave.—When death occurs while on leave or otherwise away from command, the ship, station, or hospital prepar- ing the death certificate shall proceed as directed in subparagraph (c), above. (m) Intervening disabilities while on sick leave.—(1) When taken up at the hospital (or other activity) from which granted sick leave.—The case shall be readmitted (RA), with the diagnosis under which carried at the time of departure on sick leave, the diagnosis changed, and the case taken up under the new title. (2) When taken up at a hospital (or other activity) other than the one from which granted sick leav>e.—The admitting hospital shall prepare a form F card showing the case taken up as admitted (A), under the 272 SEC. I.—INSTRUCTIONS—PREPARATION OF FORMS F 2407 title of the intervening disability, at the hospital from which absent. This card shall be closed out as transferred (T), to the admitting hospital. Line 4 (“Received as patient from”) shall carry the words, “Change of diagnosis”; line 9 (“Transferred as patient to”) shall carry the name of the admitting hospital; and line 10 (“This card sent from”) shall state the hospital from which absent “by” the ad- mitting hospital. The original of this card shall be sent to the Bureau and the duplicate to the hospital from which absent. The admitting hospital shall then take up the case as readmitted (RA), under the title of the intervening disability, as though received from transfer from the hospital from which absent (the name of the latter to appear on line 4 of the form F card). When the duplicate of the first form F card is received, the hos- pital from which the patient is absent shall readmit RA, from sick leave (line 4 of the form F card to show “sick leave”) as of the date taken up at the other hospital, with the diagnosis under which the sick leave was granted. This card shall be closed out by change of diagnosis C, to that of the intervening disability. If examination of the patient’s records shows that the intervening disability should not have been taken up as admitted (A), but as RA or ACD, a new card shall be made, its duplicate retained, and the original sent, with the duplicate received from the other hospital and a letter of explana- tion, to the Bureau to replace the original on file there. (3) Cases recovering from such intervening disabilities shall be disposed of as follows: 1. If sick leave has not expired, change C, readmit RA, with the diagnosis with which carried when granted sick leave, and transfer T, to sick leave. 2. If sick leave has ex- pired, change C, readmit RA, with the diagnosis with which car- ried when granted sick leave, and, unless otherwise directed, transfer T, to the hospital from which granted sick leave. (n) Intervening disabilities while on leave as a patient.— (1) When taken up at the hospital (or other activity) from which granted leave.—It is not necessary to readmit from leave as it is from sick leave (subparagraph (m) (1), above). The case shall be handled just as though it had been continuously in the hospital. (2) When taken up at a hospital (or other activity) other than the one from which granted leave.—The procedure shall be the same as with sick leave (subparagraph (m) (1), above) except that, when the hos- pital from which the patient is absent, receives the duplicate form F card from the admitting hospital, it shall close out the form F card on file for the case by change of diagnosis C, to that of the inter- vening disability. If the latter should not have been taken up as an 273 2408 CH. 15.—DIAGNOSTIC NOMENCLATURE admission A, but as RA or ACD, the procedure shall be as in the same case under subparagraph (m) (2), above. (o) Transfers to hospitals other than naval hospitals.— (1) A case may not be disposed of as transferred (T), on the sick list, to a hospital other than a naval hospital, except those especially designated in chapter 13 of the manual of the Medical Department. When cases are transferred to non-naval hospitals, the form F card and health record procedure is as directed in paragraph 2213. A transaction on the sick fist, or closing out and preparation of form F cards, occurs only when responsibility for the patient and custody of his health record changes from one naval activity to another. (See par. 2213 (b) (1)). (2) Foreign hospitals.—When a patient is transferred to a foreign hospital and the ship leaves port, form F card covering the period up to date of departure shah be prepared and forwarded to the Bureau If the patient’s records are transferred to another naval vessel, disposi- tion shall be T to that vessel. In the absence of another naval vessel, disposition shall be T to the custody of the nearest American consul. In the latter case, the next naval activity receiving the patient’s records shall forward form F card covering the remainder of the period on the sick list, showing a readmission RA, as of the date of transfer to the custody of the consul and disposition as indicated. (See par. 2213 (b) (2).) 2408. Venereal Diseases, Class XII.—(a) Use of titles.—Titles other than those found in class XII shall not be used for active venereal infections. Active gonococcus infections shall be designated by one of the seven specific titles listed in the nomenclature, depending on location, or by gonococcus infection, otherwise unclassified, state location—(1206). The title chancroidal lymphadenitis—(1201) is provided in addition to chancroid—(1200). The following nonve- nereal titles, as examples, shall not be used to describe the venereal conditions listed opposite them: Correct venereal title Do not report as Gonococcus infection, urethra—(1205).. Urethritis, acute—(747). Gonococcus infection, joint—(1203) Arthritis, acute—(1602). Gonococcus infection, conjunctiva— Conjunctivitis, purulent—(613). (1202). Gonococcus infection, bladder—(1206).__ Cystitis, acute—(709). Gonococcus infection, lymph node— Lymphadenitis—(1403). (1204). Chancroidal lymphadenitis—(1201) Lymphadenitis—(1403), etc. (b) Complications, sequelae, etc.—Certain complications, se- quelae, and later manifestations of venereal diseases may require diag- nostic titles found outside of class XII. For example: gonococcus 274 sec. i.—instructions—diagnosis undetermined 2409 infection, urethra, may result in stricture, urethra—(742); syphilis may result in dementia paralytica—(1508); etc. Most complications of gonococcus infection, urethra, remain within class XII; for example, gonococcus infection, epididymis—(1209). (1) When a previous admission has been made jor the primary injec- tion, the complication shall be taken up in the usual manner (see par. 2404 (b) as an admitted contributory disability (ACD). (2) When no previous admission has been made jor the primary injec- tion but it is still present with the complication, the prilnary infection shall be reported as a new admission A (or RA if it existed prior to entry into the service) and the complication as ACD. (See par. 2404 (b).) (3) When no previous admission has been made jor the primary injec- tion and it is no longer present when the complication becomes appar- ent, the case shall be taken up as a new admission A, under the diagnosis of the complication (or RA if it existed prior to entry into the service) and the following note, “No previous admission for under- lying (name of primary infection) which is not now present,” made in the health record and on line 14 of the form F card (par. 2404 (b)). (c) Erroneous diagnosis of chancroid.—When a person has been admitted under the diagnosis of chancroid and the medical officer later has reason to believe that the lesion was really the primary chancre of syphilis, the case should be handled and the diagnosis changed as directed in paragraph 2402 (h). (d) Readmission—RA, for venereal disease.—For all venereal diseases taken up as readmitted (RA), except following receipt from transfer, the date and place of the first taking up on the sick fist which was really caused by the present venereal infection (whether this first taking up was under a venereal title, diagnosis undetermined, or an erroneous title) shall be given on line 14 of the form F card. 2409, Diagnosis Undetermined.—(See par. 2402 (c). (a) When the title diagnosis undetermined is used, the suspected disability shall be entered in parentheses immediately following. Examples: diagnosis undetermined, (appendicitis, acute)—(2122); diagnosis undetermined, (fracture, skull)—(2518); diagnosis undetermined (lead poisoning)—(2600). When the nature of the disability is deter- mined, the case shall be changed from diagnosis undetermined, by reason of established, and readmitted (RA), under the estab- lished diagnosis. (b) Proper usage.—(1) This title may be used for admission to the sick list and transfer of patients when circumstances do not war- rant an immediate diagnosis. (2) A diagnosis may be changed to 275 2410-2412 ch. 15.—diagnostic nomenclature diagnosis undetermined when a patient is already on the sick list and an undetermined disability arises. This prevents the sick days, incurred in establishing the nature of the new disability, being charged improperly to the disability for which the patient is already on the sick list. (3) Only in the following events may a patient be dis- posed of under the title diagnosis undetermined: transferred (T); DIAGNOSIS CHANGED (C)j DESERTION (Ran) | Or CONTINUED to Dext year, “—.” (c) Improper usage.—(1) diagnosis undetermined shall not be used to report an admission when the case is retained and the diagnosis established at the same ship or station, except as in subparagraph (b) (2), above. (2) Under no circumstances shall a case of diagnosis undetermined be disposed of as duty (D), died (DD), invalided from service (IS), or transferred (T) to sick leave. 2410. Disabilities Existing Prior to Entry into the Naval Service.— All disabilities which are considered to have existed prior to entry (EPTE) into the naval service shall be taken up as readmitted (RA), and lines 7 and 13 of the form F card shall be completed as directed in paragraph 2405 (b). This is done in order that the vital statistics of the Navy may not be charged with cases evidently existing prior to entry into the naval service. When these prior conditions are followed by complications, or other dependent disabilities, occurring after entry into the service, the latter are considered to have devel- oped since entry and are taken up in the usual manner (see par. 2404 (b). If there has been no previous taking up for the primary disability and it is no longer present with the complication, the com- plication shall be taken up as admitted (A), if considered to have been brought on by service conditions, or as readmitted (RA), if considered to have arisen solely as a result of the primary disability which existed prior to entry into the naval service. 2411. Disabilities Arising While in Desertion Status.—All disabili- ties which are considered to have arisen while in desertion status shall be taken up as readmitted (RA), and a note, “Incurred while in desertion status,” entered on line 14 of the form F card. Complica- tions or other dependent disabilities shall be handled as in the case of disabilities existing prior to entry into the service (see par. 2410, above). For cases deserting while on the sick list, or returning from such desertion, see paragraphs 2404 (c) (7) and 2404 (i). 2412. Injuries, Class XXV.—In view of the preventable nature of injuries (and poisonings), especial attention is given to them. Rules for reporting data are given so that the latter can be received, com- 276 SEC. I.—INSTRUCTIONS—KEY LETTERS 2413-2414 piled, and analyzed for preventive purposes in the statistical section of the Buareu. In order to obtain constructive information for pre- vention, and not as a basis for disciplinary action, the following points are established for cases of injuries (and poisonings): Nature of injury (or poisoning) as shown by the diagnostic title (e. g., frac- ture of femur). Status of person when injured (or poisoned) (within command, liberty, etc.). If within command: Whether the person was also actually at work. Whether due to materiel or personnel factors, if either. If not within command: Whether the person was intoxicated. Whether the result of the person’s own misconduct. Nature (e. g., automobile) and cause (e. g., collision and overturning) of the violence as contrasted to the nature of the bodily injury. 2413. Poisonings, Class XXVI.—The general nature of information to be provided in cases of poisoning is the same as for injuries. (See par. 2412, above.) Poisoning, therapeutic, drug reactions, etc.—Poisonings by, or reactions from drugs used in therapy shall be reported as poisoning, therapeutic. State substaoce used and disability treated (2604 or 2605). Example: poisoning, therapeutic, neoarsphenamine, syph- ilis. They shall be taken up as admitted contributory disability (ACD), of the disability treated, if there has been a previous admis- sion for the latter; if not, see paragraph 2404 (b). This title shall not include anaphylaxis—(2109) serum sickness—(2165) or derma- titis—(1916) when due to external applications. If the clinical mani- festations are sufficiently characteristic and important to warrant a definitive diagnosis, the case shall first be taken up as poisoning, therapeutic and the diagnosis then changed to that of the clinical manifestation as an ACD of the poisoning. 2414. Key Letters.—(a) Key letters are used as short expressions of the nature of violence. (See par. 2405 (b) line 6.) They will be used in cases of poisoning only when the origin is suicidal, homicidal, or casualty due to poisoning in action against an organized enemy. The classification of key letters is as follows: A. Suicide and suicidal attempt. B. Homicide and homicidal attempt. To include justifiable, excusable, or felonious homicide; murder and manslaughter. C. Conflagration. To include all traumatism resulting from general conflagra- tion. Explosions as a result of general conflagration are classed hereunder. D. Drowning, accidental, not otherwise classifiable. 277 2415 CH. 15.—DIAGNOSTIC NOMENCLATURE E. Traumatism by firearms, accidental, when fired only. To include all injuries and burns caused by the projectile, shrapnel, the blast from great guns, explosion of a great gun, machine gun, rifle, pistol, and shotgun, or trauma- tism from any of these agents during firing. Exclude injuries noted under key letters I and K. F. Traumatism by cutting and piercing instruments. To include all accidental traumatism by cutting and piercing instruments and glass. Exclude injuries noted under key letters H, I, and O. G. Traumatism by fall. To include all traumatism due to falls of persons except those classified elsewhere. Not to include traumatism by falling objects. H. Traumatism by machines. To include all traumatism and burns resulting from the handling and operation of machinery, elevators, traveling cranes, engines, and boilers other than railways. I. Traumatism by aircraft. To Include all traumatism, burns, and falls caused by aircraft (both heavier-than-air and lighter-than-air). J. Traumatism, burns, sunburns and falls due to athletics and recreative sports. K. War wounds. All casualties incurred in action against an organized enemy. L. Burns (conflagration excepted). To include all burns and scalds by boiling liquids and steam, corrosive acids and substances, fire, gasoline, kerosene, petroleum, sunburn, and the effects of radium and X-ray. Include also burns and scalds as a result of explosion not classified elsewhere. Exclude friction burns which should be reported elsewhere as indicated, and sun- burn due to athletics and recreative sports. M. Traumatism due to violence other than herein defined. N. Traumatism due to violence by assault without deadly weapon, fighting, maintaining order, resisting arrest, and skylarking. Key letter B will be used if injury results in death. O. Traumatism by railroads, railways, vehicles, etc. To include all traumatism, burns, and falls caused by railroads (electric and steam), electric railways, vehicles (automobile, motor cycle, motor truck, tractor, bicycle, carriage, and wagon); earthquakes, landslides, and other unclassifiable crushing. (b) The above key letters are to be used, for example, as follows: wound, gunshot, head, key letter A showing that it was inflicted with suicidal intent, B that it was homicidal, or K that it was received in action; drowning, use key letter D, unless due to destruction of a ship by fire—C, incident to action—K, the result of aviation—I, the result of an accidental fall overboard—G, suicidal—A or homicidal—B. 2415. Specialty letters.—(a) Specialty letters are used to identify certain classes of naval hazards and peculiar duties surrounding aero- nautic, submarine, and diving duty. For this purpose the following specialty letters shall be used (par. 2405 (b), line 6.) (1) R.—Aeronautic duty for disabilities incident to actual flying. An aircraft accident is defined by the National Advisory Committee for Aeronautics as follows: An aircraft accident is an occurrence which takes place while an aircraft is being operated as such and as a result of which a person or persons are injured or killed or the aircraft receives appreciable or marked damage through the forces of ex- ternal contact or through fire. SEC I.—instructions—injury and poisoning 2416 This is interpreted to mean that an aircraft is in operation as such only from the time it starts to move by its propelling mechanism or from the force of gravity until it again comes to a standstill. Propeller accidents incident to flying should be given a specialty letter R only when the craft is in operation as such. (See preceding sentence.) (2) S—Submarine duty for disabilities incident to maneuvering of, accidents to, or peculiar living conditions aboard submarines at sea. (3) U—Diving duty for disabilities incident to actual diving or other exposure to compressed air in training or research in diving, diving with suit, shallow-water helmet diving, diving bell, experimental or training diving tank, recompression chamber, submarine escape appliance, etc. (b) Specialty letters shall not be used indiscriminately for all persons attached to special duty but only in cases of disability occurring under specialty conditions as defined above. A person attached to aeronautic, submarine, or diving duty who is disabled when not par- ticipating in specialty work shall not have a specialty letter. 2416. Injuries and Poisonings, Method of Reporting.—(a) General instructions.—Data for injuries and poisonings in the form given in subparagraph (d), below, shall be entered on line 14 of F card and following the diagnosis in the health record, as follows: (1) For all first admissions; (2) for all readmissions in cases of transfer of these first admissions. These data are not required for subsequent read- missions unless there is a correction to be made, in which case notation, “Included for correction,” shall be made on line 14 of the form F card. (b) Readmissions—RA.—The date and place first taken up under any injury (or poisoning) title resulting from the same violence shall be given on line 14 of the form F card when readmitted (RA), for an injury (or poisoning), except following receipt from transfer (pars. 2404 (c) (6) and (9) and 2405 (b), line 14). (c) Additional injuries from the same accident.—For the method of taking up under additional injury titles resulting from the same violence. (See par. (c) (6).) (d) Circumstances of occurrence.—(1) Illustrative chart.— The exact words to be used are given in quotations. Explanatory remarks are in italics. Lines shall be numbered as shown. 279 2416 CH. 15.—DIAGNOSTIC NOMENCLATURE Circumstances of Occurrence 1 Within the limits of a naval command, or while actually on duty away from ship or station, e. g., mail orderlies, messengers, working par- ties, patrols, landing forces, etc. (Report as “within command.”) While on leave or liberty, or during unauthorized absence from the command. (Report as “leave," “liberty,” or “absent.”) Injury connected with work or the actual performance of duty. (Report as "work.”) Evidence that the man was so much under the influence of liquor as to im- pair his mental and physical facul- ties. (Report as “intoxi- cated.”) 2. Not actually engaged in work or duty. (Report as “not work.”) Sober, or not obvi- ously intoxicated. (Report as “not in- toxicated.”) (a) Personnel factors—“Man's own negli- gence.” “Negligence of others.” (b) Matinel factors.—“Equipment at fault.” “Faulty design or faulty materials.” “Defective from use.” “Faulty opera- tion.” “Lack of safety device” where such could be used. “Inadequate pro- tection by safety device in use.” (c) Neither factor.—'“Negligence not apparent.” “Result of own mis- conduct ” (So state.) “Not result of own misconduct.’’ (So state.) 3. Add further remarks necessary to clarify the nature and cause of the violence resulting in the injury or poisoning for which the patient was admitted. This statement must be sufficiently clear to enable the reviewing statistician in the Bureau to visualize the accident in order that the injury may be properly classified. Consult section IVof nomenclature, appendix A, and paragraph tit9. 4. (2) Examples.— a. Injury on board ship while working on emery wheel.— On face of form F card: amputation, traumatic, right thumb—(2572); key letter—H. On back of form F card: 1. Within command. 2. Work. 3. Lack of safety device. 4. Hand slipped while working on emery wheel. No safety device. b. Injury ashore on liberty while driving an automobile.— On face of form F card: fracture, simple, right radius and ulna—(2531); key letter—O. On back of form F card: 1. Liberty. 2. Intoxicated. 3. Result of own misconduct. 4. While driving automobile skidded and overturned due to reckless driving. c. (3) Injury to mail orderly ashore in street-railway accident.— On face of form F card: wounds, incised, head and face—(2562); key letter—O. 280 SEC. I.—INSTRUCTIONS—APPENDIX A 2417-2420 On back of form F card: 1. Within command. 2. Work. 3. Negligence of others. 4. Due to broken glass from street-car collision with another street-car. Mail orderly on duty. 2417. Designation of Aviation Personnel.—The aviation status as it existed at the time of admission to the sick list, regardless of the nature of the disability, shall be reported on the form F card, {line 2), as flight (FI.) in the case of all flight personnel, even though not actually engaged in the performance of flight duties at the time of exposure to the hazard which resulted in the disability. Flight personnel are those having official flight orders and also such members of an aircraft crew making flights as a part of their regular duty. Revocation of temporary flight orders upon admission to the sick list or transfer to a naval hospital shall not be considered as in any way changing the aviation status to be reported on the form F card. These instructions apply to all flight personnel whether or not holding aviation ratings. 2418. Nomenclature of Surgical Operations.—Following the Nomen- clature of Diagnostic Titles in appendix A is a Nomenclature of Titles for Operations (Sec. Ill) which shall be used in reporting oper- ations on form P and elsewhere. 2419. Nomenclature of Nature and Cause of Violence.—Section IV of appendix A is a classified list of injury and poisoning hazards, referred to for the sake of brevity as causative agents. It is for use as a guide in selecting causative agents and determining wording in reporting conditions and circumstances of occurrence of violence, in the health record and on line 14 of the form F card (par. 2416 (d)). Every case of injury or poisoning is classified in the Statistical Section of the Bureau in one of the two classes, Naval and Military Hazards or Industrial and Miscellaneous Hazards. The wording used in the report of circumstances of occurrence shall be sufficiently complete and descriptive to enable the Bureau to identify the precise nature of the violence and the manner in which it occurred. 2420. Itemized Nomenclature. Appendix A.—Section I of the Nomenclature for the Medical Department of the United States Navy is given above and comprises chapter 15 of this manual. The item- ized nomenclature is given in appendix A as follows: Section II. Nomenclature of Diagnostic Titles. Section III. Nomenclature of Surgical Operations. Section IV. Nomenclature of Nature and Cause of Violence. 281 CHAPTER 16 Paragraph Entry of Misconduct Status for Disease or Injury 2501 Importance of Misconduct Entries 2502 Medical Officers To State Facts 2503 Medical Records To Be Complete 2504 Nature and Degree of Disability To Be Stated 2505 Early Return of Misconduct Cases to Duty Status 2506 Misconduct Cases in Hospitals 2507 Midshipmen 2508 Diagnosis and Checkage of Pay 2509 Disability Incurred on Leave, etc 2510 Suicide 2511 Official Decisions 2512 MISCONDUCT STATUS 2501. Entry of Misconduct Status for Disease or Injury.—Article 1196 (1), Navy Regulations, requires medical officers making entries in the health record, reports of death, or reports of medical survey to state specifically whether the disease or injury was or was not due to the patient’s own misconduct. 2502. Importance of Misconduct Entries.—Under the law the proper recording of all facts in regard to the misconduct status of a disease or injury is of great importance. These facts may be an important factor in deciding the right of an individual to promotion, retirement, gratuity to beneficiary, pension, civil-service employment, etc. 2503. Medical Officers To State Facts.—It is of the utmost impor- tance that medical officers shall make a clear statement, with all pertinent facts, of the evidence in each case. Such evidence shall include statements by the patients or others, previous medical history, clinical findings, and modem knowledge as to etiology. Verbal state- ments shall be recorded together with the full name and rank or rate of the person making them. If there be evidence (state whether pre- sumptive or documentary) that the disease or injury existed prior to enlistment, this fact shall be stated and opinion expressed whether or not the disability has been increased by service. Too much em- phasis can not be laid upon the fact that all possible available infor- mation pertinent to the question of how and when the disability com- plained of arose should be noted and considered. The foregoing applies to all facts, including those which are peculiar to the science of 283 2504-2509 CH. 16.—MISCONDUCT STATUS medicine and surgery, i. e., facts pertaining to the nature of the disability, its probable duration, and the conditions affecting its recurrence, as in a case of epilepsy, insanity, or disease of a like nature. No fact, however trivial, should be overlooked, and special endeavor should be made to ascertain all facts which may in any way bear upon the various angles of the disease in question. The rule for the determination of misconduct is simple. Mere negligence or carelessness is not misconduct. Misconduct is a violation of law or regulation; in short, an act for which a person could be court- martialed. 2504. Medical Records To Be Complete.—An official contempora- neous record is the best evidence as to the facts therein stated, and can be successfully rebutted only by direct, positive, and conclusive evidence that there was error or mistake of fact or fraud in making such record. The necessity for careful and complete statements in medical records is, therefore, clearly established. 2505. Nature and Degree of Disability To Be Stated.—As disability occurring in the service is usually made the basis of a claim for pension, special care shall always be taken to state in the health records the degree of disability, wound, or disease, the extent to which it deprives the patient of the use of any limb or faculty or affects his health, strength, activity, or capacity to work. If the patient declines treatment for its relief he shall be required to sign a statement in his health record setting forth the reasons why he so declines, and a signed copy of this statement shall be forwarded to the Bureau. 2506. Early Return of Misconduct Cases to Duty Status.—Medical officers shall make every effort to return patients to duty as soon as they have recovered and are fit for duty to prevent injustice to the men in the matter of pay. 2507. Misconduct Cases in Hospitals.—Men who, at the time their enlistments expire, are in hospitals from diseases or injuries result- ing from their own misconduct, and whose recovery is problematic, must not be held in the service beyond the actual date of expiration of enlistment to make up any time lost. Consult Bureau of Naviga- tion Manual for proper procedure to be followed in such cases. 2508. Midshipmen.—The medical records of a midshipman who, during his course at the Naval Academy, incurs injury or disease, are to be kept in the same manner as for commissioned officers. (Navy Department, 2552-24, May 25, 1909.) 2509. Diagnosis and Checkage of Pay.—(a) When an entry of disease or injury due to misconduct, is concurred in by the command- ing officer and the medical officer, it shall be binding until such time 284 INSTRUCTIONS 2510-2512 as a new determination is made by the Department, or by the medical officer and agreed to by the commanding officer, or by the board of officers called in accordance with article 1196, Navy Regulations. (b) When a patient is admitted for a disease in which the mis- conduct status is doubtful, or undetermined, or the diagnosis erroneous or undetermined, and the disease is subsequently found to be due to misconduct, the checkage of pay should date from the original admission. (c) In cases where the original diagnosis is to the effect that the disease or injury was due to misconduct, and a change in this diag- nosis is afterwards made, owing to error in the original diagnosis, the correction obtains from the date of the original diagnosis. (d) Injury held to be due to misconduct is not subject to checkage of pay. (e) Venereal diseases held due to misconduct are not subject to checkage of pay after expiration of more than 1 year subsequent to appearance of initial lesion or infection, regardless of whether or not the appearance of the initial symptoms occurred prior or subsequent to the date of entry into the service. 2510. Disability Incurred on Leave or in Confinement.—When an individual is disabled while on leave or in confinement, the circum- stances attending the inctirrence of the disability and the status of leave or confinement (whether awaiting trial or confined in accord- ance with sentence) should be stated (J. A. G., 29372-41, December 14, 1921). 2511. Suicide.—In cases of suicide the mental condition should be considered and, if mental or physical disability existed, an opinion should be expressed, with the facts on which it is based, whether the suicide was due to mental abnormality. See Naval Courts and Boards on this subject. 2512. Decisions.—Medical officers shall endeavor to keep them- selves informed of decisions as published in court-martial orders. The pertinent chapter of Naval Courts and Boards, and Laws Relat- ing to the Navy, Annotated, should be consulted in connection with the making of misconduct entries. 285 CHAPTER 17 Paragraphs Section I. GENERAL REGULATIONS AND INSTRUCTIONS 2601-2623 H. FIELD AND CAMP SANITATION. 2661-2680 m. SANITARY REPORTS 2691-2704 IV. INTELLIGENCE REPORTS. 2711-2713 PREVENTIVE MEDICINE AND SANITATION SECTION I. GENERAL REGULATIONS AND INSTRUCTIONS Paragraph Organization 2601 Duties of the Commander in Chief and Fleet Medical Officer 2602 Duties of Commanding and Medical Officers of a Naval Vessel 2603 Use of Immunizing Agents 2604 Vaccination for Prevention of Smallpox... 2605 Inoculation for Prevention of Typhoid Fever 2606 Biological Products, Where Obtained 2607 Inspection of Food. 2608 Inspection of Meat 2609 Water 2610 Ventilation 2611 Garbage and Refuse 2612 Sewage Disposal 2613 Lighting 2614 Mosquito Control 2615 Communicable Diseases. 2616 Lead Poisoning 2617 Swimming 2618 Ship’s Prisons and Prisoners... 2619 Naval Prisons 2620 Sanitary Standards for Barracks 2621 Sanitary Standards for Hospitals 2622 Toilet Facilities, Afloat 2623 2601. Organization.—The Bureau shall be kept informed of sanitary matters and prevalence of disease by routine and special reports. Through its publications general direction is given to epidemiological studies, and approved methods are outlined for the control of pre- ventable diseases. 2602. Duties of the Commander in Chief and Fleet Medical Officer.— (a) The following references in the Navy Regulations regarding the duties of the commander in chief are of interest to the medical officer: (1) Reports of infectious diseases (art. 699 (3e), N. R.); (2) troops 287 2603 OH. 17. PREVENTIVE MEDICINE AND SANITATION embarked on board ships of his command (art. 713, N. R.); (3) to regulate exercises and sanitary duties (art. 730 (1), N. R.); (4) pre- cautions on unhealthy stations, information regarding health of ports visited, precautionary measures in Tropics, anchorage in unhealthful ports (art. 741, N. R.); precautions when sending the sick home (art. 742, N. R.). (b) In accordance with article 764 (1), Navy Regulations, the commanders of forces, of divisions of the battleship and scout forces, and of squadrons and flotillas of other forces shall, within the limits of their respective commands and under the general supervision of the commander in chief, perform the duties enumerated above. (c) Fleet and force medical officers must be familiar with the pro- visions of Navy Regulations referred to above, and diligent in obtain- ing required information, being prepared at all times to give sound advice in technical matters relating to hygiene and the prevention or control of disease. 2603. Duties of Commanding and Medical Officers of a Naval Ves- sel.—(a) The following references in the Navy Regulations regarding the duties of the commanding officer of a naval vessel are of interest to the medical officer: (1) Provisions (art. 20 (7), N. R.). (2) Health of crew (art. 20 (8), N. R.). (3) Care of crew (art. 843, N. R.). (4) Service on unhealthy stations (art. 901, N. R., see art. 741, N. R.). (5) Effects destroyed to prevent spread of disease (art. 916, N. R.). (6) Cleanliness (art. 1319 (1), N. R.). (7) Precautions as to health of the crew (art. 1319 (2), N. R.). (8) Clothing (art. 1319 (3), N. R.). (9) Bedding (art. 1319 (4), N. R.). (10) Allowance of water (art. 1319 (6), N. R.). (11) Inspections and use of fresh food, etc. (art. 1320 (2), N. R.). (12) Food and water (art. 1320 (5), N. R.). (13) Athletic exercises (art. 1323 (1), N. R.). (14) Bumboats and traffic (art. 1323 (3), N. R.). (15) Harbor water (art. 1324, N. R.). (16) Disposal of refuse (art. 1337, N. R.). (17) Leave to enlisted men (art. 1731 (1), N. R.). (18) Unserviceable and unsanitary articles (art. 1910 (1), N. R.). (19) Clothing and personal effects of officers and men (art. 1925, N. R.). (b) The ship’s medical officer must be familiar with the above requirements, keep himself informed insofar as practicable of the occurrence of communicable diseases in other units of the fleet and of the prevalence of such disease in shore communities with which the crew may come into contact, keep the commanding officer informed of health conditions on board, and be prepared at all times to recom- 288 SEC. I.—REGULATIONS AND INSTRUCTIONS 2604-2605 mend the enforcement of any special measure which epidemiological conditions seem to require. 2604. Use of Immunizing Agents.—In the employment of vaccines and other immunizing agents designed to afford protection against diseases other than smallpox and typhoid infections, the medical officer shall be guided by current practice and the views of the Bureau as published from time to time or furnished upon request. The term vaccination shall be construed to include the inoculation of any virus, bacterin, or toxin used for the production of active immunity against any infectious disease. 2605. Vaccination for Prevention of Smallpox.—(a) All persons in the Navy and Marine Corps shall be inoculated with cowpox virus upon entering the service and repeatedly as necessary after intervals of not more than 10 days, if the result is negative, until there is reas- onable assurance that the individual will not react to potent virus, as may be the case if partial immunity exists from a previous mild attack of smallpox. (b) Revaccination.—Enlisted men shall be revaccinated upon reenlisting or extending enlistment, at any time if doubt arises as to protection afforded by previous vaccination, and whenever exposed to smallpox. Officers and members of the Navy Nurse Corps shall be revaccinated at intervals of 4 years, and whenever exposed to smallpox. When serving in the Tropics or areas of endemicity all persons shall be revaccinated annually. (c) Vaccination technique.—Vaccination shall be performed by or under the direct supervision of a medical officer. Responsibility for vaccination shall be delegated to hospital corpsmen only when on independent duty. To avoid infection at the site of vaccination the virus shall be inserted, preferably by the multiple pressure method, into as small an area as possible, not over one-eighth inch in any direction, and the site shall be kept cool and dry, without the use of a shield or other dressing. (d) Preservation of cowpox.—Virus shall be subjected to con- tinuous refrigeration, preferably below freezing. (e) Types of reactions and recording thereof.—The spreading and receding of the area of erythema is the essential part of the reaction and the following types of reaction are differentiated by the time at which this area reaches its greatest diameter. The medical officer shall determine the type of reaction by personal inspection and make the proper entry, in full, in the health record. An immune reaction occurs in a person who is fully protected against smallpox by previous vaccination or previous attack. The maximum diameter of the 289 2606 CH. 17. PREVENTIVE MEDICINE AND SANITATION erythema is reached and passed in 8 to 72 hours. There is usually no vesicle. An accelerated reaction means partial loss of protection gained from a previous vaccination or attack. The maximum diameter of the erythema is reached in 3 to 7 days. There is usually a vesicle. A primary reaction is observed in a person who has never had a successful vaccination or who has lost all protection afforded by a previous vaccination or attack of smallpox. The maximum diameter of the erythema is reached in 8 to 14 days. There is always a vesicle at the site of the reaction. (f) Transfer of recruits.—Navy and Marine Corps recruits should not be transferred from a training station, barracks, receiving ship, or other rendezvous until evidence of protection against small- pox is recorded in their health records, or, in case of failure to react, until the medical officer is satisfied the individual will not react definitely to potent cowpox virus. If an emergency requires the transfer of a man before the result of vaccination can be recorded he should be inoculated and a statement sent with his health record to inform the medical officer of his new ship or station that he was transferred before the result of vaccination could be determined. (g) Navy and Marine Corps Reserve.—Members of the Navy and Marine Corps Reserve should be vaccinated at the time of appointment or enlistment. If an individual's health record fails to show that he has already been vaccinated he must be inoculated immediately after reporting for active duty. 2606. Inoculation for Prevention of Typhoid Fever.—(a) Each per- son in the Navy and Marine Corps, who has not reached the age of 45 years, shall be protected against typhoid fever by the administra- tion of typhoid vaccine as soon as practicable after entry into the service, and this procedure shall be repeated 4 years later. A com- plete course is defined as three consecutive administrations with intervals between each two of not less than 5 or more than 15 days. The dose for the first inoculation of a course shall be 500 million; for the second, 1,000 million; and for the third, 1,000 million organisms of the prescribed typhoid vaccine. A course of three inoculations of paratyphoid A and B vaccine shall be administered to personnel serving ashore in countries where paratyphoid fever is endemic. In time of war or other emergency the Bureau will issue such instruc- tions concerning typhoid and paratyphoid prophylaxis as may be indicated. (b) A complete course shall be administered to each enlisted man upon reenlistment or extension of enlistment unless he has been so immunized within the previous 4 years or has completed the two courses described in paragraph (a). The medical officer making the 290 SEC. I.—REGULATIONS AND INSTRUCTIONS 2607 physical examination at the time of reenlistment shall start the ad- ministration when practicable. If he be unable to start or complete the course, he shall notify, through official channels, the medical officer to whom the health record is forwarded. (c) The medical officer having custody of an officer’s health record shall be responsible for the administration to that officer of the typhoid vaccine as directed in paragraph (a). If it be not practicable for such medical officer to complete the immunization, he should notify, through official channels, the medical officer to whom such health record may be transferred. (d) The only acceptable evidence of administration of the pro- phylaxis shall be an entry in the health record signed by a medical officer. Anyone who can submit bona fide evidence of having suffered an infection with typhoid fever may be excused from taking the prophylaxis. (e) Anyone who has reached the age of 45 years will be excused from taking prophylaxis in time of peace. (f) Naval Reserve personnel are subject to all the provisions of the foregoing subparagraphs and shall receive administration of the typhoid vaccine when first reporting for active duty unless the above provisions have already been complied with. Personnel who are about to engage in flying should receive typhoid prophylaxis before their arrival at the training field, and a sufficient time before they report for active training duty so as to not incapacitate them for a portion of their training period. (g) Medical officers shall furnish the following information relative to reactions following inoculations with typhoid vaccine in all monthly and annual sanitary reports: Number of complete courses of three inoculations administered during the period covered by the report. FIRST COURSE First, second, and third inoculations: (а) Number administered. (б) Number of severe reactions. (c) Number of severe reactions requiring admission to sick list. SECOND COURSE First, second, and third inoculations: (а) Number administered. (б) Number of severe reactions. (c) Number of severe reactions requiring admission to sick list. 2607. Biological Products, Where Obtained.—Procured in accord- ance with instructions contained in chapter 20, paragraph 3052, and SUPPLEMENTARY SUPPLY TABLE. 291 2608 CH. 17.—PREVENTIVE MEDICINE AND SANITATION 2608. Inspection of Food.—(a) Fresh food.—Fresh food not previously passed upon by a United States Government inspector shall be inspected by a medical officer before issue; upon delivery, accept- ance or rejection must be determined at once. Food pronounced ac- ceptable by a Government inspector in a navy yard or elsewhere shall be inspected before issue. Any food found not in accordance with purchase specifications or which may reasonably be considered to menace the health of the personnel shall be rejected or recommended for destruction, as the case may be. The ship’s medical officer shall regularly inspect the issue room, galley, butcher shop, and bake shop, and make suitable recommendation if any unsatisfactory condition is observed regarding the storage, handling, preparation, and serving of food, special attention being given to foods liable to become culture media for bacteria—meats and meat products, fish and shellfish, milk and milk products, salad ingredients, and cream fillers. (b) Food handlers.—Cooks, butchers, bakers, helpers, and mess- men must be required to keep their hands as well as utensils and imple- ments used in the preparation and serving of foods, scrupulously clean. Sufficiently close supervision should be maintained over the health of food handlers to insure prompt detection of infectious disease, includ- ing venereal infection. (c) Utensils and mess gear.—Cooking utensils should be washed thoroughly with hot water and soap or other cleansing agent after use and after application of mechanical or chemical polishing agents. Mess gear should, after each meal, be washed sufficiently to remove adherent particles of food and mouth secretions, sterilized, and allowed to dry without wiping. The minimum safe sterilization requirement is submersion in, or equivalent exposure to, water at a temperature above 180° F. for not less than 1 minute. (d) Articles for sale by ship’s service.—The medical officer shall satisfy himself as to the sanitary quality of foodstuffs, soft drinks, etc., before they are approved for sale aboard a naval vessel or on a naval reservation. (e) The ration.—The medical officer should receive copies of weekly menus for the general mess and note from month to month whether a properly balanced ration is being prepared for the crew. It should be borne in mind that the most probable defect, if any, will be a deficiency of calcium. The most important food sources of cal- cium are milk, cheese, eggs, fresh fruits, and leafy green vegetables. If these components of the ration are consumed in sufficient quantities to avoid calcium deficiency the vitamin content of the diet is likewise satisfactory. 292 SEC. 1.—REGULATIONS AND INSTRUCTIONS 2609 (f) Fresh milk.—Pasteurized milk should be purchased when obtainable. Unpasteurized milk, even though it be of high grade and produced and handled under excellent sanitary conditions is not altogether free from danger of contamination with disease producing micro-organisms. Milk not conforming essentially to Federal speci- fications shall be rejected. The medical officer should make sure by routine sampling and inspections that milk delivered under contract from day to day is fresh, clean, unadulterated, and uncontaminated. Small samples should be kept over from time to time in a refrigerator to determine keeping quality. When milk is to be obtained from a source with which the medical officer is not familiar, he should ascertain if the milk is produced and marketed under adequate sanitary super- vision by the local or state health department. If satisfactory control by governmental agencies be doubtful, the distributing plant should be visited to note whether modem methods and equipment are employed. 2609. Inspection of Meat.—(a) Medical officers must be able to recognize sound meats of acceptable quality and to distinguish signs indicative of spoilage in kind and degree sufficient to justify condem- nation of meat, poultry, fish, etc., as unfit for human consumption. Differences in potential dangers of food poisoning must be borne in mind. For example, beef, a part of which shows evidence of spoilage, is not so likely to cause food poisoning as fish or shell fish of doubtful quality, because of the possibility of contamination by disease pro- ducing micro-organisms in sewage-polluted water, along with bacteria which merely cause putrefactive changes. As a rule, bacteria of the meat-poisoning group and the causative agents of communicable diseases do not produce changes in the color, texture, taste, or odor of meat. Their presence can only be detected by bacteriological examination. Safeguarding health is the first consideration, but due care should be taken in the inspection of meat to avoid condemnation of valuable food that may be saved by proper trimming or removal of pieces which show evidence of spoilage. (b) Animals purchased alive.—When animals are purchased alive to be slaughtered by or for personnel of the Navy or Marine Corps, as may be required for a naval vessel under exceptional circumstances or for an expeditionary force in the field, a medical officer should, if practicable, inspect the animals before slaughter and examine the carcasses after slaughter, carefully inspecting serous membranes, lymph glands, tongue, viscera, glandular organs, and lungs. No crippled, feeble, emaciated, sick-appearing animal, or one with skin lesions should be accepted. At postmortem examination indications of tuberculosis, septicemia, trichinosis, tapeworm, and infection of the 293 2610 CH. 17.—PREVENTIVE MEDICINE AND SANITATION gastro-intestinal tract should be looked for especially. Care must be taken in cutting up carcasses to prevent intestinal contents from con- taminating the meat and edible organs. If possible, meat should be held in cold storage at a temperature not higher than 15° F. for at least 6 days or for 21 days if the temperature exceeds 15° F. A greater margin of safety may be had by holding for 10 days at a temperature not higher than 5° F. Refrigeration of pork at 5° F. for 20 days is a desirable general measure for the control of trichinosis. Pork and pork products should be cooked at a temperature higher than 160° F. (c) Government inspected meat.—Regulations of the United States Department of Agriculture governing meat inspection provide that all meat and meat products intended for the Navy, when found to conform to Navy specifications, shall bear a special stamp mark composed of the letters USN within a heart-shaped shield, and meat and meat products intended for the Marine Corps, a mark composed of the letters USMC and the Marine Corps insignia within an oblong. 2610. Water.—(a) Water of doubtful sanitary quality to be boiled or chlorinated.—The evaporation of water, either at atmos- pheric pressure or at reduced pressures and temperatures, is a physical separation of water from its dissolved and suspended constituents. If such evaporation separates water from the dissolved salt, it is obvious that bacteria, which are much larger particles than molecules of salt, will also be left behind. The sterilization of water by subjection to high temperatures there- fore is not a factor to be considered in the production of a sterile evaporator effluent. Low pressure, low temperature evaporation can produce, from contaminated water, as reliable a sterile effluent as can high temperature distillation, if raw water does not prime or leak into it. The salinity of an effluent, therefore, may be watched as an index of such faulty operation and the discarding of water so contaminated, before it is pumped to the ship’s tanks, will protect men as well as boilers. The saline content shall not exceed 0.5 grain per gallon. The standard of 0.25 grain per gallon should be maintained if possible. The Bureau of Engineering emphasizes the importance of avoiding priming and leakage in contaminated areas and states that only by so doing can sterile water be produced in such locations. It directs that if priming occurs, this water must not be sent to ship’s tanks. Chlorination of ship’s water by calcium hypochlorite is not desir- able. However, if water of doubtful sanitary quality must be used, it should be chlorinated in the ship’s tanks to the extent of not less than 2 parts available chlorine per million parts of water. 294 SEC. I. REGULATIONS AND INSTRUCTIONS 2610 This can be done very simply and readily by the use of commercial high-test hypochlorite. It is possible to purchase this in air-tight con- tainers of almost any desired volume. Since 1 gallon of water weighs 8.3 pounds, then 8.3 pounds of hypochlorite added to 1 million gallons of water will result in 1 part to 1 million dilution; 16.6 pounds will give 2 parts per million. But it must be remembered that the best quality of high-test hypochlorite contains 60 percent free available chlorine, therefore 27.6 pounds must be added to 1 million gallons of water in order to arrive at a dilution of 1 part of free chlorine in 1 million parts of water. This factor can then be broken down into any fractional part desired. For example, 0.027 pounds, or approximately 13 grams, added to 1,000 gallons of water will result in a dilution of 2 parts per million. (b) Water from sources ashore.—When reliable information re- garding the sanitary quality of water taken aboard at a dock or from a water boat is not available the water should be passed through the ship’s distiller, or chlorinated with hypochlorite in the ship’s tanks. Otherwise the water should not be used for human consumption unless facilities are available for making such bacteriological examination as will prove it safe for drinking without treatment. (c) Allowance of fresh water.—The average minimum actual consumption of fresh water per person on board ship required in the interests of personal hygiene is about 12 gallons per day. This figure includes water for drinking, galley and scullery use, ablution and wash- ing of clothing. Ashore the amount of water used for all purposes usually exceeds 50' gallons per capita per day. In planning a water system the Bureau of Yards and Docks makes allowance for 100 gal- lons per capita per diem, plus estimated requirements for power plant, lawn sprinkling, fire protection, and other purposes. While it is nec- essary to economize in the use of fresh water aboard ship, the Rules for Engineering Performances, United States Navy, do not contem- plate insufficient allowance of fresh water for officers and crew to meet all hygienic needs. Without imposing restrictions upon the crew as to quantity or time of use of fresh water, attention to leaks and reason- able measures to effect economy in materiel usages may result in aver- age daily per capita consumption not much greater than 12 gallons. Minimum allowance per capita per diem should be provided when prac- ticable. Arbitrary limitation of hours during which washrooms are open for use or restriction of membere of the crew to definite small quantities of water for bathing and washing clothes tends to result in serious breaches of hygiene. If unusual circumstances require drastic restrictions in the use of fresh water the allowance should be not less than two full buckets per man per day for the general crew and not 295 2611 CH. 17. PREVENTIVE MEDICINE AND SANITATION less than four buckets for men of the engine room, fireroom, and shop forces. (d) Scuttle butts.—Scuttle butt terminals should be kept in good condition and at a slight angle so that water does not fall back on the outlet. Valve handles, like door knobs, may be an important in- direct means of transmitting the causative agents of communicable disease. This can be obviated by the use of a foot-controlled valve. Under epidemic conditions they should be frequently disinfected and disinfectant solution provided for hands. In places where sanitary scuttle butts are not available suitable arrangements must be made to prevent the use in common of drinking cups or glasses. 2611. Ventilation.—(a) living compartments, offices, and work spaces are to be kept in the comfort zone insofar as weather conditions permit. The comfort zone represents air conditions agreeable to persons other than those of exceptional requirements, taking into con- sideration bodily activity, character of work to be performed in work spaces, and the amount and type of clothing, conventional or required. Comfort depends upon the combined effect of temperature of the air, relative humidity, and velocity of air movement. In sealed compart- ments the additional effects of pressure and varying concentrations of oxygen and carbon dioxide are introduced. Good ventilation implies maintenance of comfort conditions with air free from excessive amounts of dust, smoke, deleterious gases and vapors, and objectionable odors. (b) In cool and cold weather adequate ventilation requires a sufficient quantity of air flowing through a given compartment or space in each unit of time (expressed in cubic feet per minute) to keep the air reasonably free from harmful substances and disagreeable odors. Varying amounts of heat must be added and water vapor should be supplied for comfort. In hot weather the volume of air required for the removal of excess heat is so great that other ventila- tion factors usually become inconsequential. The sources of heat are hot outside air, direct rays of the sun, and heat produced in the interior of the vessel. Except where cooling by refrigeration units is practicable, maintenance of comfort conditions must depend upon: (1) Insulation of internal sources of heat—machinery, piping, and bulkheads; (2) insulation of decks and hull plating to reduce transfer of solar heat to air within the ship; (3) quantity of fresh air passing through hot spaces under natural forces arising from wind or pressure due to differences in temperature; (4) quantity of air delivered by blowers, fixed or portable; and (5) the limited effect of agitation of contained air by means of ordinary electric fans. Relative humidity and given temperature should be considered together and when practicable regulated accordingly. Supplementary exhaust system 296 SEC. I. REGULATIONS AND INSTRUCTIONS 2611 blowers are required for rapid or direct removal of overheated or malodorous air from compartments in which good ventilation cannot otherwise be maintained. A definite disadvantage of exhaust venti- lation, with two or more compartments on the same system, is that the blower will draw its air chiefly from the terminal offering the least resistance, taking less air from other compartments simultane- ously served. Both plenum and exhaust systems are considerably reduced in efficiency by accumulation of dirt in ducts and upon screens. In hot weather ordinary el ectric fans hasten the evaporation of sweat and so materially lessen discomfort. The cooling effect depends upon the interrelations of temperature and humidity. If the air is kept in motion, temperatures much higher than body temperatures may be comfortably borne provided relative humidity is low enough to give the air sufficient drying capacity. With lessening capacity of the atmosphere to absorb moisture a fan becomes increasingly in effective. Obviously, saturated air cannot absorb any body moisture. As different combinations of temperature and relative humidity approach this intolerable effect a fan affords little or no relief, and finally a point is reached where agitation of the air actually increases discomfort. (c) A temperature of 70° F. is comfortable with 50 percent relative humidity if there is not excessive movement of air (the standard of the Bureau of Construction and Repair is a temperature of 73° F. with a relative humidity of 30 percent in very cold weather). A draft greatly increases cooling power. A breeze of 15 miles per hour with temperature 60° to 68° F. has as much effect upon the metabolism of a man clad in summer clothing as still air at 36° F. Relative humidity of outside air varies greatly during the course of the day, reaching a low point in the afternoon in clear weather. In very cold weather, air heated to room temperature (72° F.) will ordinarily have only 10 to 20 percent relative humidity unless a great deal of water is added thereto. With temperature falling below 32° F. it becomes increasingly difficult to add enough water to air within a ship to keep the relative humidity at a desirable level. The amount of water vapor available in saturated air at 0° F. is not sufficient to raise the relative humidity of all the air passing through the ship to 50 percent. In certain living spaces it may be practicable to raise humidity to 30 percent, but at that level, persons in light weight clothing and at rest may not be comfortable with room temperature 70° F., even if there is comparatively little air movement. If the source of heat is local, steam or electric radiator, and cold air is being delivered by the ventilation system the quantity of air should be reduced by partially closing terminals or regulating the speed of 297 2612 CH. 17. PREVENTIVE MEDICINE AND SANITATION the motor to limit the fresh air supply to the amount necessary to keep the room air free from objectionable odor. Louvres should be turned upward if possible, or otherwise adjusted to avoid chilling drafts upon occupants of the room or compartment. With central heating, louvres should be turned so that currents of the excessively dry heated air will not fall directly upon occupants. Care should be taken to keep room temperature down to as near 70° F. as is con- sistent with comfort. In some of the newly constructed ships there is a tendency to decentralization of heating by the provision of individual heaters controlled locally. Satisfactory results usually re- quire close supervision and frequent regulation by hand rather than dependence upon thermostatic control. In changeable weather room temperatures may change from cold to hot in a few minutes. Changes in blower speeds as well as adjustments of steam valves may be re- quired from hour to hour to maintain proper room temperatures. (d) When improvement of ventilation in any part of the ship is considered desirable, in accordance with the definitive statements set forth above, the medical officer should describe the degrees of discomfort existing under hot and cold weather conditions. If over- heating is the difficulty, concurrent temperature and relative humidity observations on deck and in the overheated space should be made at suitable intervals to indicate the exact status under varying conditions of work and occupancy. United States Weather Bureau Bulletin No. 234, obtainable from the Government Printing Office, Washing- ton, D. C., contains standard tables for estimating relative humidity from dry and wet bulb thermometer readings at different barometric pressures. Determination of what structural changes or installation or modification of mechanical ventilation, may be practicable, comes within the purview of the first lieutenant as representative of the Bureau of Construction and Repair. The medical officer should, however, submit recommendations for such improvements in ventila- tion which he may consider desirable and practicable. For current information and references on this subject see Circular Letter Y, appendix D. 2612. Garbage and Refuse.—(a) Garbage.—Garbage is unsightly and usually malodorous. By attracting flies or rats it may indirectly menace health. When prompt disposal is not possible cans with well- fitting covers should be used. Retention on board for more than 24 hours, awaiting a garbage lighter, creates nuisance by littering a portion of the deck, making nearby living quarters uncomfortable and increasing fly pest. With an unusual number of cans in use it is difficult to keep them in satisfactory sanitary condition. To avoid nuisance base force arrangements should be made in advance for daily 298 SEC. I. REGULATIONS AND INSTRUCTIONS 2613“2614 lighter service at fleet anchorages. Incineration of wet garbage in large quantities is not practicable on board ship. At shore stations when garbage is disposed of by contract provision should be made in the contract that the contractor will provide clean cans after each collection to limit nuisance. Recent evidence indicates that the spread of trichina is principally by uncooked pork. In the interests of public health it is advisable that contractors be informed of this fact and recommendation made that all garbage be thoroughly cooked before feeding to animals to prevent the spread of trichinosis. (b) Refuse.—Accumulations of refuse below decks increase fire hazards and have a certain bearing on health by inviting expectora- tion. Wood, paper, and the like can usually be incinerated on the upper deck with sufficient rapidity to prevent accumulation. Article 1337, N. R., forbids disposal overboard of materials that will float and requires that tin cans be pierced. Dock garbage and refuse platforms must be properly used and kept clean by ship forces. Good sanitary condition at all hours is necessary to limit numbers of flies. (See arts. 1337 and 1505 (6), N. R.) 2613. Sewage Disposal.—Disposal of ship sewage overboard by salt water carriage offers no sanitary problem except the pollution load added to harbor water about the ship. When conditions are otherwise favorable and swimming is permitted, discharge of sewage from the side on which men are in the water should be discontinued at least one-half hour before swimming call is sounded. In the case of landing parties, when facilities for disposal by water carriage are not available advance action should be taken to provide for sanitary disposal to prevent scattered collections of excrement on the ground before suitable latrines or privies are erected. A beach privy over salt water set up on wood or rock supports serves well if there is sufficient current to prevent nuisance. Under some circumstances improvised chemical closets or septic tank latrines may be useful, with ultimate disposal of effluent and sludge. Straddle trench and bucket latrines are useful under suitable conditions. 2614. Lighting.—Hygienic lighting connotes adequate illumination, general and focal, with freedom from glare, troublesome shadows, and annoying high lights, to permit reading, writing, required work, or other activity to be performed without avoidable eyestrain. The most important single fundamental factor in lighting is brightness contrast. Adequate general illumination permits sufficiently deep vision into shadows in all parts of the room or compartment so that in glancing up from work the iris will not dilate widely and contract suddenly upon turning back to the work in hand. Moving shadows 299 2614 CH. 17.—PREVENTIVE MEDICINE AND SANITATION and flickering light should be prevented. Glare is direct when a source of light comes within the field of vision with the eyes focused upon work, and indirect when light from source is reflected to the eyes by the work or some adjacent object. In general, glare is troublesome if the work itself is not brighter than other objects in the field of vision. Focal lights while undesirable are often necessary. Such lights should ordinarily be placed directly over the work if the plane of work is horizontal; otherwise the location should be such as to afford the best view of the details of the work, while avoiding as much as possible under illumination, glare and troublesome shadows. The intensity of illumination is measured in terms of footcandles upon the work in hand, and desirable intensity depends in part upon the quantity of diffused general illlumination. With well diffused light somewhat less intensity is required. The intensity of light from any single source at any point is inversely proportional to the square of the intervening distance. The intensity of solar light outdoors, diffused, screened, filtered or reflected, as it may be, falls off but little, while indoors variation of a foot or two from the source of solar light or from the location of an artificial source of light involves marked differences in the intensity of light. Diffusion is a desirable quality in illumination, and theoretically, complete indirect lighting is most desirable, with semi-indirect fixtures next. Most authorities agree that the ideal form of artificial illumination is a combination of 80 percent indirect lighting and 20 percent of direct lighting. With this combination there is almost perfect diffusion, and glare and shadows are practically negligible. The 20 percent direct illumina- tion is added to the indirect lighting to increase the intensity of illumination on the work field. Practically, satisfactory illumination can almost always be secured with modem incandescent lamps and fixtures which by diffusion reduce the intrinsic brilliancy of lamps to the hygienic level. Sources of light, with candlepower divided, should be as numerous as expense and other conditions permit. For read- ing or writing an intensity of 10 to 20 footcandles is ordinarily suffi- cient. For severe and prolonged visual tasks, such as proofreading, drafting, difficult reading, precision instrument repairs, fine machine work, fine assembly, and discrimination of fine details of low contrast involving inspection of materials, 50 to 100 footcandles of illumination and often more is required. This or greater intensity should be pro- vided for work with dark materials. Bench and machine work, med- ium grinding, buffing and polishing operations require 20 to 50 foot- candles. For very fine work, if prolonged, 100 or more footcandles are required. When using higher footcandle values great care must be exercised to see that the light is properly diffused. Too great con- 300 SEC. I. REGULATIONS AND INSTRUCTIONS 2614 centration at one point in the work field will result in tremendous eyestrain from glare, shadows, and high lights. This is likewise true for inspecting, sorting, or sewing dark materials. Apart from the matter of eyestrain and fatigue, proper lighting for prevention of accidents is important. Places where falls may occur should be adequately illumi- nated. Focal illumination should be provided for band saws, lathes, grinders, and cutting, mixing, and chopping machines. A sufficient number of lights of adequate candlepower should be maintained in crew's compartments for reading and writing. A reading light should be provided for each bunk in the sick bay to facilitate examination of patients as well as to permit reading and writing without eye- strain. Individual lights used in focal illumination should be so placed that light rays will not enter directly into the eyes of the worker. Illuminating value should be measured by approved standard photocell footcandle meter. During the survey normal voltage should be maintained at distribution switchboards. Readings should be taken at the working level in the various compartments. For com- partments fitted with desks, workbenches, etc., this level should be the height of such furniture. The working level for shops should be the working plane at machines and tools. The working level for other spaces should be the horizontal plane 30 inches above the deck. When practicable the minimum light values for ships shall corres- pond with Bureau of Engineering specifications. Under ordinary circumstances the problem of procuring sufficient electrical energy for all purposes, including adequate illumination in shore establishments, is much less complicated than on board ship. Therefore, there is much less excuse for inadequate illumination ashore than may of necessity occur afloat. In order that conservative footcandle values for illumination may be available for guidance the following is quoted:1 Conservative footcandle recommendations on a rational basis of characteristics of the visual task and requirements of performance: 100 Footcandles or more.—For very severe and prolonged tasks, such as fine needlework, fine engraving, fine penwork, fine assembly, sewing on dark goods, and discrimination of fine details of low contrast, as in inspec- tion. 50 to 100 Footcandles.—For severe and prolonged tasks, such as proof- reading, drafting, difficult reading, watch repairing, fine machine-work, average sewing and other needlework. 20 to 50 Footcandles.—For moderately critical and prolonged tasks, such as clerical work, ordinary reading, common benchwork, and average sewing and other needlework on light goods. 1 Quoted material is reproduced from The Science of Seeing, by Luckiesh and Moss.pp. 345,348,1937. with permission of the copyright owners, D. Van Nostrand & Co., Inc., New York. 301 2615 CH. 17.—PREVENTIVE MEDICINE AND SANITATION 10 to 20 Footcandles.—For moderate and prolonged tasks of office and factory and when not prolonged, ordinary reading and sewing on light goods. 5 to 10 Footcandles.—For visually controlled work in which seeing is im- portant, but more or less interrupted or casual and does not involve dis- crimination of fine details or low contrasts. 0 to 5 Footcandles.—The danger zone for severe visual tasks, and for quick and certain seeing. Satisfactory for perceiving larger objects and for casual seeing. For prolonged reading it may be of considerable value to know the point size of type used for printing the material being read. Then vary the illumination as required by the reading task.2 Footcandlet Approximate footcandles necessary to maintain a given standard of visi- bility for different reading tasks: 1. For 12-point type of high standard of printing. Minimum size desirable for anyone, particularly young and old 10 2. For 6-point type of high standard of printing. Minimum size com- monly used 30 3. For 6-point type of lower standard of printing. A common char- acteristic of newspapers 100 4. For recognizing individual 6-point letters or numerals. A char- acteristic of proofreading 200 5. For commonly deficient and defective vision. An additional step in the footcandle scale of effectiveness appears conservative * 500 2615. Mosquito Control.—(a) General considerations.—For this purpose mosquitoes may be classified as dangerous, or disease carry- ing, and harmless but pestiferous. The control campaign is directed largely against larvae rather than adults. Mosquito control to be successful requires careful planning, unremitting work, personal supervision, and painstaking care. It cannot be left to laymen or natives without supervision. Because of the number of genera and species with different habits, it is necessary to identify the species against which control measures are to be directed before wasting unnecessary time in search for breed- ing places. Identification may be made from specimens of adults, larvae, or pupae in order of importance. Adults may be captured intact by the catching tube built up in a large test tube as follows: Lower third, rubber bands saturated with chloroform, layer of filter paper, middle third cotton, layer of filter paper, upper third empty, and finally a tight fitting cork. To use, remove cork and clap open end over resting mosquito, holding until insect becomes motionless. The top layer of filter paper facilitates removal with minimum loss of scales or other damage. Larvae and pupae may be taken from • This type Is 10 point.* • This type Is 8 point. ‘These footnotes are In 6 point. 302 SEC. I.—REGULATIONS AND INSTRUCTIONS 2615 infested water by dipper, concentrated, and removed to specimen bottles by large mouth medicine dropper. Specimens may be preserved in formalin (4 to 6 percent) and forwarded to laboratory for identification. Flight detectors consisting of two intersecting boards at right angles mounted 5 to 8 feet above ground not unlike a four-way street sign may be used to determine the direction of flight. Each of the four sectors or leaves should be approximately 2 by 3 feet and coated with a slow drying oil or paint renewed each day. The surface holding the greatest number of mosquitoes each morning indicates the direction from whence they came. Any mos- quito taking human blood will, if produced in excessive numbers, fly much farther than normal for the species to secure blood meals. The presence of adult males and females indicates nearby breeding places. Female mosquitoes have preference according to species for deposit of eggs but, in absence of conditions of choice, will lay them in any collection of water. Control measures successful in one place may be unproductive of results in another. In general in any method of control, the area to be treated, the population, and the cost should be taken into consideration and that method selected in which the benefits will justify the cost, giving the greatest protection to the largest number of persons at the least expense. Each control measure should be tested for its efficiency locally before general adoption. Areas under treatment should be frequently inspected to determine effectiveness of the measures adopted. (b) Breeding places.—The following list is indicative (in general) of places capable of holding water where larvae may be found: Pails, rain barrels, eave troughs, tin cans, bottles, fruit peelings, abandoned machinery, catch basins, latrines, septic tanks, marshes, ditches, ponds, streams, temporary rain-water pools, hoofprints, bamboo stubble, plants, such as taro or banana, hollow trees, lilypads, bap- tismal fonts, and in fact any formations, natural or artificial, capable of holding water. Old automobile tires are particularly troublesome and difficult to dispose of. Small natural collections of water are the sites of election of anopheline mosquitoes. When these are un- available, anopheline larvae may be found in collections of water not natural to the species. (c) Elimination of breeding places.—Most artificial containers, such as those listed in paragraph (b), may be destroyed or breeding controlled by appropriate measures. With natural collections of water, however, the problem is more involved but may be solved by the application of one or more of the measures outlined in the follow- ing paragraphs: 303 2615 CH. 17. PREVENTIVE MEDICINE AND SANITATION (1) The filling of natural depressions with earth, trash, or other available material is effective and permanent but costly Large areas may be treated by the hydraulic method but it may be neces- sary to repeat the process one or more times because of the fissures which form in drying. (2) Drainage may be accomplished by the construction of the following ditches either singly or in combination: Surface earthen ditches may be constructed largely at the cost of labor. They may be dug to any depth, may be used to intercept the flow of ground water, and may be easily changed in studying a problem before proceeding to the more costly type. Laterals constructed at right angles to the main ditch are prac- tically as effective as those at a more acute angle and save labor. All ditches must be maintained or they are likely to do more harm than good. The so- called Panama whale, a large mop made of unraveled rope with a 30-pound weight in the forward end and kept saturated with crude oil, is of great assistance in cleaning ditches. Pulled by a double line attached to the forward end, it smoothes, grooves, and oils the ditch. Sections of concrete pipe, one-third or one-half the circumference, may be used to line open ditohes which have proved their worth, or fixed concrete drains may be constructed. They have obvious advantages over open earthen ditches in that they are more easily cleaned and maintained and when covered by concrete slabs maintenance is simplified. The slabs may be removed for inspection or cleaning. Subsurface drains are useful to intercept the flow of ground water (springs) and to lower the ground water level, thus presenting dry ground to rainfall. Unglazed tile or cement tile surrounded by crushed rock, stones, gravel, shells, or similar material are most commonly used. Trunks of palm trees with central pith removed may be substituted. Fagots laid end to end (cigarette drains) or even rock, cinders or similar pervious materials may be used if the ditch has sufficient pitch and is not long. To prevent root growth and silting, especially in the tropics, subsurface drains should be placed at least 30 inches below the surface. Double deck drains are a combination of surface and subsurface drains and have special though limited application. (d) Destruction of larvae.—(1) OH and paris green are the larvicides of choice. Samples of each lot should be tested before widespread distribution. Oil is effective against larvae and pupae. Filming qualities primarily determine its larvicidal efficiency. It is usually distributed by means of compressed air sprayers with jets adjust- able from fine to coarse. A spray composed of crude cresol 5 percent, kerosene 10 percent, and crude oil 85 percent is both larvicidal and deodorant. Paris green kills larvae only. Mixed in the proportion of 1 to 3 percent with dry slaked lime, soapstone, road dust, or similar diluents, it is dusted by hand or ma- chine. However, the United States Public Health Service recommends that no hand dusting be done with less than 5 percent paris green. In airplane dusting it is used in the proportion of 25 to 50 percent depending upon height of plane and wind velocity. Mixed with the above diluents paris green is effective against surface feeding (anopheline) larvae but 1 part mixed with 99 parts of moist sand 304 SEC. I.—REGULATIONS AND INSTRUCTIONS 2615 kills subsurface as well as surface feeding larvae. This mixture is not so effective in turbid or deep water. Any mixture should be tested in small areas before general adoption. (2) Fish, particularly top minnows, are effective in streams and natural or artificial pools. Some authorities question the value of fish in streams. They may be used where other methods of control may not, such as cisterns. Each species of fish available should be tested against larvae. Variations of depth in streams or ponds aid in control by fish. Tadpoles and turtles are not effective. (e) Destruction of adult mosquitoes.—Good results have followed the destruction or capture in daytime of all mosquitoes which have gained entrance to buildings during the preceding night. Most mosquitoes found indoors congregate on screens at sunup for about an hour and then hide away. Agents such as the catching tube, fly swatters, or insecticides may be used for this purpose. Mosquitoes captured by the catching tube are available for identification and laboratory study. A pyrethrum spray is the most effective insecticide (pars. 2834 and 2881). (f) Protection against mosquitoes.—All buildings should be screened with 16 by 16 mesh preferably of copper bronze wire. Doors should be in pairs with a vestibule intervening, similar to storm doors. All doors must swing outward. Double-swinging, or inward-swinging doors are ineffective for obvious reasons. Cracks in buildings should be filled or covered with suitable material. On field duty mess tents and cook tents should be provided with nets. Kepellants such as citronella are not effective. In places where mosquito-borne diseases are prevalent, men should be required to sleep under bed nets. (g) Surveys and treatment of carriers.—The human host is the reservoir of diseases transmissible by mosquitoes to man. The local prevalence of malaria may be determined by surveys through blood smears and the splenic index. In endemic areas blood smears should be made in the case of each patient in the Navy who is treated for any disease or condition. All proved carriers must receive appropriate treatment. In an emergency the so-called prophylactic quinine in a dosage of not less than 10 grains per man per day may be adminis- tered to reduce the number of ineffectives, but in most instances this treatment cannot be depended upon to prevent infection. The League of Nations—Malaria-Control Division—has recommended 6 grains of quinine daily for prophylactic purposes and has claimed better protection is afforded by the use of atabrin (0.2 decigrams) per day for 2 days, the procedure to be repeated weekly. 305 2616-2618 CH. 17. PREVENTIVE MEDICINE AND SANITATION 2616. Communicable Diseases.—(a) Prevention and control of the seven diseases designated by quarantine laws and regulations of the United States as quaranfinable diseases are discussed and measures required by the regulations are epitomized in chapter 18. Prompt control of an outbreak of any communicable disease depends largely upon earliest possible detection and recognition of primary and second- ary cases with effective isolation. Cerebrospinal fever and the pneumonias require definite regulation of activities to avoid fatigue, exposure to chilling and wetting of clothing and other predisposing influences. Attention to personal and group hygiene to limit trans- mission by indirect as well as direct contact is important in the presence of any communicable disease. In contemplation of other measures, such as mass applications to nose and throat, isolation, and especially restrictions interfering with ship routine and liberty, consideration should be given to the gravity of the disease, epidemiological behavior and history in the Navy, character of the personnel, and the least irksome measures required to prevent further spread of the infection on board ship. (b) An authoritative guide for control of communicable diseases is the report of a committee of the American Public Health Association published by the United States Public Health Service. This report is revised periodically and is officially approved by the United States Public Health Service. It suggests methods of disease control but does not formulate health regulations. See Circular Letter Y, appen- dix D, on THE CONTROL OF COMMUNICABLE DISEASE for Current information and instructions. 2617. lead Poisoning.—When men are required to work in com- partments containing lead-laden dust the following precautions should be taken: (1) Some type of respiratory mask should be worn. (2) A full meal, with plenty of milk, when available, should be eaten before going to work. (3) Eating or drinking while at work must be avoided. (4) The hands should always be washed with a brush and the face with hot water and soap, the mouth rinsed, and the finger nails cleaned immediately after stopping work and before eating. A bath should be taken after finishing work, followed by a change to clean clothing. (5) The compartments must be kept well ventilated. (6) Smoking and chewing tobacco or chewing gum while at work must be avoided. 2618. Swimming.—Article 1323, Navy Regulations, provides that when the weather and other circumstances permit, a regular period for swimming shall be established, such exercise to include every en- 306 seo. i.—regulations and instructions 2619-2621 listed person on board except those recommended to be excused by the medical officer. Caution should be taken, especially when the temperature of the water is below 70° F., to recall men who, not re- acting well in the water, develop cyanosis and severe shivering. In the Tropics care should be taken to prevent swimmers from develop- ing severe sunburn. Swimming should not be permitted in water contaminated with sewage (par. 2613). 2619. Ships’ Prisons and Prisoners.— (a) Cells for the confinement of prisoners shall not be less than 6 feet long and 3J4 feet broad, with the full height between decks, and shall be properly ventilated. They shall not be altered without the authority of the Navy Department (art. 215, N. R.). (b) Prisoners shall not be confined in any other spaces than those which have been designated by the Navy Department as prisons or spaces proper to be used as such. In cases of necessity extra spaces may be authorized by a commander in chief on a foreign station, by a senior officer present, or by the commanding officer of a ship acting singly, and the medical officer of the ship shell be called upon to report whether such spaces are fit for prison use (art. 216, N. R.). 2620. Naval Prisons.—Medical officers shall be guided by instruc- tions in the manual for the Government of the United States Naval Prisons. 2621. Sanitary Standards for Barracks.—(a) Housing.—The fol- lowing are minimum requirements per man in all dormitories or sleeping rooms: 50 square feet floor space per man. 450 cubic feet room space per man. 5 feet minimum distance between heads of sleeping men. Hammock fastenings usually provide a 12-foot swing to avoid exceed- ing the first and second of the above requirements (because of building cost); hammocks are placed 2% to 3 feet on centers and alternate men should be required to sleep with heads in opposite direction. (b) Ventilation.—Natural ventilation is satisfactory unless the location of the spaces to be ventilated require forced mechanical ventilation. Overhead outlets or roof ventilators with ceiling ducts or registers are desirable. Heating by steam or hot-water radiators is desirable, but indirect heating is satisfactory when the system is properly regulated. Under some conditions stoves or gas heaters must be substituted for radiators. With proper management, such sources of direct heat serve satisfactorily. Good ventilation with comfortable temperature should be maintained at all times when barracks are occupied. The number of changes of air per hour should be sufficient to remove body and clothing odors and keep the air smelling fresh. With the standards set forth above, five or six changes of air per hour ordinarily suffice. 307 2622 CH. 17. PREVENTIVE MEDICINE AND SANITATION (c) Toilet and bathing facilities.—For units of approximately 200 men the proportions of plumbing fixtures to the number of men to be accommodated are as stated below. These proportions may be decreased for larger units but must be increased when smaller numbers are to be accommodated. As an example, a detention barracks for 12 men should have 2 toilets, 2 lavatories, a 4-foot trough urinal, and 3 showers. (1) Water closets.—One toilet for every 20 men. (2) Urinals.—One foot of trough urinal for every 10 men, or 25 men to each individual urinal fixture. A small room containing a urinal for use at night only has been found to be a necessity in the barracks or dormitory when latrines are located in separate buildings. (3) Lavatories.—One lavatory, or 2 linear feet of trough lavatory or wash sink, for every five men. (4) Dental lavatories.—One dental lavatory for each 15 men. (5) Showers.—One shower for every 25 men. (6) Hot~water tanks.—The type of hot-water generator installed is, of course, determined by the facilities available. The required capacity of the storage tank may be roughly determined from the following allowances per fixture: Gallons Each lavatory 5 Each sink 10 Each shower 20 (7) Scrub decks.—One scrub deck 4 feet wide for every 20 men. Scrub decks when located in the latrine building should be in an entirely separate compartment with separate entrance. The general weather conditions prevailing at a station will determine the necessity for a separate room where the clothes are dried or of outdoor washing places and drying rig. 2622. Sanitary Standards for Hospitals.—(a) It has been found by experience that for Navy use a ward of 30 patients is the size most satisfactorily and economically handled. In tropical climates and in hospitals where a large number of convalescents are treated, the size of the ward can be increased advantageously. The basis upon which the floor space of naval hospital wards is figured is 100 square feet of floor area and 1,200 cubic feet of space for each bed. These figures are the minimum. The average size for beds, used in the esti- mate, is 6 feet 7 inches by 3 feet. Beds should be spaced 8 feet from center to center. Ceiling heights of at least 10 feet are desirable. (b) The minimum number of plumbing fixtures required for patients is as follows: Patients 1 bathtub to each 15 1 lavatory to each 10 1 water closet to each 10 1 urinal to each 10 1 shower to each 10 1 slop sink to each 30 308 SEC. n. FIELD AND CAMP SANITATION 2623-2662 2623. Toilet Facilities, Afloat.—The following is considered a satis- factory allowance of fixtures: Officers Chief petty officers Firemen Other en- listed men Water closets or seats in troughs 1 per 8 1 per 18. 1 per 40. 1 per 25. 1 per 100. Urinals .. 1 per 20 Lavatories 1 each stateroom Bucket space in wash troughs or at benches. Showers, fresh water SECTION II. FIELD AND CAMP SANITATION Paragraph General 2661 Military Value of Field Sanitary Measures 2662 Preparation for Field Service 2663 Camp Sites 2664 Water Supply 2665 Water Consumption 2666 Water Purification. 2667 Food 2668 Mess gear 2669 Disposal of Waste Products 2670 Latrines 2671 Bathing 2672 Laundry 2673 Picket Lines 2674 Insect Control 2675 Breaking Camp 2676 Marching Troops 2677 Water Discipline on the March 2678 Marching in the Tropics 2679 Control of Communicable Disease 2680 2661. General.—(a) Medical officers in the field should be familiar with the instructions contained in chapter 10 of this manual. For current information and references on this subject see Circular Letter Y, appendix D. (b) Field and camp sanitation differs from barracks and garrison sanitation in the following respects: (1) Field sanitary appliances are more simple in construction than permanent installations of garrisons. (2) Field sanitary devices require more attention—as a general rule—to main- tain them in a satisfactory operating condition in order to prevent a weak link in the chain of sanitation. 2662. Military Value of Field Sanitary Measures.—Land forces, in order to fight, are compelled to take the field, literally and figura- tively speaking, consequently field hygiene and sanitation constitute one of the most important subjects for military sanitarians, because 309 2663-2664 oh. 17.—preventive medicine and sanitation the principles of preventive medicine are then made applicable to war, and this adaptability to wartime conditions is one of the supreme tests of military efficiency. 2663. Preparation for Field Service.—Prior to leaving barracks for field service all officers and men should be examined and inspected to eliminate physical defectives. Typhoid prophylaxis and vaccination for smallpox should be checked at this time and administered to those needing protection. Food handlers should be carefully selected for field service. In particular select those with previous field experience. After selection, they should be minutely examined for evidence of contagious diseases. If time and facilities permit, stool cultures should be run to rule out the possibility of typhoid, paratyphoid, or intestinal staphylococcus carriers. Instruction should be given in first aid, the principles of personal hygiene, the proper care of the feet, the avoidance of common poisonous plants and insects, and in emer- gency measures for poisonous snake bite when going into snake-infested areas. The dangers of drinking water from unauthorized sources should be stressed. If possible, the medical officer should cooperate with the organization commanders to insure that each man will be provided with two pairs of properly-fitted, broken-in shoes, and with clothing adequate to meet the probable climatic influences that will be encountered. (See Circular Letter P, appendix D.) 2664. Camp Sites.—In campaign, tactical necessity may leave little choice in the selection of camp sites, but under any conditions the requirements of sanitation should be given every consideration con- sistent with the tactical situation. In general the following principles should govern the selection of camp sites: (1) The site should be convenient to an abundant supply of pure water. (2) Good roads should lead to the camp, and the interior communication of the camp should be easy and with minimum interference between the units of the camp. (3) Wood, grass, forage, and supplies should be at hand or easily obtainable. (4) The area should accommodate the command without crowding. (5) The site should be sufficiently elevated and rolling to drain off storm water readily and, if the season be hot, to catch the breeze. In cold weather it should have, preferably, a southern exposure, with woods to the north to break the cold wind. An eastern exposure is desirable in warm weather and, if possible, on ground moderately shaded by trees. (6) The site should be dry. For this reason porous soil, covered with stout turf and underlaid by a sandy or gravelly subsoil, is preferable. A site on clay ground, or where the ground water approaches the surface, is liable to be damp, cold, and unhealthful. (7) Alluvial soils, marshy ground, and the ground near the base of hill or near thick woods or dense vegetation, are undesirable as camp sites on account of dampness. Ravines and depressions are likely to be unduly warm and to have insufficient or undesirable air currents. 310 SEC. II.—FIELD AND CAMP SANITATION 2665 (8) Proximity to marshes or stagnant water is undesirable on account of dampness, mosquitoes, and the diseases which the latter transmit. The high banks of lakes or large streams often make desirable camp sites. (9) Dry beds of streams and adjacent ravines should be avoided, as they may be subject to sudden freshets. Old camp grounds and land in the vicinity of cemeteries should be avoided. (10) A sanitary order, prepared by the medical officer, should be issued by the commanding officer to coordinate sanitary activities of all units of the com- mand. By this order unit commanders should be made responsible for the policing of their respective areas, but responsibility for supervision should be placed definitely upon the medical officer. (11) In areas where, because of military necessity, the locating of a camp 4n marshy or damp ground cannot be avoided, or in areas underlaid by a high water table, every effort should be made to promote natural drainage away from the immediate camp area. In many cases this can be done by constructing suitable drainage ditches leading away from the camp, in the lowest part of the camp site. (12) Where a camp site is located on a slope it can be protected from uphill drainage by the simple expedient of constructing diversion ditches on the up- hill side of the camp. These should be so planned that surface water will be diverted to one or both sides of the camp site, but well outside of the camp area. The longer the slope, the more precipitous it is, and the more impermeable the subsoil the greater will be the necessity for this protection against drainage through the camp area. (13) Whenever possible, location along a stream or body of water known to be grossly polluted should be avoided. (14) It is desirable to have some shade trees on the camp site. On the other hand, too much shade is deleterious in that the camp ground may never become thoroughly dry, and the beneficial effects from the ultra-violet rays of the sun are lost. This is an important consideration not only from the point of view of the health of the individual, but also from that of sunning and airing tents, bedding, clothing, etc. (15) Areas known to be badly infested with poisonous snakes or ticks should be avoided. 2665. Water Supply.—(a) When a stream serves as the source of supply of a camp it should be so arranged that, beginning upstream, the water from the stream will be used in the following order: (1) Drinking and cooking. (2) Watering animals. (3) Bathing. (4) Washing clothes. (b) When in the field special attention should be given the following: (1) Regsrd all water as contaminated unless proved otherwise. (2) Do not permit the men to fill their canteens from any unauthorized source. (3) Place a guard at the source of the water supply to prevent its pollution. (4) Water discipline on the march should be rigidly enforced. (5) Not only the quality of the water supply but also its quantity should be supervised by the medical officer. 311 2666-2667 ch. 17.—preventive medicine and sanitation (6) The results obtained by modern military organizations demonstrate that water-borne diseases are preventable, consequently the prevalence of a water- borne disease in a camp indicates a weak link in the chain of sanitary measures. (7) Do not permit the men to bathe or swim in a stream or body of water until it has been inspected, and any possible health hazards ruled out by the medical officer. 2666. Water Consumption.—Water constitutes 60 percent of the body weight, or the equivalent of 10 gallons (Imperial), which equals 100 pounds, approximately, in the average man’s body. The loss of 1 gallon of this water has serious consequences. If 1% gallons are lost the result may be fatal. The minimum allowance of water for the needs of men and animals varies according to the amount of daily labor performed and also the condition of the weather. One gallon per man per day may be taken as an absolute minimum—lj4 quarts for drinking, 2){ quarts for cook- ing and drinking with meals. In combat and on the march a soldier can maintain physical efficiency for only 2 days on one-half gallon of drinking water each day. One gallon per day is the minimum allow- ance for drinking and cooking and provides no allowance for the washing of person or clothing. In camps of more than one night duration the following minimum allowance should be furnished: Gallons In barracks 20 In camps 5-10 The daily requirements for animals are: Gallons Horse 10 Mule or donkey 6 2667. Water Purification.—(a) Boiling.—Boiling is a simple and effective method of water sterilization and may be used in the pres- ence of an epidemic of intestinal disease, such as dysentery and cholera, and when materials are lacking for sterilization by other methods. Great caution should be exercised to see that the water is boiled. Boiled water has a flat taste unless it is aerated after cooling; its taste may be improved by the addition of tea or coffee. It can be aerated by allowing the water to trickle through the air, falling slowly for some distance from one container to another. Each man can boil water in his canteen, by placing the filled and open canteen in a fire or upon hot coals, until the water boils, then it is allowed to cool and capped. Troops can, after a day’s march, prepare their canteens full of boiled water for use on the next day. (b) Iodinization.—Two and one-half teaspoonfuls (10 cc) of 7 percent tincture of iodine added to a sterilizing bag (36 gallons capac- ity) of water will purify it in 30 minutes. Two drops of the tincture 312 2667 SEC. II.—FIELD AND CAMP SANITATION added to one canteen full of water and allowed to stand for 30 min- utes will sterilize the contents. (c) Chlorination of water.—A mobile water purification unit is the most convenient and satisfactory means of chlorination as it supplies between 80 and 100 gallons of filtered and chlorinated water each hour. It is well to remember that the presence of organic matter in solution or suspension tends to interfere with chlorination to a greater or lesser degree depending upon concentration. Organic matter combines with free chlorine, rendering it inert. It can be detected grossly either in solution or suspension by the presence of a faint coffee color. However, it may be present in amounts imper- ceptible to the naked eye, and the proper estimated amount of cal- cium hypochlorite may be added with the feeling of assurance that the water has been perfectly chlorinated, thereby generating a false sense of security. One is never wholly safe in the chlorination of water unless one of the tests for free chlorine is used. The sterilizing bags or water carts must ordinarily be used for chlorination of water. The water is treated in the bag as follows: (1) Arrange sterilizing bag on tripod. Strain water and fill bag to within about 4 inches of the top. (2) Procure a clean stick, or cut a limb from a tree for use in stirring of water. Place this in water and leave it there during sterilization. (3) Break one of the glass ampules of calcium hypochlorite (one-half gram) and shake the powder into a cup. Mix with water until a fine paste results, and then stir with a spoon adding more water until the paste is entirely dissolved. (4) Add the hypochlorite solution to the contents of the bag and mix thor- oughly with the stick provided for that purpose. Draw three cupfuls through each of the faucets (to clean and sterilize) and pour back into the bag. (5) Draw off one cup of water and add to it the contents of one ampule of orthotolidin, stirring with a clean, dry spoon. As the water is stirred it turns yellow, the degree depending on the amount of hypochlorite present. An orange or orange-red color indicates a sufficient amount for sterilization, while a canary yellow indicates an insufficient amount. Hypochlorite should be added, one tube at a time until the right color is obtained, and the water is then allowed to stand for half an hour. (6) Excess chlorine gives the water an unpleasant taste. This can be dispelled by neutralization with sodium thiosulphate, which is provided in glass ampules. The contents of one ampule should be added to a cup of water, stirred until dis- solved, and after chlorination of the contents of the bag is complete, should be poured into it. (7) The faucets should then be rewashed for the last time, running at least five cups of water through each faucet and returning the water to the bag. This treatment renders the water relatively safe, even though it were previously heavily contaminated. (8) The percentage of available chlorine in high-test calcium hypochlorite which has been hermetically sealed for 1 year, may be safely taken as 60 percent. It is highly probable that this percentage will be only slightly reduced at the end 313 2668 CH. 17.—PREVENTIVE MEDICINE AND SANITATION of 2 years in storage. For the present, however, it should be assayed if prac- ticable after the 1 year period, by the method outlined in the United States Pharmacopoeia and United States Dispensatory. If it be impracticable to assay, precaution should at least be taken to use only calcium hypochlorite from a con- tainer recently opened for the first time. The percentage of available chlorine following air-tight storage of 1 year and exceeding 2 years, may reliably be as- sumed to be not less than 50 percent. That percentage of the calcium hypochlorite in 36 gallons will give approximately 1.8 parts free available chlorine per million. The following table indicates the degrees of chlorination which may be ex- pected with calcium hypochlorite holding different percentages of available chlorine: Percentage available Cl in the calcium hy- pochlorite Vi gram calcium hypochlorite in 36 gallons of water Amount of cal- cium hypochlorite required to yield 1 part Cl per mil- lion in 100 gallons of water Percent Parts Cl per million Oram 60 2.20 0.63 55 2.01 .60 50 1.85 .75 (9) Another easily available method for qualitatively testing for free chlorine in water is by the so-called starch-iodine test. This is based upon the familiar formation of a blue color when starch and free iodine come into contact. Make up a 3 to 5 percent aqueous solution of potassium iodide. A starch solution is then produced by making a paste of two teaspoonfuls of cooking starch, adding this to a cupful of water and bringing to the boiling point. Allow to cool, bottle, and add two drops of chloroform to 100 cc as a preservative. To a cupful of water to be tested, add 5 to 10 cc of starch solution, stir and add 2 to 5 cc of the KI solution, or a few crystals of KI. When free chlorine is present in the water, a blue color will appear. The potassium ion combines with the chlorine ion, liberating free iodine which is soluble in an aqueous solution of its own salt KI. The iodine then combines with starch, forming the characteristic blue color. (10) In the absence of orthotolidin and materials for the starch-iodine test the usual field method is to add calcium hypochlorite until the water gives a slight taste and odor of chlorine. 2668. Food.—Food supplies should be inspected when received and also when issued to messes. All places where food is handled should be closely supervised and thorough cleanliness required. The galley should be sheltered, if practicable. Thorough screening of all places in which food is prepared, served, or stored shall be done as soon as practicable. Suitable provision should be made for the guard on duty at night. A simple cooling box for field refrigeration of food where ice is not available can be constructed by procuring two packing cases of such size that the smaller will be of the capacity desired and will fit within the larger, allowing a reasonable space between the two. This space is stuffed with sawdust or other insulating material, and the tops of the two cases hinged. The completed product is buried in the 314 SEC. II.—FIELD AND CAMP SANITATION 2669~2670 ground in a shady place so that the top of the outer box is level with the ground. The temperature within is maintained fairly constant, and low enough to prevent spoilage of all foodstuffs except fresh meat, by the simple expedient of wetting the insulating material every 48 hours or as needed. 2669. Mess Gear.—Adequate provision should always be made, in the vicinity of places where rations are issued, for the proper clean- ing of mess gear. A shallow trench fire should be built, of sufficient size to accommodate three cans of water. A garbage can should be placed nearby. Soap should be added to two of the cans of water and the third filled with clean water only. When the water is boiling the men should file by, depositing uneaten food in the garbage can and immersing their mess gear in each of the cans of boiling water, passing through the soapy water first. This procedure cleans and sterilizes the mess gear. A simple improvised mess-gear sterilizer can be made from a large lard can or from a 5-gallon oil can. In using the oil can, the top must be removed, and the edges turned down. Two long wire handles are fitted to the side of either of these, and the bottom and sides perforated. Two of these will fit within the ordinary general issue 30-gallon galvanized can. After the usual washing with soap and water and rinsing mess gear or dishes can be packed in these, and the can and contents immersed in boiling water contained in the 30-gallon galvanized can. The cans and contents are then kept in the boiling water at least 10 minutes, or as long as local conditions indicate. One advantage of this method lies in the fact that the containers can be removed, allowed to drain, and the heat retained in the mess gear or dishes will be sufficient to evaporate off all water, thereby obviating the use of drying towels or rags. 2670. Disposal of Waste Products.—The ultimate disposal of waste products is classified into the following procedures, applicable in general to the following types of camps: (1) Shallow burial Temporary camp. (2) Deep burial Semipermanent camps. Shallow burial.—Nitrification of excreta and other waste products is the pri- mary aim of the field sanitarian, and the germs that break up the waste products into harmless and inoffensive substances exist in upper layers of the soil. Con- sequently shallow burial is frequently a more satisfactory method of disposal than deeper burial. Under favorable conditions pathogenic organisms and solid con- tents—including toilet paper—of shallow trenches disappear in 4 to 5 weeks. Incineration.—A type of field incinerator consists of two trenches intersecting each other at right angles to form a cross. The dimensions of each trench are 8 feet long, 1 foot wide, and 1 foot deep in center, sloping from center to the surface at either end. At the intersection of these trenches place scrap iron to act as a grate and serve as a support for a galvanized iron can with bottom removed, or a wooden barrel, covered with a layer of wet clay, may be used. The fire will de- stroy the wood and bake the clay which serves as a chimney. The trench facing the wind is left open for ventilation and three other openings beneath the barrel are closed with a few shovels of earth. The trenches are lined with large stones, which become heated when the incinerator is in operation and thus assist in evaporation of any liquid waste. 315 2671 CH. 17.—PREVENTIVE MEDICINE AND SANITATION An excellent type of incinerator can be constructed inexpensively as follows: Construct a trench approximately 8 feet long, by 3 feet wide, and 2 feet deep, or better, construct two walls of brick or stone, 8 feet long, 2% feet high, and 3 feet apart. In either of these structures, two cross grates are built. The lower or fire grate about 6 inches from the bottom, with grating spaced 4 to 6 inches apart. This keeps the fire off the bottom, allows for a greater and more uniform draft, and prevents the fire from becoming stifled by ashes and garbage debris. The second grate consists of movable pieces of grating laid crosswise over the top of the pit or walls. The pieces are movable so that some adjustment can be made for the relative size of garbage particles, and so they can be removed for cleaning purposes. With this size and type of incinerator all of the garbage from a camp of 250 men can be spread out in a thin layer over the top grate, after building a roaring fire, and literally can be forgotten. Steel rods of the type used for rein- forcing concrete, angle irons of suitable thickness, or discarded rails make ideal grating. The disadvantages of the cross-trench type of incinerator are that the garbage must be added to it slowly, a shovelful at a time, for if it be added in bulk, the garbage will settle to the bottom of the incinerator in a layer, and this plus the liquid drippings will tend to choke off the fire. The cross-trench incinerator requires the full-time duties of one man. Such is not the case with the grate- type incinerator. In semipermanent camps, or for field camps in one location 1 month or longer, kitchen, bath, and laundry sullage water should be disposed of by running it through a seepage pit. This, in essence, is a coarse rock filter bed. For a camp of 250 men, in an area where the ground is pervious, a pit 8 by 8 by 8 feet, filled with crushed stone, coarse rock, cinders, gravel, or other rubble will suffice. The construction of radiating lateral drains from all sides of the base of the pit will increase the absorptive efficiency of the surrounding ground. Care must be exercised in locating the inlet pipe so that there will be a uniform flow of sullage water throughout all parts of the filter bed of the pit. Otherwise the section in use may become clogged prema- turely. In camps wdiich will be in the field a month or more, a grease trap should be located between the source of the sullage water and the seepage pit. This may be constructed of wood or concrete, and con- sists of a tank or compartment with two or more subdivisions, sepa- rated by partitions. Each subdivision should contain at least one baffle plate. The trap functions by allowing the water to cool, and the grease to congeal and collect on the surface. The resulting scum, a collection of fats and fatty acids, is then skimmed off daily and burned or buried. 2671. Latrines.—Straddle trenches should be used in bivouacs and camps of short duration or in rocky soil when larger pits cannot be constructed. Straddle trenches are dug 1 foot wide—about width of shovel—2 feet, or less deep, and 3 feet in length. Latrines should be 316 SEC. II.—FIELD AND CAMP SANITATION 2672-2677 located in a secluded spot at least 100 yards from galleys, to the lee- ward and at points not likely to be flooded by rains. They should be placed so as not to contaminate the water supply. In camps to be occupied for more than a few days deep trenches should be provided with seat capacity for 5 to 10 percent of the command. It may be advisable to place a guard over the latrine area, which should be lighted by a lantern at night. Latrines, when closed, should be covered with lime or crude oil and a layer of burlap before the final surface soil is replaced. Abandoned latrines should be marked by an “L” on a stake. Urine soakage pits should be constructed at the end of company streets in camps that are to be occupied for a week or more. Night cans should be placed in company streets at night and suitably lighted. These cans should be removed in the morning, emptied, and burned out. 2672. Bathing.—Facilities should be provided for bathing either in streams or by means of improvised showers. 2673. Laundry.—Wash benches should be provided in camps to be occupied for more than a few days. They should be adjacent to the bathing points. 2674. Picket Lines.—Picket lines should be established outside the living area. They should be policed twice daily and burned over once each week. 2675. Insect Control.—Whenever the stay in camp is protracted, all practicable methods should be employed to reduce the number of flies, mosquitoes, and other disease-transmitting insects. Drainage, clearing of underbrush, oiling, incineration of refuse, fly traps, etc., may be practicable means of insect control (par. 2615). 2676. Breaking Camp.—About 25 percent of the latrines should be kept open until the actual departure of the main body. The whole camp area should be thoroughly policed, small details being left to complete this task if necessary. 2677. Marching Troops.—(a) Before leaving camp a sanitary order, covering the hygiene and sanitary principles to be followed on the march, should be prepared by the medical officer and issued by the commanding officer. Sanitary memoranda may be issued in a similar manner to meet unusual situations. The start of the march should be made as soon as the troops fall in, and there should be a gradual warm- ing up until a uniform rate of march is reached. The first halt should be made in about three-quarters of an hour so as to allow men to adjust packs and attend to calls of nature. Excreta should be de- posited in circumscribed areas and properly covered with earth. Further halts should be made for 10-minute periods each hour, with 1 hour allowed for the noon meal. The last halt should be made well 317 2678 CH. 17.—PREVENTIVE MEDICINE AND SANITATION clear of camp, in order to allow men to attend to calls of nature. The remainder of the march should be a gradual slowing up to allow the men to cool off before arrival at camp. Companies should alternate the order of march each day, and care- ful thought should be given any measure that will promote a cheerful spirit in the men. (b) Canteens.—Before leaving the base with troops for the field, all canteens should be turned in at the galley and should be sterilized by boiling a sufficient length of time, under the supervision of a medical officer or a reliable assistant. This can be done on a large scale by boil- ing in the large 30-gallon galvanized cans. In prolonged service in the field this procedure should be repeated periodically. Water may be chlorinated on the march in canteens by dissolv- ing 1 gram of calcium hypochlorite in a quart of water and adding one canteen capful (not cupful) of this concentrated solution to each canteen of raw water. This water should be allowed to stand for at least a half hour before using. The taste of over chlorination may be somewhat removed by thoroughly shaking the canteen. Ordinarily, however, water should be chlorinated in water carts the night before the march, in order to provide a resupply during the march. Issue of sodium chloride tablets to men on march will be of value in prevent- ing heat exhaustion. (c) Food.—The issue of cooked rations before beginning the day’s march is often necessary. If the march is to be completed shortly after midday, however, it is more desirable to serve a hot meal upon arrival in camp. Sugar should form a liberal part of the ration of marching troops. (d) Care of the feet.—Blisters should receive prompt attention. Early aseptic puncture and an adhesive plaster covering offer a ready and satisfactory treatment on the march. After arrival in camp each man should wash his feet in cool water and put on a clean pair of well- powdered socks. He should wash the removed pair at once. Im- perfect socks should be discarded. 2678. Water Discipline on the March.—The strictest discipline will be required to regulate water consumption on the march and par- ticularly to prevent the use of water from unauthorized sources. In marching 1 mile a fully equipped soldier generates 90 calories, which will require the evaporation of 180 cubic centimeters of water to dissipate the heat. For 3 miles, or 1 hour of hiking, he will require 540 cubic centimeters of water, which is a little over 1 pint (473 cc) and for 2 hours of hiking the soldier will lose 2 pints or the equivalent of one canteen of water. 318 SEC. III. SANITARY REPORTS 2679-2680 There are so many factors—such as climatic conditions, loads carried, hills, muddy roads, etc.—influencing the water requirements that an attempt to standardize the fluid intake for the marching soldier is apt to result in more damage than good, if a standard is too rigidly adhered to. It is fairly safe however to use the following as a guide, assuming the soldier starts the march with about 1 pint of fluid in his stomach. Drink half the contents of the canteen, 1 pint, for each hour of marching, includ- ing rest periods; the soldier to take the first drink at the end of the second hour after leaving camp. 2679. Marching in the Tropics.—In warm countries the march should be started, if practicable, shortly after daybreak. Marching in the middle of the day should be avoided by a prolonged mid-day rest of 2 to 4 hours. Green leaves or a wet handkerchief in the hat serves to protect the head and neck from the sun’s rays. It is par- ticularly necessary in tropical marching to open up shirt fronts and roll up sleeves, as this will aid thermolysis. 2680. Control of Communicable Disease.—When a communicable disease makes its appearance in the neighborhood of the camp or within the camp, suitable measures, including quarantine methods, depending upon the epidemiological characteristics of the disease, should be taken to protect the personnel of the camp, the civilian population, or both, as circumstances dictate. Persons from an in- fected locality should be kept out of the camp and intercourse with civilians limited to such contact as involves no appreciable risk of infection. Within the camp prompt isolation of infected persons and suspects is imperative. Careful observation of all personnel is re- quired to insure prompt detection of cases. All mess gear should be disinfected, preferably by boiling. Proper cooperation with civilian health officials shall be carried out. Paragraph Annual Report 2691 Fleet Medical Officer’s Report 2692 Notes and Data 2693 Special Epidemiological Report 2694 Monthly Report of Communicable Diseases 2695 Monthly Sanitary Report, Ships___ 2696 Monthly Sanitary Report, Shore Stations 2697 Method of Preparing Annual Sanitary Report 2698 Annual Sanitary Report from Ships 2699 Annual Sanitary Report from Shore Stations Other than Hospitals 2700 Annual Sanitary Report from Hospitals 2701 Calculation of Annual Rates 2702 Form A 2703 Public Works 2704 SECTION III. SANITARY REPORTS 319 2691-2695 CH. 17. PREVENTIVE MEDICINE AND SANITATION 269L Annual Report.—All medical officers in charge of medical departments ashore and afloat including hospitals, navy yards, naval stations, marine barracks, and marine detachments, shall prepare and forward through official channels to the Bureau on January 1 of each year, a report relating to all matters of sanitary and professional interest coming under their observation during the previous year. This report should be in triplicate; one copy being retained in the files of the medical department, and one, in the case of ships, being marked For the Commander in Chief. 2692. Fleet Medical Officer’s Report.—The fleet medical officer and force medical officers shall prepare and forward, through official chan- nels, a general sanitary report at the end of each year. 2693. Notes and Data.—Notes, data, and memoranda of value for the compilation of sanitary reports shall be made from time to time by the medical officer and placed in the files in order that they may be available for the next sanitary report. Senior medical officers when detached shall be careful to see that such data are available for use by their successors. 2694. Special Epidemiological Report.—An epidemiological report (letter form) shall be submitted by the medical officer of a ship or shore station whenever any communicable disease occurs in epidemic form and a copy forwarded to the commandant of the naval district or commander in chief. In special instances, such as the occurrence of smallpox, plague, yellow fever, typhus fever, cholera, or the occur- rence of other communicable disease of an epidemic nature, a report shall be made to the Bureau by radio or telegram. 2695. Monthly Report of Communicable Diseases.—A report of communicable diseases is required monthly from each ship and station (including hospitals for duty personnel), navy yards, marine barracks, and marine detachments. This report shall be made in letter form and forwarded to the Bureau on the first day of each month. The statistical data shall be tabulated as indicated below: (1) Average strength for the month. (2) Total admissions (A and ACD but not RA): A ACD Diseases Injuries — — Poisonings Total, all causes. (3) All cases of communicable diseases (A and ACD but not RA) which were admitted to tfte sick list during the month under titles of the United States Navy 320 SEC. III.—SANITARY REPORTS 2696-2697 Nomenclature of Diseases and Injuries, in classes VIII (A), VIII (B), IX, X, XI, XII, and XIII shall be listed separately under each of these classes. For example: Class VIII (A): a acd Measles 2 0 Pneumonia, broncho- 2 1 Etc. Class VIII (B): Bronchitis, acute ---- 4 1 Catarrhal fever, acute 6 0 Etc. Class IX: Dysentery, amebic 3 1 Typhoid fever 1 0 Etc. Class X: Dengue 3 0 Malaria, benign tertian 2 1 Etc. Class XI: Tuberculosis, pulmonary, chronic, active 3 1 Tuberculosis, pulmonary, acute pneumonic 1 0 Etc. Class XII: Chancroidal lymphadenitis 0 3 Gonococcus infection, urethra 4 0 Gonococcus infection, epididymis 0 4 Syphilis 1 0 Lymphogranuloma inguinale 2 0 Etc. Class XIII: Abscess, unclassified 5 1 Erysipelas 1 0 Cellulitis 5 1 Etc. 2696. Monthly Sanitary Report, Ships.—A monthly sanitary report shall be submitted to the commander in chief from all medical officers at sea in accordance with fleet orders. 2697. Monthly Sanitary Report, Shore Stations.—In accordance with article 1184, Navy Regulations, the medical officer of each shore station shall submit a sanitary report to the commandant (via his immediate commanding officer) at the end of each month. This report shall embrace all matters of interest in connection with sani- tation, hygiene, and the prevention and control of disease. Particular attention should be given to the sanitary condition of public buildings, the drainage, the sewerage, the amount and quality of the water supply, the food and its preparation, the disposal of refuse and garbage, and an epidemiological report of any communicable diseases which may 321 2698 CH. 17. PREVENTIVE MEDICINE AND SANITATION have been present during the month, as well as any statistical data which may be of interest. The regulations require the commandant to indorse the report and return it to the medical officer, who shall enter the indorsement in the journal of the medical department and forward the report through official channels to the Bureau. 2698. Method of Preparing Annual Sanitary Report.—(a) In the preparation the annual sanitary report the title page shall read as follows: Sanitary Report of the • U. S (b) The second page shall contain the table of contents with index of pages. (c) All reports, except those of the fleet medical officer and the force medical officers shall contain the following tabulated data: Table 1 Causes Officers 1 Enlisted men Admis- sions Admitted contrib- utory disability Deaths Sick days Admis- sions Admitted contrib- utory disability Deaths Sick days All causes. Diseases only Accidents and injuries other than drownings Poisonings Drownings Communicable diseases: Cerebrospinal fever (meningo- Cerebrospinal meningitis (pneu- mococcus, streptococcus, etc.). i To include aviation cadets. 322 SEC. III. SANITARY REPORTS 2698 Causes Officers Enlisted men Admis- sions Admitted contrib- utory disability Deaths Sick days Admis- sions Admitted contrib- utory disability Deaths Sick days Venereal disease (all): Chancroid infection Gonococcus infection Syphilis Verruca acuminata Lymphogranuloma inguinale Any other communicable disease which has occurred or any noneom- municable disease or injury which has proved of sufficient importance during the year to receive separate mention Table 1—Continued Note.—Separate compilations shall be made for nurses and midshipmen. Vaccinations Total number vaccin- ated Number having vaccina or pri- mary re- action Number having vaccin- oid or second- ary re- action Number having immune reaction Number of failures Primary vaccinations (persons never before vaccin- ated) Revaccinations (persons having history of previous Table 2 (1) Number of persons who completed 3 inoculations of antityphoid vaccine for the first time (2) Number of persons receiving antityphoid inoculations in accord- ance with paragraph 2606 (b) (3) Number of complete courses of 3 inoculations administered during the period covered by the report (4) Detailed report: First inoculation: Number administered Number of severe reactions Number of severe reactions requiring admission to the sick list Second inoculation: Number administered Number of severe reactions Number of severe reactions requiring admission to the sick list Third inoculation: Number administered Number of severe reactions Number of severe reactions requiring admission to the sick list FIRST COURSE 323 2699 CH. 17.—PREVENTIVE MEDICINE AND SANITATION SECOND COURSE First inoculation: Number administered Number of severe reactions Number of severe reactions requiring admission to the sick list Second inoculation: Number administered Number of severe reactions Number of severe reactions requiring admission to the sick list Third inoculation: Number administered Number of severe reactions Number of severe reactions requiring admission to the sick list (5) Number of persons actively or passively immunized against diphtheria, tetanus, cholera, measles, or any other com- municable disease (list separately). 2699. Method of Preparing Annual Sanitary Report from Ships.— The first sheet shall be the title page (see par. 2698). The second page shall contain the table of contents, with index of pages. The body of the report shall be arranged as follows; Paragraph 1.—Size of ship, displacement tonnage. Class. Date when first commissioned. Number of officers and, separately, number of enlisted personnel attached on date of report. Paragraph 2.—Summary of the movements of the ship during the period covered in the report. For example: Arrived Departed Days in port Days at sea 2-2-37 2- 6-37 4 i 2-7-37 2-20-37 13 Paragraph S.—Average strength, separately, for officers and for enlisted personnel, for period covered in report. Average strength of enlisted personnel is obtained from number of rations issued and commuted. Paragraph 4-—See paragraph 2698 (c). Paragraph 5.—Brief presentation of epidemiological facts and information of interest in connection with the health of the personnel, together with such comments as the statistical data seem to require and mention of preventive meas- ures instituted. Paragraph 6.—Structural details of the ship in their sanitary aspects: (1) Number of decks used for berthing purposes, number of men berthed on each deck, and cubic air space per billet in sleeping quarters; ventilation means—ap- proximate amounts in cubic feet of air per man per hour, and possible remedies; lighting—amount, means, defects, and remedies; heating—amount, means, de- fects, and remedies; water—source, supply, facilities for storage and preservation; sanitary fittings—water closets, urinals, and bathing facilities. (2) The status of ventilation and heating during the year should be commented upon, however, and in case of inadequacy, the circumstances and the times during which inadequate should be mentioned. The numbers and the ratios of urinals 324 SEC. III.—SANITARY REPORTS 2699 or unit urinal spaces, and of water closets to the number of men to be accommo- dated should be stated, with brief comment as to conditions and possible means of improvement of these facilities. The numbers and the ratios of standing wash- bowls, faucets, and showers (indicate whether fresh or salt water) to the number of men to be accommodated should be stated, together with brief comment with regard to location, condition, and possible means of improvement. With regard to toilet and bathing facilities, the number of men to be accommodated by each fixture should be stated in every instance. (3) This section of the report should always include a summarized statement of the medical officers’ judgment as to whether ventilation and heating have been adequate, excellent, good, fair, or poor. Information relating to berthing and air space should be presented on a per capita basis in order that the relation to stand- ard conditions may be appreciated. Whenever it is possible to estimate the air supply the amount in cubic feet per man per hour should be given. All changes made in living compartments, berthing spaces, and toilet or bathing facilities should be fully reported, including a statement of the effects upon ventilation, modification of cubic air space, and deck area per man, and convenience or general welfare of the crew. Paragraph 7.—Navy ration. Quality of food supplied, variety and prepara- tion; the general messing system; sanitation of ship’s stores and storerooms, ice machines, and refrigerating rooms; location and sanitation of ship’s galley; method of garbage and refuse disposal. Mention should be made of the facts concerned in any outbreak of food poisoning or supposed food poisoning which has occurred during the year. The composition of the ration is fixed by the Navy Department. If the quality of food supplied has been good and its preparation satisfactory, no further comment is necessary. Information relative to the other items under this heading should be furnished from the standpoint of constructive criticism, which will lead to the accumulation of information of possible value for the guidance of the Bureau in making recommendations with regard to new installations or im- provement of existing conditions. Paragraph 8.—Clothing. Adaptability for different climates, texture, and durability of clothing issued; ship’s laundry capacity and efficiency. Comment from the hygienic viewpoint should be made with regard to special types of clothing and underclothing in use during the year. Paragraph 9.—Cells for prisoners. Number and location, cubic capacity, ventilation, heating, lighting, and sanitary policing of each cell. (See par. 2620.) Paragraph 10.—Medical, surgical, and dental supplies. Is the ship’s supply-table allowance sufficient? Have all supplies furnished been of satis- factory quality? Suggestions relating to additions to the supply table or elimina- tions therefrom. With due regard to conditions on board ship, suggestions bearing on possible improvement of the containers or method of packing any article. Paragraph 11.—Facilities for the treatment of the sick. Sick bay—loca- tion, capacity in cubic feet, number of berths, equipment and fittings, ventilation, lighting, and heating; dispensary—location, cubic capacity, equipment and fit- tings, ventilation, heating, and lighting; medical storerooms—location, capacity, ventilation, lighting, and arrangements for storing medical and surgical supplies. Similar information will be furnished regarding operating rooms, dental spaces, isolation wards, and venereal-disease treatment and prophylaxis rooms, if the ship be provided with them. Paragraph 12.—Stations in battle. Battle-dressing stations, arrangements for the care and transportation of the wounded, instruction in first aid. 2700 CH. 17.—PREVENTIVE MEDICINE AND SANITATION Paragraph 13.—Hospital corps. Is the complement of hospital corpsmen sufficient? Brief comment as to the efficiency of hospital corpsmen, attentive- ness to duty, contentment, and qualities making for advancement in rating; habits, aptitude for the service, and application to studies; proficiency in drills and general duties of enlisted men of the Navy; opportunity afforded by the nature of duties performed to qualify for higher ratings; duties performed worthy of mention; character and amount of instruction given; special methods of transportation and apparatus employed in handling the wounded. Paragraph 14.—General hygienic considerations and suggestions. Paragraph 15.—Recommendations. (1) For action within the command. (2) For action by other authority. 2700. Annual Sanitary Report from Shore Stations Other Than Hospitals.—The yearly sanitary report from navy yards and naval stations shall include a general description of the grounds and buildings, with such sanitary suggestions and recommendations as may deemed necessary. For title page and index see paragraph 2698. The body of the report shall be arranged as follows: Paragraph 1.—Number of officers and, separately, number of enlisted personnel attached on day of report. Paragraph 2.—Average strength, separately, for officers and for enlisted personnel, for period covered in report. Average strength of enlisted personnel is obtained from number of rations issued and commuted. In case of navy yards, average number of civil employees. Paragraph S.—The statistical data for naval personnel shall be given in accordance with paragraph 2698 (c). Paragraph 4.—Brief presentation of epidemiological facts and information of interest in connection with the health of the personnel (Navy and civilian em- ployees), with such comment as the statistical data seem to require, and mention of preventive measures instituted. Paragraph 5.—General description of topography of station, including dis- cussion of drainage projects, etc. If this has been given in previous sanitary reports, it will be sufficient to discuss changes only. Paragraph 6.—General description of buildings. If such information is contained in previous reports, discussion of changes, such as ventilation or other measures to improve sanitation, or of new buildings, will be sufficient. Paragraph 7.—Living quarters. Number of men berthed in quarters, particu- lar attention being given to overcrowding; ventilation—means, approximate amount of air per man per hour, and possible remedies; lighting—amount, means, defects, and remedies; heating—amount, means, defects, and remedies. Paragraph 8.—Toilet and bathing facilities. Description of the bathing facilities, toilet facilities, etc., giving the number and ratios to personnel of wash- bowls, faucets, showers, urinals, and water closets. This should be done for both civil employees and naval personnel. Paragraph 9.—Water supply. Its source and method of purification. State whether water supply has been at all times pure and adequate. Paragraph 10.—Disposal of sewage, garbage, and refuse. General discussion. Paragraph 11.—Navy ration. Quality of food supplied, variety, and prepara- tion; the general messing system; sanitation of galleys, refrigerating rooms, mess 326 SEC. III.—SANITARY REPORTS 2701 halls (civil employee as w'ell as Navy), and sculleries. Mention should be made of the facts concerned in any outbreak of food poisoning or supposed food poison- ing which has occurred during the year. Paragraph 12.—Clothing. Adaptability for different climates, texture, and durability of clothing issued. What are the facilities for washing clothes for the men? If a laundry is on station, give capacity and efficiency. Paragraph IS.—Prison spaces. Location, cubic capacity, ventilation, heating, lighting, and sanitary policing of cells. (See par. 2620.) Paragraph 14.—Medical, surgical, and dental supplies. Is the station’s allowance sufficient? Have all supplies furnished been satisfactory? Suggestions relating to additions to the supply table or eliminations therefrom.' Paragraph 15.—Facilities for the treatment of the sick. Description of sick quarters—location, capacity, equipment, fittings, ventilation, lighting, and heating. Paragraph 16.—Hospital Corps. Is the complement of hospital corpsmen sufficient? Brief comment as to efficiency of hospital corpsmen, etc. Paragraph 17.—General hygienic considerations and suggestions. Paragraph 18.—Recommendations. (1) For action within the command. (2) For action by other authority. 2701. Annual Sanitary Report from Hospitals.—The first sheet shall be the title page (par. 2698). The second page shall contain the table of contents, with index of pages. The body of the report shall be arranged as follows: Paragraph 1.— Number attached in duty status on date of report: (a) Officers. (b) Enlisted men. (c) Nurses. Average strength, duty personnel, for period of report: (a) Officers. (b) Enlisted men. (c) Nurses. Number of patients for period covered by report: (a) Officers. (b) Enlisted men. (c) Nurses. Paragraph 2.—The statistical data shall be given for duty personnel only, in accordance with paragraph 2698 (c). Paragraph S.—A similar table shall be made out showing all original admissions from patient personnel. Paragraph 4-—Brief presentation of epidemiological facts and information of interest in connection with the health of the personnel, together with such com- ment as the statistical data seem to require and mention of preventive measures instituted. Commanding officers of hospitals are expected to express themselves freely concerning transfers of patients to hospital with incorrect diagnoses, as well as to comment on the character oL naval personnel. Paragraph 5.—Topography. General description of topography of hospital grounds. 327 2702 CH. 17.—PREVENTIVE MEDICINE AND SANITATION Paragraph 6.—Buildings. General description of buildings. If such informa- tion is contained in previous sanitary reports, discussion of physical condition of building, changes, or new building will be sufficient. Paragraph 7.—Wards, offices, operating room, quarters, etc. General description of internal arrangements, ventilation, and heating of all buildings not previously reported upon in an annual sanitary report; if previously reported, state whether adequate and make necessary recommendations, giving, in full, reasons for such recommendations. Paragraph 8.—Equipment, furniture, linen, etc. State whether adequate or inadequate. Suggestions for improvement. Paragraph 9.—Food. Quality of food supplied to general mess, variety, prep- aration, and service. Special diets. Sanitation of kitchens, diet kitchens, mess halls, sculleries, and refrigerating rooms. State how food is handled when delivered. Mention should be made of any cases of food poisoning. Paragraph 10.—Water supply. Its source and method of purification. State whether water supply has at all times been pure and adequate. Is it ade- quate in case of fire? Paragraph 11.—Toilet and bathing facilities. The numbers and ratios of urinals, water closets, showers or tubs, and washbasins to numbers of duty personnel and patients. Paragraph 12.—Disposal of sewage, garbage, and refuse. Methods used for each. Paragraph 13.—Laundry and sterilizing apparatus. General description. If described in previous sanitary reports, discuss changes or improvements only. Paragraph 14-—Methods for the transportation of the sick and injured. Ambulance service and regulations adopted by hospitals for such service. Paragraph 15.—Personnel of hospital. State whether numbers of medical officers, nurses, hospital corpsmen, and civil employees have been sufficient, and whether work has been satisfactory. Make recommendations or suggestions. Paragraph 16.—Medical department. General summary of the activities of the medical department. Are facilities for this work adequate? Are facilities for the treatment of communicable diseases adequate? Paragraph 17.—Surgical department. General summary of the activities of the surgical department. Are the operating facilities adequate? Paragraph 18.—Laboratory. General summary of work. Report of any special procedures of interest. Are the facilities adequate? Paragraph 19.—Special departments. General summary of the activities of eye, ear, nose, and throat department, x-ray department, dental department, etc. Are the facilities adequate? Paragraph 20.—Medical, surgical, and dental supplies. Is the hospital allowance sufficient? Have all supplies furnished been adequate? Suggestions relating to medical supplies. Paragraph 21.—Disposal of dead. Facilities for disposal of dead. Condition of cemetery, if located at hospital. Paragraph 22.—General hygienic considerations and suggestions. Paragraph 23.—Recommendations. (See par. 2704). 2702. Calculation of Annual Rates.—Annual rates per 1,000 are obtained as follows: The number of cases or deaths is multiplied by 1,000 and divided by the average strength. If the period covered by the report be the whole year, this is the 328 SEC. III.—SANITARY REPORTS 2703 annual rate per 1,000. If the period be less than a year, the number of cases or 365 deaths, as the case may be, is first multiplied bv and " number of days in the period, then the rate per 1,000 is computed. Thus: Period, June 6 to December 31, 208 days. Average strength, 962. Admissions to sick list, all causes, 312. 365 3l2xm=647-5 Then, 547.5X1,000 —— >=569.13 annual rate per 1,000. 962 Again: Cerebrospinal fever, 2 admissions. 365 2X2lT8“3-51 3.51X1,000 = 3.65 annual rate per 1,000. 962 It will be noted that a short cut may be taken in computing the annual rates for the above table by determining the annual rate for one case, and then determin- ing the other rates from this figure, but in that event the rate for a single case 365 must be determined more closely than in the above example. Thus, IX— if 208 carried to four decimal places is 1.7548, multiplied by 1,000 and divided by the average strength, the annual rate per 1,000 for one case becomes 1.824. This figure multiplied by 312 cases gives an annual rate of 569.09, which is close enough to the rate obtained by the longer method. 2703. Form A, Report.—(a) Report of arsenical compounds admin- istered and reactions is required monthly from each Navy and Marine Corps activity, the original of this form to be forwarded to the Bureau. (b) Arsenical reactions.—The following information, in dupli- cate, shall be forwarded to the Bureau in each case in which a reaction follows the administration of an arsenical compound: (1) Full name, rate, and date of birth.—This information must be given as it is for reference purposes. (2) Approximate time and place of syphilitic infection.—State date and place of infection. If date and place of infection is unknown or questionable, state cir- cumstances of the case. (3) How syphilis was diagnosed.—State location and date of appearance of initial lesion; state all clinical manifestations which tend to substantiate the diagnosis; state date or dates of all dark-field examinations and give their results; state date or dates of all blood-serum reactions and give their results. If disease treated is a disease other than syphilis, state particulars of the case. 329 2703 CH. 17.—PREVENTIVE MEDICINE AND SANITATION (4) Previous treatment: 1. Amounts and dates of each course of arsenical treatment.—In all instances, give inclusive dates of each course, the number of injections comprising the course, the total amount in grams of each course, and the type of arsenical administered. 2. Amounts and dates of each course of mercury, bismuth, etc.—State the inclusive dates, the number of injections, the total amount in grams or grains, and the type of heavy metal or other treatment administered. (5) Course of treatment during which reaction occurred: 1. Size and date of each dose of arsenical compound.—State arsenical compound administered. 2. Size and date of each dose of mercury, bismuth, etc., given as con- current treatment snd how administered. (6) Information regarding dose causing reaction: 1. What was the dilution?—The concentration and method of prepara- tion, as recommended by Moore in collaboration with other syphilog- raphers (U. S. Public Health Service, Venereal Disease Information, vol. X, No. 2, February 20, 1929, p. 19), preferably should not exceed 0.1 gram of neoarsphenamine to 5 cubic centimeters of water. The drug must be sprinkled, not dumped, into the water and allowed to go into solution with no agitation whatever. Slight rotation of the flask is per- missible. Shaking the solution increases its toxicity and should be avoided. If the solution is not perfectly clear and transparent, it should not be used. Whether it requires 1 minute or 10 minutes for the drug to form a perfect solution is unimportant, but it should not require more than 10 minutes. The important point is not the rate of solubility but the complete solu- bility of the drug. Do not prepare any more solution at one time than can be administered within 20 minutes. 2. Age of drug.—The stability of neoarsphenamine is affected by the age of the product and instability increases with age. It can be inferred that, in general, neoarsphenamine may be expected to remain stable on the-average for a period of 3 years. S. Size of dose. If.. Lot number. 5. Name of preparation as labeled. 6. Name of manufacturer. 7. Time elapsing between the injection and the first symptoms of reac- tion.—State in minutes, hours, or days the time that has elapsed between the completion of the injection and the onset of the first symptoms of the reaction. 8. All clinical manifestations as entered in health record.—In every instance the medical history must be stated in detail. 9. All laboratory findings.—In each instance all laboratory reports, es- pecially blood counts, must be stated. The reports are necessary in order to properly classify certain types of reactions, especially the blood dyscrasias.) 10. Treatment given for the reaction.—Sizes of doses of drugs, time administered, and how administered. 11. Time of recovery.—State date of recovery and condition of patient at time of recovery. If patient is disposed of prior to complete recovery, state date of transfer and place to which transferred. 330 SEC. IV.—INTELLIGENCE REPORTS 2704-2712 (c) Annual report of number of cases of syphilis and num- ber treated.—To be submitted on Form A. See Circular Letter Y appendix D for current instructions. 2704. Public Works.—Recommendations regarding new construc- tion or repairs and improvements to buildings and grounds should be forwarded as an appendix to the sanitary report, entitled public works. Items should be arranged in the order of their relative importance and performance during the current calendar year and under the two headings necessary and desirable, with an approxi- mate estimate of the cost of each item of work. It should be borne in mind that work which of itself may be of the greatest ultimate importance might be of minor importance for immediate performance and items unauthorized one year may occupy an entirely different relative position in work recommended in a subsequent year. In order that these recommendations may be before the Bureau at the earliest practicable date this appendix should be submitted separately, if for any reason the complete sanitary report should be unavoidably delayed. SECTION IV. INTELLIGENCE REPORTS 2711. Medical officers aboard ship or with expeditionary forces shall cooperate with the intelligence officer and submit data for intelligence reports and monographs. The following data should be obtained: (1) Living conditions (State and city).—Housing—good or bad, and whether sufficient; sanitation—good or bad; epidemics—frequency, type, serious- ness, and preventive measures used. Is there a well-organized public-health service? (2) Hospitals (seaport city and town).—Names, location on map, number of beds, sanitary conditions, operating facilities, isolation facilities, etc. (3) Water supply (city).—Quantity, sources of supply, and purity. Trace mains on map if possible. (4) Sanitation (State and city).—Good or bad; sewage disposal—water- carriage system, open or closed; privies—systems used. (5) Medical organization of Army and Navy.—Efficiency, equipment, number of personnel. Sanitation of ships and stations. To what extent is pre- ventive medicine practiced? Hospitals ashore and afloat and all other available data. (6) Camp sites.—Locate from medical viewpoint sites for camps, considering topography of land, swamps, mountains, etc. (7) The above data should be accompanied by maps and photographs whenever possible, with important locations marked. 2712. Whenever the opportunity presents itself, medical officers shall, if practicable, submit to the Bureau all information of sanitary and professional interest pertaining to foreign naval medical estab- lishments. 331 2713 CH. 17. PREVENTIVE MEDICINE AND SANITATION 2713. When on foreign stations or cruising in waters beyond the continental limits of the United States, medical officers desiring to report in full upon the sanitary conditions of the various ports visited shall use the following outline, making such reports to the Bureau. u. s. s Date From: Medical officer. To: The Chief of the Bureau of Medicine and Surgery. Subject: Special medical report. Name of city or town. Location and population. General description of topography of town and surrounding country. Communicable diseases. Epidemic diseases. Endemic diseases. Venereal diseases and available information concerning prevalence and status of prostitution. Temperature, average day, ; night, ; yearly maximum, ; yearly minimum, Prevailing winds. Prevalence of mosquitoes, flies, etc. Rainfall. Drainage. Sewerage. Height above sea level. Camping sites. Water supply: Quantity. Quality. Method of collection. Method of purification. Food: Character and sanitary conditions of hotels, restaurants, etc. Availability of surgical and medical supplies. Structures suitable as emergency hospitals. Health laws and regulations. Quarantine regulations. Local laws or regulations regarding disinterment. Facilities for cremation. 332 CHAPTER 18 QUARANTINE, BILLS OF HEALTH, AND DISINFECTION Paragraphs Section I. QUARANTINE LAWS 2801-2808 II. QUARANTINE REGULATIONS 2811-2818 III. QUARANTINABLE DISEASES 2820-2827 IV. NAVY QUARANTINE REGULATIONS 2828-2834 V. BILLS OF HEALTH 2835-2845 VI. DISINFECTION AND DISINFECTANTS 2851-2864 VII. FUMIGATION OF VESSELS 2871-2874 VIII. DESTRUCTION OF VERMIN 2881-2888 SECTION I. QUARANTINE LAWS Laws Relating to Sanitation and Quarantine 2801 Compliance With Quarantine Laws Compulsory 2802 Bill of Health Required 2803 Rules and Regulations To Be Published 2804 Arrival of Infected Vessel in a Port Without Quarantine Facilities 2805 Entry of Persons or Property May Be Prohibited 2806 Quarantine of a State, Territory, or the District of Columbia 2807 Quarantine Measures Applicable to Aircraft 2808 Paragraph 2801. Laws Relating to Sanitation and Quarantine.—The following (pars. 2802-2808 inclusive) and other laws relating to sanitation and quarantine may be found in sections 9150 to 9182 (inclusive) of the United States Compiled Statutes, 1918. 2802. Compliance with Quarantine laws Compulsory.— It shall be unlawful for any merchant ship or other vessel from any foreign port or place to enter any port of the United States except in accordance with the pro- visions of this act and with such rules and regulations of State and municipal health authorities as may be made in pursuance of, or consistent with this act; and any such vessel which shall enter, or attempt to enter, a port of the United States in violation thereof, shall forfeit to the United States a sum, to be awarded in the discretion of the court, not exceeding $5,000, which shall be a lien upon said vessel, to be recovered by proceedings in the proper district court of the United States. In all such proceedings the United States district attorney for such dis- trict shall appear on behalf of the United States; and ail such proceedings shall be conducted in accordance with the rules and laws governing cases of seizure of vessels for violation of the revenue laws of the United States. (Feb. 15, 1893, c. 114, sec. 1, 27 Stat. 449.) (Title 42, U. S. Code, 81.) 333 2803-2804 CH. 18.—QUARANTINE 2803. Bill of Health Required.— (a) Any vessel at any foreign port clearing for any port or place in the United States shall be required to obtain from the consul, vice consul, or other consular officer of the United States at the port of departure, or from the medical officer where such officer has been detailed by the President for that purpose, a bill of health, in duplicate, in the form prescribed by the Secretary of the Treasury, setting forth the sanitary history and condition of said vessel, and that it has in all respects complied with the rules and regulations in such cases prescribed for secur- ing the best sanitary condition of the said vessel, its cargo, passengers, and crew; and said consular or medical officer is required, before granting such duplicate bill of health, to be satisfied that the matters and things therein stated are true; and for his services in that behalf he shall be entitled to demand and receive such fees as shall by lawful regulation be allowed, to be accounted for as is required in other cases. (b) The President, in his discretion, is authorized to detail any medical officer of the Government to serve in the office of the consul at any foreign port for the purpose of furnishing information and making the inspection and giving the bills of health hereinbefore mentioned. Any vessel clearing and sailing from any such port without such bill of health, and entering any port of the United States, shall forfeit to the United States not more than $5,000, the amount to be determined by the court, ■which shall be a lien on the same, to be recovered by proceedings in the proper district court of the United States. In all such proceedings the United States district attorney for such district shall appear on behalf of the United States; and all such proceedings shall be conducted in accordance with the rules and laws governing cases of seizure of vessels for violation of the revenue laws of the United States. (c) The provisions of this section shall not apply to vessels plying betwreen foreign ports on or near the frontiers of the United States and ports of the United States adjacent thereto; but the Secretary of the Treasury is hereby authorized, when, in his discretion it is expedient for the preservation of the public health, to establish regulations governing such vessels. (Feb. 15, 1893, c. 114, sec. 2, 27 Stat. 450, amended, Aug. 18, 1894, c. 300, 28 Stat. 372.) 2804. Rules and Regulations To Be Published.— The Secretary of the Treasury shall from time to time issue to the consular officers of the United States and to the medical officers serving at any foreign port, and otherwise make publicly known, the rules and regulations made by him, to be used and complied with by vessels in foreign ports, for securing the best sanitary conditions of such vessels, their cargoes, passengers, and crew, before their departure for any port in the United States, and in the course of the voyage; and all such other rules and regulations as shall be observed in the inspection of the same on the arrival thereof at any quarantine station at the port of destination, and for the disinfection and isolation of the same, and the treatment of cargo and persons on board, so as to prevent the introduction of cholera, yellow fever, or other contagious or infectious diseases; and it shall not be lawful for any vessel to enter said port to discharge its cargo, or land its pas- sengers, except upon a certificate of the health officer at such quarantine station certifying that said rules and regulations have in all respects been observed and complied with, as well on his part as on the part of the said vessel and its master, in respect to the same and to its cargo, passengers, and crew; and the master of 334 SEC I. QUARANTINE LAWS 2805-2807 every such vessel shall produce and deliver to the collector of customs at said port of entry, together with the other papers of the vessel, the said bills of health required to be obtained at the port of departure and the certificate herein required to be obtained from the health officer at the port of entry; and that the bills of health herein prescribed shall be considered as part of the ship’s papers and when duly certified to by the proper consular or other officer of the United States, over his official signature and seal, shall be accepted as evidence of the statements therein contained in any court of the United States. (Feb. 15, 1893, c. 114, sec. 5, 27 Stat. 451.) 2805. Arrival of Infected Vessel in a Port Without Quarantine Facilities.— On the arrival of an infected vessel at any port not provided with proper facilities for treatment of the same, the Secretary of the Treasury may remand said vessel, at its own expense, to the nearest national or other quarantine station, where accommodations and appliances are provided for the necessary disinfec- tion and treatment of the vessel, passengers, and cargo; and after treatment of any infected vessel at a national quarantine station, and after certificate shall have been given by the United States quarantine officer at said station that the vessel, cargo, and passengers are each and all free from infectious disease, or danger of conveying the same, said vessel shall be admitted to entry to any port of the United States named within the certificate. But at any ports where sufficient quarantine provision has been made by State or local authorities the Secretary of the Treasury may direct vessels bound for said ports to undergo quarantine at said State or local station. (Feb. 15, 1893, c. 114, sec. 6, 27 Stat. 452.) 2806. Entry of Persons or Property May Be Prohibited.— Whenever it shall be shown to the satisfaction of the President that by reason of the existence of cholera or other infectious or contagious diseases in a foreign country there is serious danger of the introduction of the same into the United States and that notwithstanding the quarantine defense this danger is so increased by the introduction of persons or property from such country that a suspension of the right to introduce the same is demanded in the interest of the public health, the President shall have power to prohibit, in whole or in part, the introduction of persons and property from such countries or places as he shall designate and for such period of time as he may deem necessary. (Feb. 15, 1893, c. 114, sec. 7, 27 Stat. 452.) 2807. Quarantine of a State, Territory, or the District of Columbia.— Whenever it shall be made to appear to the satisfaction of the President that cholera, yellow fever, smallpox, or plague exists in any State or Territory, or in the District of Columbia, and that there is danger of the spread of such disease into other States, Territories, or the District of Columbia, he is hereby authorized to cause the Secretary of the Treasury to promulgate such rules and regulations as in his judgment may be necessary to prevent the spread of such disease from one State or Territory into another or from any State or Territory into the Dis- trict of Columbia or from the District of Columbia into any State or Territory, 335 2808 CH. 18. QUARANTINE and to employ such inspectors and other persons as may be necessary to exe- cute such regulations to prevent the spread of such disease. The said rules and regulations shall be prepared by the Supervising Surgeon General of the Marine Hospital service, under the direction of the Secretary of the Treasury. And any person who shall willfully violate any rule or regulation so made and promul- gated shall be deemed guilty of a misdemeanor, and upon conviction shall be punished by a fine of not more than $500, or imprisonment for not more than two years, or both, in the discretion of the court. (Mar. 27, 1890, c. 51, sec. 1, 26 Stat. 31.) (Title 42, U. S. Code.) 2808. Quarantine Measures Applicable to Aircraft.— (a) Aircraft from South American ports shall be adequately sprayed in all accessible compartments for destruction of mosquitoes during flight, after taking off from the last foreign port and before arrival at the first American port, and also after leaving any United States insular port and before arriving at any United States continental port. The required pyrethrum spray shall contain not less than 0.4 percent pyrethrins and not less than 20 percent of kerosene or similar hydro- carbon oil. At least 5 cc of the spray shall be used for every 1,000 cubic feet of space, and during the spraying all openings into the aircraft shall be closed and held closed for not less than 5 minutes after spraying is completed. A different spray shall not be used unless a sample has been submitted to the quarantine officer and found by comparative tests to be as effective as the spray described. Operating officials and pilots shall be informed of these requirements. (b) Any person upon arrival by aircraft from a district where yellow fever prevails, who is definitely febrile shall be detained until the nature of the illness is determined, in a room at the airport, at the quarantine station, or at some other point mutually agreeable to the quarantine officer and the health officer of the district in which the person is detained. Persons who have not been in a district suspected of infection with yellow fever for 6 days prior to embarkation may be released without surveillance. (c) The pilot of each arriving aircraft shall furnish the quarantine officer with a statement showing the itinerary of all passengers and the crew for 6 days prior to embarkation for the United States. Unless the pilot’s information is complete, all persons involved should be interrogated, under oath if necessary. Persons who have been in districts suspected of infection with yellow fever within 6 days prior to embarkation shall be required to state future itinerary covering a period that will complete nine days from the date last in the infected territory. They will be informed that contact is to be maintained through local health organizations until this period has expired and instructed to report immediately any illness that may develop. Health officers of localities south of the northern boundary of Mary- land which will be visited by persons from infected areas shall be notified and requested to maintain direct contact with said persons until the period of required surveillance is completed. In seaport cities surveillance will be maintained by the quarantine officers. Persons presenting satisfactory evidence of immunity by recovery from yellow fever or by artificial immunization may be released without detention or surveillance. (Abstracted from Treaty Information Bulletin No. 60, September 1934.) 336 SEC. II.—QUARANTINE REGULATIONS 2811-2812 SECTION II. QUARANTINE REGULATIONS PROMULGATED BY THE SECRETARY OF THE TREASURY Paragraph Bill of Health Required-.. 2811 Naval Vessels Usually Exempt From Inspection—Radio Pratique 2812 Naval Vessel From Infected Port Subject to Inspection 2813 Certificate of Naval Medical Officer Accepted in Lieu of Actual Inspection.. 2814 Naval Vessels From Infected Ports Where no Communication was Held... 2815 Naval Vessels not Carrying a Medical Officer 2816 Persons Authorized to Board Vessels Subject to Quarantine 2817 Inspection of Vessels Subject to Quarantine 2818 2811. Bill of Health Required.— Masters of vessels or aircraft clearing from or leaving any foreign port or any port in the possessions or other dependencies of the United States for a pbrt in the United States or its possessions or other dependencies must obtain a bill of health, in duplicate, signed by the proper officer or officers of the United States as provided for by law, unless there is no such officer at the port of departure, excepting vessels operating, during the absence of quarantinable disease in the foreign ports of call, exclusively between ports in the United States and ports in Canada, and exclusively between ports in Florida south of 28° north latitude and port3 in the Bahama Islands and ports in Cuba, and excepting aircraft, departing from ports free of quarantinable disease, which may present statements in the journey log book attested by proper officials of airports of departure and by the masters of the aircraft in lieu of bills of health. Guantanamo Bay, Cuba, is considered under the law as a foreign port. Bill of health is required and may be obtained from the medical officer prior to departure. 2812. Naval Vessels Usually Exempt From Inspection.— Vessels of the United States Navy which carry a medical officer, upon entering United States ports from foreign ports, are exempt from quarantine inspection provided that such vessels have not sailed from a port infected with cholera, yellow fever, or plague, or in which typhus or smallpox is epidemic, and further provided that no cases of these quarantinable diseases have occurred on board en route. Naval vessels coming within the above provisions will radio to the naval authori- ties at the port of destination for relay to the quarantine officer, or will radio direct to the quarantine officer, a report of the pertinent facts, including a state- ment by the ship’s medical officer to the effect that no cases of these quarantinable diseases have occurred on board during the voyage. The prescribed radio quar- antine message will hereafter include an enumeration of the port of departure and all subsequent ports of call on the homeward-bound voyage, together with a state- ment as to the reported presence or absence of quarantinable diseases in those ports. Immediately following the arrival of the vessel at the first United States port of entry a letter will be addressed and mailed by the medical officer to the quarantine officer, confirming the prescribed radio quarantine message, giving the name and rank of the ship’s medical officer, and enclosing the duplicate copies of all bills of health procured by the vessel at port of departure and each subse- quent port of call on the homeward-bound voyage. 337 2813-2818 CH. 18.—QUARANTINE When two or more vessels of the smaller type, such as destroyers, one of which carries a medical officer, are cruising together, each vessel is construed as equiva- lent to carrying a medical officer and they may be reported by radio, including each ship in the squadron or division, and confirmed upon arrival by a letter from the squadron or division medical officer. 2813. Naval Vessel From Infected Port Subject to Inspection.— Vessels of the United States Navy are subject to quarantine inspection upon arrival at ports of the United States, its possessions or dependencies, when from a foreign port known or suspected to be infected with yellow fever, bubonic plague, typhus, or cholera, and such subsequent detention for disinfection as may be required by reason of disease aboard or exposure to such disease in foreign ports. 2814. Certificate of a Naval Medical Officer Accepted in lieu of Actual Inspection.— The certificate of a medical officer of the United States Navy as to the sani- tary history of the vessel and its personnel may be accepted for naval vessels by the quarantine officer boarding the vessel in lieu of actual inspection. 2815. Naval Vessels From Infected Ports Where no Communica- tion was Held.— Vessels of the United States Navy having entered the harbors of infected ports, but having held no communication which is liable to convey infection, may be exempted from the disinfection and detention imposed on merchant vessels from such ports. 2816. Naval Vessels not Carrying a Medical Officer.— Vessels of the United States Navy not carrying a medical officer or upon which a case of any of the quarantinable diseases has occurred while enroute, shall, upon arrival at ports of the United States from foreign ports, be subject to the same provisions of these regulations as apply to merchant vessels. (See par. 2802.) 2817. Persons Authorized to Board Vessels Subject to quarantine.— No person except the quarantine officer, his employees, or pilots shall be per- mitted to board any vessel subject to quarantine inspection until after the vessel has been inspected by the quarantine officer and granted pratique; and all such persons so boarding such vessel shall, in the discretion of the quarantine officer, be subject to the same restrictions as the personnel of the vessel, or otherwise action may be taken as provided for in section 10, act of March 2, 1901: Provided, however, That the United States customs officials may be permitted to board a vessel that has been inspected and held in quarantine for detention or treatment, they being subject to the same restrictions as the personnel of the vessel. 2818. Inspection of Vessels Subject to Quarantine.— Every vessel subject to quarantine inspection entering a port in the United States, its possessions or dependencies, shall be considered in quarantine until given free pratique. Such vessel shall fly a yellow flag at the foremast head and shall observe all other regulations for vessels actually quarantined. No direct communication shall be allowed between any vessel in quarantine and any person 338 SEC. III.—QUARANTINABLE DISEASES 2820-2821 or place outside. The quarantine officer shall report to the Secretary of the Treasury, through the Surgeon General of the United States Public Health Serv- ice, all violations of the quarantine laws. SECTION III. QUARANTINABLE DISEASES Paragraph The Quarantinable Diseases 2820 Cholera 2821 Yellow Fever 2822 Plague 2823 Smallpox 2824 Typhus Fever 2825 Leprosy 2826 Anthrax 2827 2820. The Quarantinable Diseases.—The quarantine laws and regulations of the United States designate the following as quaran- tinable diseases: (1) Cholera, period of incubation 1 to 5, usually 3 days. (2) Yellow fever, period of incubation 3 to 6 days. (3) Smallpox, period of incubation 8 to 16 days. (4) Typhus fever, period of incubation 5 to 20 days. (5) Leprosy, if an alien, not permitted to land; if a citizen, the case is dealt with according to the State laws of the port of entry. (6) Plague, period of incubation 3 to 7 days. (7) Anthrax, period of incubation 7 days. Essential requirements of the quarantine regulations are briefly stated below, and under the headings, epidemic prevalence ashore, pertinent information is given which conforms to the report of the committee of the American Public Health Association on the control of communicable diseases as approved by the United States Public Health Service. 2821. Cholera.— (a) At a port where cholera prevails, drinking water, unless of known purity, should be boiled and food thoroughly cooked and protected against contamination by flies and cockroaches. Food products which are ordinarily consumed in an uncooked state, except fruits grown on trees or shrubs, coming from cholera-in- fected localities or through such localities, if exposed to infection therein, should not be taken on board ship. Passengers for transports or other naval vessels coming from a cholera infected district, should not be received on board unless they produce satisfactory evidence as to exact place of abode during the 5 days immediately preceding embarkation. If possibly exposed they should be sub- jected to bacteriological examination; otherwise, detention for 5 days in a place free from risk of infection should be required prior to embarkation. Upon arrival at a port in the United States, a vessel upon which cholera has appeared during the voyage will be held in quarantine. All persons on board will be detained until found to be free from cholera vibrios. Detained persons found free from cholera vibrios by bacteriological examination performed not less than 24 hours after 339 2822 CH. 18.—QUARANTINE removal from the possibility of infection by case or carrier, may be discharged from quarantine without further detention. If a case of cholera develops on board ship the infected person shall be isolated at once in a screened space with rigid concurrent disinfection and transferred to quarantine hospital upon arrival in port. All contacts should be segregated in small groups, and the dejecta of all persons in quarantine on account of cholera shall be disinfected before final disposal. Special precautions shall be taken to prevent contamination of food or water or spread of the infection through the agency of flies or other insects. The water supply of a vessel detained in quarantine on account of cholera shall be sterilized unless determined to be free from cholera vibrios and E. coli. Otherwise it shall be disinfected and discharged. Personal effects contaminated by a cholera case or carrier shall be disinfected. Any part of the ship contaminated by case or carrier dejecta shall be washed down with a strong solution of bichloride of mer- cury or cresol. Carriers and recovered cholera cases shall be released from quar- antine detention only after three negative bacteriological tests performed on consecutive days. (b) Epidemic prevalence ashore.—Consider bacteriological examination for the detection of carriers among persons exposed in infected localities. Isolation of carriers in screened room or hospital ward. Disinfection of excreta before disposal. Detention in sanitary environment for 5 days of persons desirous of leaving for another locality or until a negative bacteriological test is performed not less than 24 hours after entering detention. Inoculation with cholera vaccine of persons liable to be exposed, since active artificial immunity for about 1 year is probable. Water for drinking, ablution, and culinary purposes boiled or so treated as by chlorination that the cholera vibrio cannot survive in it. Only cooked foods to be eaten; cooked and uncooked foods protected from contamina- tion by human hands and by insects. 2822. Yellow Fever.— (a) For the purpose of quarantine regulations 6 days is considered the period of incubation. At ports where the disease prevails, precautions should be taken against introduction of mosquitoes on board ship. All collections of water about the vessel shall be so guarded or treated as to prevent the breeding of mosquitoes, and measures will be taken to discover and kill any that may have come aboard. Persons known to have been definitely exposed ashore should not be allowed to embark for 6 days after said exposure. Persons immune to yellow fever are exempt from this provision. Upon arrival of a vessel in which a case of yellow fever has occurred during the voyage, at a domestic or insular port, the following measures are to be taken: Visual and thermometric inspection of all persons; immediate transfer of the sick to a place of isolation protected against access of Aedes aegypti mosquitoes; disembarkation of other persons, if possible, with detention under observation for 6 days dating from the day of last possible exposure, and isolation in a screened apartment of any showing elevation of temperature. The ship should be anchored or moored at least 225 yards from the inhabited shore, and shall be fumigated for the destruction of mosquitoes—before removal of cargo, in the case of a cargo carrier. A vessel which has lain in such proximity to the shore of an infected port as to make access of Aedes mosquitoes possible shall be fumigated and the personnel held in detention under observation for 6 days. A vessel which has not had yellow fever on board, coming from an infected or suspected port, upon arrival at a southern port of the United States, directly or via a northern port, in a good sanitary condition as regards breeding places for mosquitoes on 340 SEC. III. QUAKANTINABLE DISEASES 2823 board, if not having lain within mosquito access distance of the suspected port, or if fumigated under the supervision of an accredited United States medical officer immediately before sailing, may be granted pratique with or without fumigation at the discretion of the quarantine officer without further detention than is necessary to complete 6 days from date of departure. If arriving after 6 days enroute the vessel shall be immediately fumigated, if not previously fumigated at a northern port, and then may be admitted without detention. A vessel from a suspected port, calling during the active quarantine season at a port south of the southern boundary of Virginia, April 1 to November 1, or at a port north of that line and south of the southern boundary of Maryland, be- tween May 15 and October 1, for fuel or other supplies, may be allowed to take such supplies after fumigation provided the vessel is anchored in a place inac- cessible to Aedes aegypti mosquitoes and the crew and passengers, if any, are detained on board. During the active quarantine season traffic from ports infected with yellow fever to ports in the United States south of the southern boundary of Maryland, is permitted, provided an accredited medical officer of the United States specifically certifies that the vessel lay at approved moorings in the open harbor; that no member of the crew was ashore at the port of depar- ture; that every possible precaution was taken to prevent ingress, harboring, and breeding of Aedes aegypti mosquitoes; and that the officer who had contact with the authorities in the infected port is a yellow fever immune. Persons embarking, unless immune to yellow fever, must have been free from possible exposure to infection for 6 days immediately prior to embarkation. Such persons may be permitted to land without detention. (b) Endemic and epidemic prevalence ashore.—Aedes aegypti is not the exclusive vector of yellow fever. The so-called jungle type of yellow fever prevails despite the absence of this mosquito. A yellow fever patient can only transmit the disease if bitten by a suctorial insect during the first 3 days of the fever, possibly 4 days. Passive immunity of brief duration may be conferred by convalescent serum, and artificial active immunity of several years duration may develop from combined inoculation with modified living virus and human immune serum. Concurrent disinfection is not required and terminal measures are limited to the destruction by fumigation of mosquitoes in the building in which the case has developed and been treated, and in near-by buildings. 2823. Plague.— (a) At ports where plague in rodents may exist every precaution shall be taken to prevent rats, mice, and fleas from getting aboard. Vessels sailing from such ports will be simultaneously fumigated in all parts, preferably empty, for destruc- tion of rats. Lighters should be fumigated periodically to insure freedom from rats. At dock all connecting lines must be guarded by inverted cones not less than 3 feet in diameter maintained always at a right angle to the guarded line. Articles liable to harbor rodents or fleas should not be brought on board unless freedom from such vermin is insured by use of chemicals, fumigation, or preventing access of rats. A ship in which human or rodent plague has occurred will be detained in quarantine upon arrival at a domestic or insular port; the sick, if any, will be removed and isolated, and destruction of rats will be effected as soon as practicable by simultaneous fumigation in all parts, every precaution meanwhile being taken to prevent escape of rats from the ship. All dead rodents will be collected and examined bacteriologically at the quarantine station. Persons sick of plague will be detained in quarantine until well. Healthy contacts will not be detained, unless the disease is present in pneumonic form. If pneumonic plague has developed 341 2824 CH. 18. QUARANTINE during the voyage all persons who have been exposed will be detained for 7 days, or at the discretion of the quarantine officer, until their secretions have been found free from the plague bacillus. Personal effects which may be contaminated with the causative agent or infested with fleas will be disinfected and disinfested. A vessel from a foreign, insular, or domestic port suspected of being infected with plague, which is of such type or so loaded as to preclude effective fumigation may be permitted to enter port subject to provisional pratique. Such ship will be fended off from wharf or dock not less than 4 feet with sheet metal rat guards of approved design, not less than 3 feet in diameter, on all connecting lines. All gear and devices extending between the ship and shore structures shall be removed at night unless in actual use; likewise gangways and ladders unless guarded. All vessels from ports known to be infected with plague, when effective measures have not been taken under the supervision of an accredited medical officer of the United States to destroy rats and fleas and prevent the ingress of such vermin, will be fumigated for destruction of rats upon arrival at a port in the United States. Vessels engaged in trade with foreign ports are required to undergo fumi- gation for destruction of rats in periods not greater than 6 months, but the periods may be extended for vessels plying regularly between ports not infected with plague and for vessels whose construction does not favor harborage of rats. A certificate signed or visaed by an accredited medical or consular officer of the United States may be accepted by the quarantine officer as competent evidence as to the last fumigation, provided such certificate contains the same, or sub- stantially as complete information as contained in—Certificate of Fumigation, United States Public Health Service—Form 1939 or Form 1945. In the fumigation of a loaded vessel as a plague preventive measure the time of exposure shall be doubled, and when necessary, in the treatment of an infected vessel, the quaran- tine officer may require the master to partially discharge cargo to insure effective fumigation. (b) Epidemic prevalence.—Effective measures for control include prompt detection, reporting and isolation of new cases in screened apartments free from vermin; confirmation of diagnosis by bacteriological examination of blood, pus from glandular lesions, and sputum in pneumonic cases; concurrent disinfection; burning sputum and boiling of articles soiled there-with; thorough cleaning upon termination of the case followed by fumigation to destroy rats and fleas. The incubation period is commonly less than 7 days but in rare instances may be as long as 14 days. The pneumonic type is intensely communicable during the course of the disease and susceptibility is general. The bubonic type is not communi- cable from person to person. Passive immunity of 3 to 4 weeks duration is conferred by antiplague serum. Plague vaccine usually confers active immunity of about 6 months duration. General measures: Methodical destruction of rats and other rodents living in the wild state in areas of endemic rodent infection; examination of carcasses for the detection of plague; rat proofing of buildings and elimination of breeding places; guarding of grains and other food materials against access to rats; investigation of all deaths during an epidemic, with autopsy and laboratory examination when indicated. 2824. Smallpox.— (a) For the purpose of quarantine regulations the incubation period is consid- ered to be 14 days. Persons from districts where smallpox is epidemic must be vaccinated before embarkation unless satisfactory evidence is presented of suf- cessful vaccination within 1 year or of immunity acquired by previous attack of smallpox. Baggage should be inspected and if necessary, disinfected. A vessel 342 SEC. IIJ. QUARANTINABLE DISEASES 2825 arriving at a domestic or insular port, having had smallpox on board during the voyage will be detained at quarantine and all compartments liable to contamina- tion with smallpox virus will be disinfected. The sick will be removed and de- tained until recovered. All persons presumably exposed to smallpox shall be vac- cinated, or in case of refusal to submit to vaccination, detained in quarantine for 14 days after last possible exposure to infection, unless there is satisfactory evi- dence of a previous attack of smallpox. Persons who have not been exposed to the infection may be released. (b) Epidemic prevalence ashore.—The incubation period is 8 to 16 days; in rare instances, 21 days. The onset is gradual—fever 1 to 4 days before eruption appears; papular stage, 1 to 4 days; vesicular, 1 to 4; pustular, 2 to 6; separation of crusts, 10 to 40 days after first appearance of skin lesions. The eruption is general and symmetrical, having predilection for extensor surfaces, with fewer lesions on protected surfaces, depressions and flexures. Lesions are earlier and more abundant on distal portions of the limbs than on the trunk; more abundant on the shoulders and chest than on the abdomen and loins. Quick control of an outbreak requires prompt detection of new cases with careful differentia- tion from chickenpox and isolation in screened apartments free from flies and vermin, together with immediate vaccination of contacts with cowpox virus of undoubted potency. Frequent revaccination of all persons liable to contact with a source of infection is indicated. If already adequately protected the in- dividual experiences no discomfort. Even an immunity reaction, if fully potent virus is used, may strengthen existing immunity. Case contacts should be vac- cinated at once and held in quarantine under daily observation until the height of reaction is passed, provided vaccination was performed within 24 hours of first exposure; otherwise for 16 days from last exposure. The American Public Health Association with the approval of the United States Public Health Service, recommends vaccination in early infancy, revaccination of children upon entering school, and of the entire population when the disease appears in severe form as a general measure for the prevention of smallpox. 2825. Typhus Fever.— (a) For the purpose of quarantine regulations the incubation period is con- sidered to be 12 days. At ports infected with typhus, persons shall not be allowed to embark unless demonstrably free from vermin. Otherwise suitable treatment of infected persons will be enforced and their personal effects, wearing apparel, and baggage shall be disinfected and disinfested. Persons from a house, barracks, or other structure in which a case of typhus has occurred will not be allowed to embark for 12 days after removal from the infected environment. Upon arrival at a domestic or insular port, a vessel in which typhus has occurred will be detained in quarantine, and the sick, if any, removed and isolated. All persons not demon- strably vermin free will be treated for the destruction of lice and their clothing, personal effects, and baggage will be disinfested. All who have been exposed to infection will be detained under observation for 12 days after date of last exposure to infection. Persons demonstrably free from vermin, who have not been exposed to infection, may be released without detention or disinfestation of baggage. A vessel in which typhus has appeared will be held in quarantine and fumigated for destruction of vermin. (b) Epidemic prevalence ashore.—The incubation period is from 5 to 20 days; usually less than 12 days. The causative agent is believed to be Rickettsia prowazeki, and the source of infection, blood of infected persons or rats; vector, 343 2826-2827 CH. 18.—QUARANTINE body lice, and in some outbreaks, fleas. The disease is communicable (transmis- sion to lice) until 36 hours after the infected person’s temperature has become normal. Immunity conferred by an attack is not always permanent. Flea-borne typhus is usually encountered in late summer and autumn; louse-borne infection occurs predominantly in winter and spring. Cases should be isolated in a vermin proof apartment. No concurrent or terminal disinfection is required but all body and head lice on the person and in the clothing of the patient should be destroyed. Rats as well as infected persons may be a transmission factor and their destruction is therefore an indicated general measure of prevention, along with the operation of facilities for the delousing of persons, clothing, and premises. 2826. Leprosy.— (a) Alien lepers are not permitted to embark at a foreign port for a port in the United States, possession, or dependency. If a citizen of the United States, found to be leprous, wishes to embark, the case shall be reported promptly to the Navy Department, if transportation in a naval vessel is involved. In case of commercial carrier, prompt report to the Surgeon General of the United States Public Health Service is required, pending further action. A vessel arriving in quarantine with leprosy on board will not be granted pratique until the leper and his baggage have been removed to the quarantine station. (b) Endemic prevalence.—Source of infection is limited'to infected persons with open lesions, i. e., while discharging leprosy bacilli. The incubation period is long and may extend to several years. The conditions and circumstances under which transmission occurs are not completely understood. Control measures include isolation of bacteriologically positive cases in a national leprosarium for 6 months after apparent arrest has been secured, with reexamination of paroled lepers at intervals of 6 months. Terminal disinfection consists of thorough cleans- ing of the patient’s living premises. No immunization method is recognized and quarantine of contacts is not contemplated. 2827. Anthrax.— Quarantine regulations contemplate that anthrax is primarily a disease of animals, not transmitted from man to man, and that responsibility for exclusion of the disease rests upon the United States Bureau of Animal Industry. It was designated a quarantinable disease to afford additional protection from infection from imported animal products, especially hair and bristles for shaving brushes. It is required that shaving brushes destined for shipment to the United States be made only from hair or bristles known to be free from anthrax spores, or that such hair or bristles before being made into brushes shall be disinfected by one of three methods: (1) Boiling for 3 hours; (2) autoclaving for 30 minutes at 15 pounds pressure with preliminary vacuum of at least 10 inches; and (3) exposure to streaming steam for 6 hours. SECTION IV. NAVY QUARANTINE REGULATIONS Paragraph Bill of Health To Be Exhibited to Health Officer 2828 Quarantine Regulations To Be Complied With 2829 Commanding Officer’s Duty When Infectious Disease Exists 2830 Boarding Vessels; No Concealment of Facts 2831 Personnel Remain Aboard Ship Subject to Quarantine 2832 Quarantine Inspection of Naval Vessels 2833 Quarantine Measures Applicable to Aircraft Flying to Hawaii 2834 344 SEC. IV. NAVY QUARANTINE REGULATIONS 2828-2832 2828. Bill of Health To Be Exhibited to Health Officer — Upon arrival of the ship in port he (the medical officer) shall be prepared to receive the health officer and exhibit to him the bill of health; also to answer any questions that may be asked concerning the sanitary condition of the ship. (An. 1172 (2), N. R.) 2829. Quarantine Regulations To Be Complied With.— (1) Commanding officers of ships shall, on entering a port, foreign or domestic, comply strictly with all its quarantine regulations. (2) They shall, whether liable to quarantine or not, afford every facility to visiting health officers, and give all the information the latter may require. (3) Should doubt exist a£ to the regulations of the port, no communication shall be held with the shore, with boats, or with other ships, until a sufficient time has elapsed to allow of the visit of the health officer. (Art. 1451, N. R.) (4) While en route to a domestic port from a foreign port or from a port in the possessions or other dependencies of the United States the master shall send a message to the quarantine officer of the domestic port of destination, either direct or through naval personnel at that port, requesting advice as to quarantine procedure. (5) Upon arrival of the ship in port the medical officer shall be prepared to receive the health officer and exhibit to him the bill of health; also to answer any questions that may be asked concerning the sanitary condition of the ship. (Art. 1172, (2) N. R.) 2830. Commanding Officer’s Duty When Infectious Disease Exists.— (1) Should a naval vessel arrive in port with a quarantinable disease on board, or should such a disease break out while lying in port, the fact shall be at once reported to the commander in chief or senior officer present. The commanding officer shall hoist the quarantine flag and prevent all communication likely to spread the disease elsewhere until pratique is received. (2) In order to check the spread of such disease on board ship, he shall arrange with the authorities of the port for the care and treatment of patients on shore or on board a hulk. (3) If at sea in company with other ships and a quarantinable disease exists or appears on board, he shall keep the quarantine flag flying as long as the disease lasts and shall do all in his power to prevent dissemination. (Art. 1452, N. R.) 2831. Boarding Vessels; No Concealment of Facts.— (1) In boarding arriving vessels, care shall be taken not to violate the rules of the port, and in case they are subject to quarantine the boarding officer shall, if possible, obtain the information required without going alongside. (2) Vessels at sea coming from a suspected port not having a clean bill of health or otherwise liable to quarantine shall not be boarded unless it be absolutely necessary, and the fact of such communication, when it occurs, shall be reported on arrival in port to the health officer. (3) No concealment shall be made of any circumstances that may subject a ship of the Navy to quarantine. (Art. 1453, N. R.) 2832. Personnel Remain Aboard Ship Subject to Quarantine.— No naval officer or other person subject to these regulations, who, as passenger, member of the crew, or in other capacity, is aboard any ship, other than a vessel 345 2833-2834 CH. 18. QUARANTINE of the Navy, which is subject to quarantine inspection shall depart from such ship without permission of the quarantine officer, except when boarding at sea under competent orders. 2833. Quarantine Inspection of Naval Vessels.—Vessels of the United States Navy may be subjected to quarantine inspection upon arrival at ports of the United States, its possessions, or dependencies when coming from a port known or suspected to be infected with cholera, plague, or yellow fever, or where smallpox or typhus fever is present in epidemic form, and may be detained in quarantine for such disinfection or disinfestation as may be required by reason of disease aboard or exposure to quarantinable disease at the port of departure or call. By arrangement with the Treasury Department, ships of the Navy to which medical officers are attached are ordinarily exempt from quarantine inspection. A certificate furnished by the ship’s medical officer as to the sanitary condition of the vessel and record of communicable diseases is accepted by the quarantine officer in lieu of actual inspection. In case pratique is granted by radio communication the medical officer upon arrival in port must forward the bill of health in duplicate to the quarantine officer, together with a statement as to sanitary condition, including number of cases of any communicable disease on board. A vessel of the Navy without a medical officer is subject to the provisions of quarantine regulations as they apply to merchant vessels. 2834. Quarantine Measures Applicable to Aircraft Flying to Hawaii.—Aircraft proceeding from the United States to Hawaiian ports shall be thoroughly sprayed with an effective insecticide immediately prior to departure, and inspected upon arrival to discover and destroy mosquitoes and other insects, which may have escaped destruction. The object is to prevent the introduction of insect vectors of disease, especially Anophelene mosquitoes, which are not present now in the Hawaiian Islands or in American Samoa. When airship flights from the United States to Hawaiian ports are projected the nearest officer of the United States Public Health Service should be informed in order that he may arrange for the required quarantine treatment. When circumstances do not permit such arrangements the spraying shall be supervised by a naval medical officer, and he shall report to the nearest Public Health Service officer that the quarantine treatment has been conducted in accordance with these instructions. The following is regarded as an effective insecticide: One part of a No. 20 pyrethrum extract in 4 parts of carbon tetrachloride or deodorized kerosene, preferably kerosene, which must have its flash point sufficiently high to avoid fire hazard. 346 SEC. V.—BILLS OF HEALTH 2835-2838 Special attention shall be given protected surfaces, appendages, and inspection accesses on the outside of the ship where mosquitoes may find shelter and survive flight, as well as interior spaces. SECTION V. BILLS OF HEALTH Paragraph Medical Officer to Procure Bill of Health 2835 Between Ports in the United States 2836 From a U. S. Port to a Port in Canal Zone or U. S. Possessions 2837 From a U. S. Port to a Foreign Port 2838 From a Foreign Port to a Home Port 2839 Data Required to Obtain a Bill of Health 2840 Calling at Intermediate Ports. 2841 Bill of Health for Fleet _ 2842 Expense 2843 Where Obtained 2844 Additional Information To Be Furnished Upon Entering Port 2845 2835. Medical Officer to Procure Bill of Health.—In all cases, unless otherwise directed, the medical officer shall procure a bill of health before leaving port (art. 1172 (1) N. R.). 2836. Between Ports in the United States.—Naval vessels clearing from one United States port for another United States port do not ordinarily procure a bill of health for presentation at the port of arrival. Local or State authorities at the port of arrival may, how- ever, require the exhibition of a bill of health under special circum- stances, such as when some epidemic disease exists at the port of departure, and under such circumstances it is advisable for the medical officer to procure a bill of health. 2837. From a U. S. Port to a Port in Canal Zone or U. S. Possessions.- (a) A naval vessel departing from a port in the continental United States for a port in the Canal Zone or United States possessions is not required to procure a bill of health or port sanitary statement at such port of departure, except when plague, cholera, or yellow fever exists, or typhus fever or smallpox prevails in epidemic form, in the port of departure. (b) A naval vessel departing from a port in the possessions or dependencies of the United States for a port in the Canal Zone or other United States possessions is required to procure a bill of health in duplicate at each port of departure. (c) Bills of health or port sanitary statements are issued in United States ports by medical officers of the Public Health Service where available; otherwise by the collector of customs. 2838. From a U. S. Port to a Foreign Port.—Naval vessels sailing from a United States port to a foreign port shall always procure a 347 2839-2841 CH. 18.—QUARANTINE bill of health from the proper authorities and have it visaed by the consular or other representative of the country or countries of ports of call, if such ports can be determined upon prior to sailing. It is sometimes advisable to secure bills of health for several ports to which the vessel might go, when definite information of the exact destination is not procurable. A naval vessel sailing from a foreign port to another foreign port shall likewise procure and have visaed a bill of health. 2839. From a Foreign Port to a Home Port.—A vessel leaving a foreign port for a home port shall obtain a bill of health from a port official and also a United States consular bill of health, at a port where the issue of consular bills of health is customary, or from the United States Public Health officer, if one be stationed there. 2840. Data Required to Obtain a Bill of Health.—The form, United States of America bill of health, sets forth under hand and seal of the officer authorized to sign, certification that the vessel has complied with quarantine rules and regulations and leaves the port of issue bound for stated port of the United States via the designated port of call, if any, under circumstances described, including the name of the vessel; nationality; master’s name; gross tonnage; net tonnage; med- ical officer’s name; number of officers; number of crew; including petty officers; number of officers’ families; number of passengers destined for the United States; number of first cabin, second cabin, and steerage passengers; names of ports visited during the preceding 4 months; statement as to the location of the vessel while in port— wharf, open bay, distance from shore; character of communication with shore; time the vessel was in port; sanitary condition of the vessel; sanitary measures, if any, adopted while in port; sanitary condition of the port and vicinity; and the names of diseases pre- vailing at the port and in the vicinity. The form also calls for entering the number of cases and number of deaths from each of the quaran- tinable diseases during the most recent fortnight for which statistics are available, as well as the date of the last case within the preceding year. 2841. Calling at Intermediate Ports.—Vessels clearing from a foreign port or from any port in the possessions or other dependencies of the United States for any port in the United States, its possessions, or other dependencies, and entering or calling at intermediate ports, must procure at all such ports a bill of health in duplicate signed by the proper officer or officers of the United States. 348 SEC. V.—BILLS OF HEALTH 2842-2845 2842. Bill of Health For the Fleet.—Bills of health for naval vessels in the fleet may be procured for th.8 fleet as a whole by the fleet medical officer, if no diversion of individual ships is contem- plated. Bills of health for individual ships should always be procured, however, in the absence of orders to the contrary, in view of the fact that a ship may at any time be detached from the fleet and ordered to operate singly. 2843. Expense.—Bills of health for naval vessels and indorsement by consular officers are usually extended gratis. Any expense involved in procuring bills of health or in quarantine is a charge against appro- priations not under the Bureau. Quarantine expenses (bills of health and pratique) are a charge against Instruments and supplies, Bureau of Navigation. (For decision as to the liability of a naval vessel for the payment of quarantine charges growing out of a State law, see Official Opinions of the Attorney General, 1906, vol. 25, p. 234.) 2844. Where Obtained.—(a) In the United States a medical officer procures a bill of health by applying in person to the medical officer of the Public Health Service where available, otherwise to the collector of customs. (b) In foreign ports request for a bill of health should be made at the office of the captain of the port (Bureau du Capitaine du Port, Uffizio dell Capitano dell Porto, Capitania del Puerto). (c) The medical officer should take with him bills of health from last port of departure and be prepared to furnish the details given in paragraph 2840. If epidemic or contagious diseases are present in the port at the time of making the request, a visit should also be made to the consul of the nationality of the next port of call, particularly in the Mediterranean, for his visas. 2845. Additional Information to be Furnished Upon Entering port.— On entering port, in addition to the bill of health, the medical officer of the ship shall be prepared to furnish the quarantine officer, if required, with a statement relative to the health conditions prevailing on board ship. Certain diseases of a communicable or infectious character, not included among the quarantinable diseases under the quarantine laws and regulations of the Treasury Department, such as the exanthemata, diphtheria, cerebrospinal fever, etc., will ordinarily be viewed by local or State authorities as constituting quarantinable diseases and their presence on board should be considered as rendering the vessel subject to quarantine restrictions. All such diseases should be fully reported to the inspecting health officer. 2851-2854 CH. 18.—QUARANTINE Paragraph Sunlight.. 2851 Burning 2852 Boiling. 2853 Steam.. 2854 Bichloride of Mercury 2855 Phenol 2856 Solution of Formaldehyde 2857 Formaldehyde Gas 2858 Lime 2859 Chlorinated Lime 2860 Sulphur Dioxide 2861 Carboxide 2862 Hydrocyanic-Acid Gas 2863 Cyanogen-Chloride Gas Mixture 2864 SECTION VI. DISINFECTION AND DISINFECTANTS Physical Disinfectants 2851. Sunlight.—Direct sunlight kills nonspore-bearing patho- genic bacteria in from one to several hours, the time depending upon moisture, temperature, and other conditions. Exposure equivalent to 30 hours is usually required to kill anthrax spores. The ultra- violet rays are the most active, the red and yellow being practically inert. 2852. Burning.—Of unquestioned efficiency but seldom practiced on account of expense. 2853. Boiling.—Very efficient and of wide range of applicability. Nonspore-bearing bacteria are killed almost instantly by a boiling temperature but spores may resist destruction for many hours at 100° C. Boiling for 1 hour in a 1 percent solution of sodium carbonate is efficient for sterilizing surgical and laboratory instruments. 2854. Steam.—(a) Flowing steam (not under pressure) when applied under suitable conditions is an efficient disinfecting agent. The exposure must be continued 30 minutes after the temperature has reached 100° C. (b) Steam under pressure without vacuum will sterilize, provided the process is continued 20 minutes after the pressure reaches 15 pounds per square inch. The air must be expelled from the appa- ratus at the beginning of the process. (c) The best method of applying steam under pressure is in a special apparatus with vacuum attachment, the object of the vacuum apparatus being to expel the air and to promote the penetration of the steam. The process is to be continued for 20 minutes after 350 SEC. 71.—DISINFECTION AND DISINFECTANTS 2855 the pressure reaches 10 pounds to the square inch. A vacuum should be drawn before articles are removed from the sterilizer. (d) Clothing, fabrics, textiles, curtains, hangings, etc., may be treated by either of the above methods as circumstances may demand. (e) Articles injured by steam, such as leather, furs, skins, rubber, trunks, valises, hats and caps, bound books, silks, and fine woolens should not be disinfected by steam. Such articles should be disin- fected by formaldehyde gas or any of the agents mentioned below which may be applicable thereto. Those which will be injured by wetting should be disinfected by a gaseous agent. (f) Clothing, textiles, and baggage which are clean and in good condition, but suspected of infection, can be efficiently and least injuriously disinfected by formaldehyde gas generated by one of the methods described. (g) Textiles which are soiled with discharges of the sick or which are presumably deeply infected must be disinfected by one of the following methods: (1) Boiling, (2) steam, (3) immersion in one of the germicidal solutions. (h) Cooking and eating utensils are always to be disinfected by immersion in boiling water or by steam. Chemical Disinfectants 2855. Bichloride of Mercury.—As a chemical disinfectant corrosive sublimate or bichloride of mercury in solution has been used quite extensively. It has some marked disadvantages, however, which tend to limit its usefulness. It has a destructive action on metals and must be placed in wooden, glass, or earthenware vessels. It can not be used to disinfect any material containing albumen, since it forms inert albuminates. It acts as a mordant and fixes stains in soiled fabrics. It is very poisonous and its solutions should not be used to disinfect dishes to be used later for food. Solutions of bichloride of mercury in distilled water become, after a time, reduced in strength through the formation of oxychloride, and all solutions are incompatible with alkalies and their carbonates, limewater, soaps, and most metallic salts. As a disinfectant bichloride of mercury is commonly used in a strength of 1-1,000, adding to the water used for solution 2 parts per 1,000 of sodium or ammonium chloride. The material to be disinfected should be immersed in the solution (con- tained in an earthenware or wooden vessel) for at least an hour. Walls and floors may be scrubbed down with the solution, which should be allowed to dry on them. 351 2856-2858 CH. 18. QUARANTINE 2856. Phenol.—The standard solution of phenol is a 5 percent solution. To make this solution pure phenol crystals should be melted over a water bath and hot water gradually added. It is an efficient disinfectant and is the standard used for standardizing other disinfectants. Owing to its expense other members of the same group have been introduced for general disinfectant purposes. Among the more efficient and convenient of these is cresol, as liquor cresolis compositus, United States Pharmacopoeia. This may be made by mixing 1 part of cresol and 1 part of soft soap and letting stand over night. The resulting compound makes a perfect solution with water, and 1 in 20 solution is considered equal to a 5 percent phenol solution. Feces, urine, sputum, etc., to be disinfected, should remain in contact with an equal quantity of the cresol compound in 5 percent solution for an hour. A 5 percent solution of the cresol compound is suitable for disinfecting spit kits, contaminated cloth- ing, and the walls and decks of compartments. Lysol, creolin, cyllin, izal, and tricresol are other members of this group, but are too ex- pensive for general use. 2857. Solution of Formaldehyde.—Solution of formaldehyde contain- ing not less than 37 percent of formaldehyde gas may be used in a 5 percent solution (commercial formalin 50 cubic centimeters, water 950 cubic centimeters) as a substitute for bichloride of mercury or phenol, and is useful for the disinfection of surfaces, fabrics, and a great variety of objects, because of its noninjurious character. It is also an excellent deodorant. Formalin to act efficiently must be in at least a 5 percent solution. For instance, if a pint of feces is to be disinfected, 1 pint of a 10 percent formalin solution should be used, the mixture to stand for 1 hour. 2858. Formaldehyde Gas.—(a) Formaldehyde is effective as a surface disinfectant if applied by one of the methods given below. Formal- dehyde gas has the advantage as a disinfectant that it doe3 not injure fabrics or most colors. It is valueless as an insecticide and fails to kill vermin, such as rats, mice, roaches, bedbugs, etc. It is not ap- plicable in the disinfection of holds of large vessels. Formaldehyde is used in the disinfection of rooms, clothing, and fabrics, but should not be depended upon for bedding, upholstered furniture, mattresses, and the like, where deep penetration is required. The temperature should be above 50° F., and there should be at least 60 percent of humidity for efficient formaldehyde disinfection. (b) The method of producing formaldehyde gas by pouring formalin on potas- sium permanganate is one of the most convenient and efficient of the various 352 SEC. VI.—DISINFECTION AND DISINFECTANTS 2859“2860 methods and has largely replaced the more expensive autoclaves and lamps. To prepare a room for disinfection, measure the net cubic space and calculate the amounts of ingredients required. Allow 500 cubic centimeters of formalin and 250 grams of potassium permanganate or 250 grams of barium dioxide for each 1,000 cubic feet of space. Paste up with paper strips all cracks and openings. Then take a pan partly filled with water and place in this a second receptacle of glass or metal containing the permanganate or barium dioxide. Then pour the formalin from a pitcher or bucket on the permanganate crystals or barium dioxide powder. The gas is generated in great amount in a few seconds. The receptacle containing the formalin and permanganate or barium dioxide should be large enough to contain 10 times the volume of formalin, as there is a tendency for the mixture to foam over the sides of the container. The room or compartment should be closed tightly for 6 to 12 hours and then flooded with air and sunshine if possible. (c) Another practical method is that of spraying formalin on sheets. The formalin (40 percent) should be sprayed on sheets suspended in the room in such a manner that the solution remains in small drops on the sheet. Spray not less than 10 ounces of formalin (40 percent) for each 1,000 cubic feet. Used in this way a sheet will hold about 5 ounces without dripping or the drops running to- gether. The room must be very tightly sealed in disinfecting with this process and kept closed not less than 12 hours. The method is limited to rooms or com- partments not exceeding 2,000 cubic feet. The formalin may also be sprayed upon the walls, floors, and objects in the room. 2859. Lime.—Freshly slaked lime must be used because the inert carbonate is formed upon exposure to carbon dioxide in the air. Of limited value aboard ship, whitewash is useful afield. Spore-free bacteria are destroyed in about 1 hour by 3 percent solution of cal- cium hydroxide. For disinfection of feces unslaked lime should be mixed with 4 volumes of water and added to equal volumes of excreta which should remain in contact with the lime for at least 1 hour before disposal. 2860. Chlorinated lime.—It should contain not less than 30 per- cent of available chlorine and is an excellent disinfectant. When the package containing it is opened there should be a strong odor of chlorine. Its efficacy depends on the chlorine it contains in the form of hypochlorite of lime. (a) For a working disinfectant solution, mix 1 pound with 2 gallons of water, allow insoluble matter to settle and use the supernatant liquid. This is satis- factory for mopping floors and for disinfecting feces, sputum, and urine; equal parts of the excreta and disinfecting solution being mixed and allowed to stand for 1 hour. (b) For chlorination of drinking water, dissolve the soluble portions of Yi gram of high-test chlorinated lime of tested chlorine strength in a small volume of water and add this amount to each 36 gallons of water. This should be allowed to act for at least 1 hour before drinking. Consult paragraph 2667 for the method of use for Lyster bags. 353 2861-2862 CH. 18.—QUARANTINE (c) Shower baths.—In order to prevent ringworm and other skin infections of the feet, shower-bath space will be provided with shallow containers in which bathers will immerse their feet for approximately 15 seconds before entering and immediately after leaving the shower bath. (1) Solutions used.—Either one of the following solutions may be used in the containers: 1 High-test calcium hypochlorite (65 percent available chlorine), in solution. It is estimated that 0.2 pound of this chemical to 3 gallons of water will make a solution of the required strength (5,000 parts per million available chlorine). 2 Sodium thiosulphate, 15 percent strength (3% pounds for 3 gallons solution). (2) Containers.—Containers should be at least 2 feet square and of sufficient depth so that 2 inches of solution may be maintained without spilling over the sides when the bather stands in it. The containers should be made of rubber or concrete. No metal should be used. (3) Renewal.—The solution should be maintained at a depth of 2 inches by daily replacement and completely changed once a week. 2861. Sulphur Dioxide.—(a) Sulphur dioxide is both a germicide and an insecticide. For destruction of rats, fleas, lice, mosquitoes, cockroaches, and bedbugs, sulphur dioxide ranks next to hydrocyanic acid gas and cyanogen chloride gas mixture. Sulphur should be burned in shallow iron pots (Dutch ovens) standing in larger fireproof pans or vessels containing water. Better results are obtained from burn- ing the total amount of sulphur in a number of properly distributed small pots, 5 to 10 pounds of sulphur in each, rather than in a few large ovens. Not more than 30 pounds should be burned in the largest pot. The water pans containing the pots should be elevated by bricks or metal supports from the bottom of the com- partment to insure maximum percentage of combustion. The sulphur should be broken and crushed to a state of fine division. Sufficient alcohol should be used to insure ignition. Two pounds of liquefied sulphur dioxide if available may be used as the equivalent of 1 pound of sulphur. An atmosphere containing 4.5 percent of sulphur dioxide may be obtained by the combustion of 5 pounds of sulphur in 100 cubic feet of space. Sulphur dioxide lacks penetrating properties, is of little value as a disinfectant, and is efficient as an insecticide only where penetration is not required and only in the presence of moisture. About 1 pint of water per 1,000 cubic feet of space should be simultaneously volatilized. Sulphur dioxide injures most metals, destroys fabrics, and bleaches materials colored with vegetable or aniline dyes. When used in spaces containing machinery all exposed metal parts should be coated with vaseline. (b) Fumigation standards.—The amounts of sulphur to be burned per 1,000 cubic feet of space are as follows: (1) For destruction of mosquitoes, 2 pounds with exposure 1 hour; (2) lice, 4 pounds with 6 hours exposure; (3) rats and fleas, 5 pounds with 6 hours exposure. For well-filled compartments and storerooms the exposure time should be doubled. 2862. Carboxide Gas.—(a) This gas is a mixture of 9 percent ethylene oxide and 91 percent carbon dioxide. It is not a germicide but is an efficient insecticidal fumigant. Its toxicity for animals is 354 SEC. VI.—-DISINFECTION AND DISINFECTANTS 2863 comparatively low being about one-fiftieth of that for hydrocyanic- acid gas. Carboxide gas has been adopted as a substitute for hydro- cyanic-acid gas, primarily for the extermination of bedbugs and cock- roaches, with the special advantage of relative safety for use by naval personnel aboard naval vessels and at shore stations. The mixture is supplied in steel cylinders under moderate pressure, issuing as a liquid atomized to a fine mist and completely vaporizing within a few minutes. The gas has a distinct ether-like odor which is readily recognized and does not exert any injurious effect on clothing, metals, gold braid, furniture, or foods. (b) Complete detailed instructions relative to the use of carboxide gas will be found in a joint circular letter of the Bureau and the Bureau of Construction and Repair, promulgated under date of April 18, 1935. 2863. Hydrocyanic-Acid Gas.—(a) This gas is lethal to animals and insects, but is not a germicide. This is the most penetrating and toxic of fumigants used for the destruction of rats, vermin, and insects. The gas is generated from sodium cyanide. Watertight barrels are required for large spaces such as the holds of ships; earthenware crocks or jars for smaller compartments. The amounts of sodium cyanide required per 1,000 cubic feet of space and method of disin- festation are: (1) For destruction of mosquitoes, one-half ounce, with exposure one-half hour; (2) rats, mice, and their fleas, 5 ounces with exposure 2 hours; (3) lice, 10 ounces with exposure 2 hours; (4) bedbugs, 5 ounces with exposure 1 hour. In spaces packed with cargo, stores, supplies, etc., the exposure period should be doubled. For each ounce of sodium cyanide 1 % ounces of commercial sulphuric acid, 66 B, and 2 fluid ounces of water are to be used. The calculated quantity of cyanide is placed in a gauze or cheesecloth bag. After preparing and sealing the space to be fumigated, except for a safe opening for retreat of the operator, the required quantity of water is put into the container and the sulphuric acid is added at the last moment. In the case of a ship’s hold or large compartment where one section of an overhead hatch can be left open for the purpose, the barrel containing the freshly mixed water and acid is placed directly below and the bag of cyanide is lowered into it by a rope, after which the hatch is immediately closed and battened down. In fumigating the smaller compartments, crocks are pre- pared with the proper quantities of water and acid and placed in the different compartments. Beginning in the compartment most distant from the final point of exit the cyanide is placed in the acid mixture by hand and the door is quickly sealed. (b) Precautions.—In fumigating with hydrocyanic acid gas special anticyanide gas masks are required; the ordinary military gas mask canister does not afford adequate protection. Hydrocyanic acid gas involves so much danger to personnel that its use is not con- 355 2864 CH. 18.—QUARANTINE templated except in great emergency. Such fumigation should be conducted only with trained and experienced personnel. All other persons must be excluded and accounted for by written statement, and suitable precautions must be taken to prevent the return of any person while preparations are being made for generating the gas, and during the fumigation period until all spaces have been ventilated and pronounced safe for occupancy. Accidents are less likely -with cyanogen chloride gas mixture. 2864. Cyanogen-Chloride Gas Mixture.—(a) This is one of the most penetrating and toxic of fumigants although cyanogen chloride gas in pure form is only approximately half as lethal as hydrocyanic acid gas. Cyanogen chloride is highly lachrymatory, even in non- lethal quantities, so that warning of its presence is given and fumiga- tion with this mixture is therefore less hazardous than fumigation with hydrocyanic acid gas alone. Also, generation of the mixture by the prescribed method is somewhat slower than generation of hydrocyanic acid gas by the method required by quarantine regula- tions, briefly stated in paragraph 2861. Therefore more time is allowed the operator to reach safety. (b) Chemical agents used.— The gas is generated for fumigation purposes by a mixture of hydrochloric acid, water, sodium cyanide, sodium chlorate, and talc. The sodium chlorate and talc may be mixed in the proper proportions and kept in bulk. Sodium cyanide should be kept in original airtight packages. When used in the form of cyanegg the sodium cyanide should be roughly crushed in pieces about half an Inch in diameter but it must not be powdered. The proper quantity is to be prepared separately for each fumigation and then added to the required quantity of sodium chlorate talc mixture. Dilution of the hydrochloric acid with equal parts of water may be done at any convenient time, as the process is not dependent upon the generation of heat. Standard concentration of the gas mixture in any given space is that sufficient to kill an average weight adult rat in not more than 10 minutes. Such concentration requires, per 1,000 cubic feet of space, 0.941 ounce of cyanogen chloride gas and 0.327 ounce of hydrocyanic acid gas, to pro- duce which there will be required 4 ounces of sodium cyanide, 3 ounces of sodium chlorate, 2 ounces of talc, and 17 fluid ounces each of hydrochloric acid and water. (c) Quarantine service standards.—The amounts of ingredients for generation of cyanogen chloride gas mixture per 1,000 cubic feet of space for different purposes, and the required exposure periods, are as follows: (1) For destruction of mosquitoes.— Sodium cyanide jounce. Sodium chlorate % ounce. Talc jounce. Hydrochloric acid 2 fluid ounces. Water 2 fluid ounces. Exposure *4 hour. 356 SEC. VI.—DISINFECTION AND DISINFECTANTS 2864 (2) For destruction of rats, mice, and fleas.— Sodium cyanide 4 ounces. Sodium chlorate 3 ounces. Talc 2 ounces. Hydrochloric acid 17 fluid ounces. Water 17 fluid ounces. Exposure, 2 hours. (3) For destruction of lice, bedbugs, and roaches.— Sodium cyanide 8 ounces. Sodium chlorate 6 ounces. Talc 4 ounces. Hydrochloric acid 34 fluid ounces. Water 34 fluid ounces. Exposure, 2 hours. The above standards apply to empty holds and superstructures. In filled compartments, storerooms, and staterooms, the length of exposure must be doubled. (d) Method of fumigating.— All parts of the vessel should be placed under fumigation simultaneously, but on account of tarnishing effect on highly polished metals the chart room and radio room need not be fumigated in the absence of special reasons for including them. The materials required include tight wooden barrels and tubs, preferably of oak with wooden hoops, for use in holds, and earthenware crocks or wooden buckets, preferably of oak, for smaller compartments. In addition there are required vessels for mixing sodium chlorate and talc; scales for weighing or scoops for measuring, and bags for the mixed ingredients to be placed in the acid. The crocks or buckets containing the acid mixture are to be placed in position in all small compartments and spaces which are to be fumigated, with the bags con- taining the proper amounts of the solid ingredients beside them. Doors, port holes, and other openings except those needed for egress of the operator must be closed and sealed before actual fumigation begins. Prior to placing the chemicals in the acid containers, the officer in charge of fumigation, accompanied by a repre- sentative of the commanding officer of the vessel, shall inspect each compartment to determine that no unauthorized person remains on board. Before the inspec- tion begins a guard shall be placed at the gangway to prevent any unauthorized person from returning. The men who actually place the bags of cyanide, chlorate, and talc in the mixtures of acid and water shall be trained and experi- enced, and the number so employed shall be kept at an absolute minimum. Each of them shall wear and have ready for immediate use a gas mask of approved design equipped with a canister which affords protection against cyanogen chloride gas and hydrocyanic acid gas. When holds and superstructure spaces are to be fumigated at the same time, the holds shall be prepared, the water and acid mixed in the containers, and the other ingredients placed in bags alongside and attached to ropes leading to the main deck. Hatch covers, with the exception of one section of each open for the purpose of handling the rope, shall be in place and covered with tarpaulin. Staggering of hatch covers is prohibited. As soon as the placing of the chemicals in the acid mixtures in superstructure compartments and rooms has been completed, the generation of gas in the holds shall be begun by lifting the 357 2871 CH. 18.—QUARANTINE bags of chemicals by means of the above mentioned ropes and lowering them into the acid containers, and the remaining hatch coverings shall be quickly replaced and covered with tarpaulin. Fumigation of crew’s compartments, storerooms, staterooms, and other small compartments below the main deck shall be started when possible before the larger volumes of gas required in holds or large spaces are generated. (e) Safety precautions.— All persons engaged in opening up after fumigation, who may be in any manner exposed to the gas shall wear gas masks of the prescribed type. Specific arrange- ments must be made for debarkation or other safe disposition of the crew, espe- cially if one or two compartments are to be fumigated. A written statement must be obtained from the commanding officer that the vessel is ready for fumi- gation and that all personnel of the ship have been accounted for as not being in or on the vessel except men specifically detailed to assist in the fumigation and to stand by in the engine room or on deck as may be necessary under insurance requirements. Compartments above deck should have danger labels pasted over the doorways after fumigation has commenced. No one shall be permitted to enter the various compartments until entry is declared safe by the medical officer in charge of fumigation. Before declaring the vessel safe for entry he shall per- sonally visit each compartment, except that in the discretion of the medical officer, the holds may be inspected by the chief fumigator accompanied by a trained employee, each of whom shall enter the holds and report their freedom from dangerous quantities of gas before release. The medical officer in charge of fumigation shall certify in writing that the vessel is safe for entry. Compart- ments shall not be declared safe until absence of the lachrymatory effect of the gas has been positively determined. Personnel engaged in emptying barrels, tubs, crocks, and other containers used for generating the gas shall be required to use gas masks when removing and emptying the same. Employees of the United States Public Health Service engaged in cyanogen chloride and hydrocyanic acid gas fumigation are required to undergo a course of instruction in the use and care of gas masks and demonstrate ability to use the masks properly, before they are permitted to engage in the fumigation of vessels. At quarantine stations, a standard fumigation crew consists of a chief fumigator, two assistant chief fumigators, and five laborers, including a truck driver when necessary. The quarantine regulations require immediate dismissal from the service of any opera- tor who fails to have a gas mask ready for use while engaged in fumigation work. Paragraph How to Compute Air Space - 2871 Preparation for Fumigation 2872 Expense of Fumigation 2873 Disinfecting Stations 2874 SECTION VII. FUMIGATION OF VESSELS 2871. How to Compute Air Space.—For computing the air space of a vessel a registered ton should be estimated as containing 100 cubic feet. A vessel of 1,000 net tonnage would, therefore, contain 100,000 cubic feet of air space in the holds alone, since net tonnage indicates 358 SEC. VIII.—DESTRUCTION OF VERMIN 2872-2874 the cargo carrying capacity in contradistinction to the gross tonnage, which indicates the ship’s total cubic capacity. The cubic capacity of crews’ quarters, cabins, engine room, poop deck, or other above- deck compartments has to be computed for each individual com- partment. 2872. Preparation for Fumigation.—All dead space in the vessel must be opened up to permit free circulation of air and fumigant. All dunnage and loose materials should be arranged in compact order and placed on elevated platforms to avoid rat harborage. Pipe casing should be opened up, and from one end of the vessel to the other a certain number of limber boards should be removed to permit pene- tration of the gas into the bilges. Any planked over space between the outer and inner sheathing should be freely opened. Attention should be given to lifeboats. These are often infested by rats and vermin. Preferably, lifeboats should be cleaned and flooded with water prior to fumigation. Close attention should be given to the poop deck, which frequently contains a heterogeneous collection of litter, and to all spaces in the superstructure where rats may seek refuge. In general the engine room and fireroom do not harbor rats but when infection by plague is suspected they should be fumigated. 2873. Expense of Fumigation of Naval Vessels.—The cost of fumigation and disinfection of naval vessels is a charge against the Bureau of Construction and Repair; not against the Bureau of Medi- cine and Surgery. 2874. Disinfecting Stations.—Quarantine stations operated by the United States Public Health Service are prepared to fumigate and disinfect naval vessels when called upon. Smaller stations should be notified in advance in order that the fumigating materials may be procured. Absence of wharfage facilities is not an indication of incapacity of a station to perform fumigation and disinfection. See Circular Letter Y, appendix D, for current list of disinfecting stations. SECTION VIII. DESTRUCTION OF VERMIN Paragraph Agents for Destruction of Vermin 2881 Mosquitoes 2882 Rats 2883 Fleas 2884 Lice. 2885 Roaches 2886 Bedbugs 2887 Responsibility for Control of Insect Infestation 2888 359 2881-2883 CH. 18. QUARANTINE 2881. Agents for Destruction of Vermin.—The following agents are useful for the destruction of vermin: (1) Hydrocyanic acid gas. (See par. 2863.) (2) Sulphur dioxide. (See par. 2861.) (3) Steam. (See par. 2854.) (4) C arb oxide gas. (See par. 2862.) (5) Cyanogen-chloride gas mixture. (See par. 2864.) (6) Pyrethrum. (Navy standard liquid insecticides.) (7) Cresol. The Navy standard liquid insecticide consists of a mixture of 0.3 percent pyrethrins and 2.5 percent B-butoxy, B'-thiocyanodiethyl ether in a straight run product from a paraffin base crude having an initial boiling point not below 177° C. and an end point not exceeding 266° C. These initial and end boiling points give a fraction of proper volatility and suspension. An effective spray may be made by an infusion of 1 pound of pyrethrum flowers to 1 gallon of kerosene or similar hydrocarbon oil. Pyrethrum sprays are effective against all insects. Cresol 5 percent in kerosene may be used, but it is a better germicide than insecticide. 2882. Mosquitoes.—The fumes of burning pyrethrum may be used to destroy mosquitoes when the more lethal fumigants are not avail- able or cannot be used. Four pounds per 1,000 cubic feet of space with 2 hours exposure will kill or stupefy mosquitoes, which should be swept up and burned. Pyrethrum stains walls and paper. In suit- able spaces and for destroying mosquitoes in aircraft pyrethrins mixed with kerosene or kerosene and carbon tetrachloride may be used (pars. 2817, 2835, 2881, and 2885). 2883. Rats.—Where fumigation with cyanogen chloride gas or with sulphur dioxide is impracticable, an endeavor should be made to reduce the rat population to a minimum by trapping, poisoning, rat- proofing compartments, and preventing access to foods and contents of refuse cans. Red squill is an effective rat posion when it is of standard toxicity. Ratproofing of ships has proved as effective as ratproofing of houses, warehouses, wharves, etc. See United States Public Health Service pamphlet, entitled “The Rat Proofing of Vessels/’ ob- tainable by requisition on naval medical supply depot. As a rule more success is had with ordinary snap traps than with the more expensive cage traps. Rubber gloves should be used when cleaning and baiting traps to prevent imparting odor of the human 360 SEC. VIII.—DESTRUCTION OF VERMIN 2884-2885 body. Suitable baits include cheese, bacon rind, skin of a ham, grain, or other food not easily obtained by rats. The traps should be placed in or at the openings of recognized rat runways. A sustained trapping campaign, with a sufficient number of traps, placed daily in compartments where there are signs of infestation will effect a marked reduction in the number of rats on board in a few weeks, and if access to food is prevented rats can practically be eliminated by trapping provided measures are taken routinely to prevent rats from gaining entrance to the vessel from shore sources over unguarded mooring lines and gangways and in stores. Poisoning is useful at times. Powdered barium carbonate may be used in the proportion of about 25 percent by weight, combined with corn-meal mush or boiled rice, to which syrup may be added. Fresh portions should be set out daily because the barium imparts a bitter taste to sour bait. A mixture of plaster of paris, 6 parts; powdered sugar, 1 part; and flour, 2 parts, may be placed in dry places in open dishes. To make this bait more attractive the edges of the dishes may be smeared with oil in which sardines have been packed. Poisoning aboard ship has the disadvantage that access to dead rats behind sheathing and elsewhere may be difficult. 2884. Fleas.—When destruction of fleas is indicated on account of suspected infection by plague, fumigation with a highly lethal gas is required. Fleas may be destroyed by: (1) Hydrocyanic-acid gas; (2) carboxide gas; (3) sulphur dioxide; (4) crude petroleum (fuel oil), kerosene oil, or gasoline; (5) pyrethrum; (6) and emulsion of kerosene oil made as follows: Kerosene 20 parts, soft soap 1 part, water 5 parts. The soap is dissolved in the water by aid of heat and the kerosene oil gradually stirred in the hot mixture. 2885. lice.—(a) Lice and their eggs are destroyed by dry heat at 54° C. to 57° C., in 5 to 10 minutes, and by moist heat at 60° C. The viruses of typhus fever, trench fever, and relapsing fever are killed by moist heat at 71° C. with exposure for 30 minutes. Flat- iron heat with careful attention to seams suffices. Steam under pres- sure with initial vacuum should be used when practicable. Garments and articles of leather, rubber, furs, books, etc., which cannot be steamed without damage may be subjected to dry heat, with precau- tions to avoid scorching. While destruction of lice is simple in iso- lated instances, administration difficulties arise when large numbers of persons are infested. Repellents are therefore sometimes useful. Garments may be treated with kerosene, kerosene and cresol mixture, gasoline, carbon bisulphid, turpentine, dichlorethylene or tetrachlore- 361 2886 CH. 18. QUARANTINE thane, and Navy standard insecticide, depending upon what is avail- able. Powdered naphthalene or naphthalene with 2 percent each of creosote and iodoform may be dusted into garments two or three times a week. Flowing steam can be utilized in a ship’s laundry-washing machine, barrel or oil drum, with exposure for 30 minutes after the temperature has been brought up to 100° C. (b) In addition to the treatment of the clothing of infested persons, it is necessary to wash the body with liquid soap, made by boiling soap chips 1 part, in 4 parts water, and adding kerosene 2 parts. After this mixture jellies, use by mixing 1 part with 4 parts of warm water. (c) In the case of a male person infested with Pediculus capitis, the hair should be clipped short. In the case of a female, the hair should be treated by a thorough application of a mixture of equal parts of kerosene oil and vinegar. The head should then be covered with a towel and after a lapse of a half hour, washed with warm water and soap. The kerosene kills the lice and the vinegar loosens the nits. Pyre thrum may also be used (par. 2881). (d) Pediculi pubis should be destroyed by clipping the pubic hairs, and by application of mercurial ointment (50 percent) or kerosene oil. 2886. Roaches.—Cockroaches as well as other vermin are destroyed by fumigation with cyanogen chloride gas mixture and by sulphur dioxide where penetration can be secured. Ordinarily, other methods must be depended upon to suppress roaches. Cleanliness, storage of food in places and containers inaccessible to roaches and elimination of hiding places are important. Oily sprays are useful to kill roaches in sight and to drive others from hiding places into the open, where the spray may be directed upon them. Five percent or more cresol in kerosene is suitable. Kerosene or deodorized kerosene, having a flash point above 52° C., containing 15 percent of 20-1 pyrethrum concentrate and 5 percent of lethane, is more effective. A 20-1 con- centrate contains in 1 gallon the pyrethrins from 20 pounds of Pyre- thrum cinerariaejolium, the flowers assaying not less than 0.9 percent pyrethrins. Lethane is a commercially produced aliphatic thiocyanate. Many of the insecticidal sprays on the market contain one or both of these ingredients. Sodium fluoride is toxic if ingested. The powder should be sprinkled or blown into cracks, cabinets, and other hiding places, into spaces under and around drawers and on shelves, where it will not be swept up or removed.. Reduction in number of roaches is effected gradually as the sodium fluoride adhering to their feet and bodies in tracking through the powder is licked off and swallowed. Sodium fluoride may also be mixed with fine com meal. Roaches 362 SEC. VIII.—DESTRUCTION OF VERMIN 2887 breed slowly; probably not more than one or two generations a year are produced. Under some circumstances trapping is useful. A basin or bowl with steep sides from which roaches cannot climb, may be baited with mucilage, stale beer, or sweetened meal, a stick being placed to serve as a runway to the rim. Plaster of paris mixed with 3 or 4 parts of flour may be placed in a flat dish with a plate of water near by to encourage the roaches to drink and set any plaster swallowed. The use of the power spray greatly increases the effectiveness of all liquid insecticides. 2887. Bedbugs.—Fumigation with cyanogen chloride gas mixture is effective but seldom justified on board ship when destruction of bed- bugs is the principal reason for fumigating. Infested rooms and com- partments may be sealed and fumigated with sulphur dioxide without danger to persons in adjacent spaces, but it is difficult to secure penetra- tion into all hiding places. The habits of bedbugs must be borne in mind. Their breeding and hiding places are often at some distance from the bed or bunk in which a blood meal is sought; in cracks and crevices in walls, furniture, stanchions, suitcases, closets, under linoleum, etc. The principal hiding place between molts may be in another compart- ment or passageway. Eggs hatch in 7 to 10 days, releasing yellowish white larvae which become mature bedbugs only after the skin is shed five times. At least one blood meal is required before each molt, without wliich no change takes place, so that progress to maturity and further production of eggs varies from 7 to 8 weeks to a long and indefinite period. Eradication of bedbugs requires destruction of eggs and mature insects. Careful search must be made for possible hiding places. Crevices should be closed and sealed with paint. Bedbugs and their eggs are destroyed by scalding hot water and soap suds which should be used freely where damage will not result. Kerosene, gasoline, and other penetrating petroleum oils are generally useful. Kerosene containing 5 percent or more cresol is effective against bed- bugs and their eggs, applied by painting liberally into cracks and other openings, and by spraying. (Kerosene containing 5 percent cresol is a better germicide than insecticide.) Mixtures of deodorized kerosene, pyretkrins, and lethane have a less objectionable odor. The eggs and bugs in all stages of development succumb to dry and moist heat above 45° C. in a few minutes. Aboard ship it is some- times practicable to raise the temperature of infested staterooms to 49° C. by means of electric heaters. Piping and springs of bunks can be heated with a gasoline torch, with scalding hot water, or 363 2888 CH. 18. QUARANTINE treated with flowing steam. Mattresses may be disinfected by steam or subjected to dry heat with less resulting damage. As a rule, bed- bugs do not gain access to the interior of kapok or inner-spring mat- tresses covered with properly closed ticking of heavy material. Where outlets are available a steam hose is useful for applying heat to possible hideouts, especially if the room or compartment is to be renovated. Articles which will not be damaged by heat and moisture may be exposed to flowing steam for 30 minutes in a bag disinfector made of heavy canvas. 2888. Responsibility for Control of Insect Infestation.—Insect infes- tation not kept at a minimum is an index of poor construction, poor administration of cleanliness, ineffective use of known insecticides, or a combination of all three. The medical officer and his assistants should prepare themselves to assist and guide insect eradication but cannot be held to complete responsibility for action which must be taken by nonmedical personnel involved. 364 CHAPTER 19 DEATHS AND RESULTING DUTIES Paragraphs Section I. RECORDING AND REPORTING OF DEATH __ 2901-2911 H. INVESTIGATION OF DEATH. 2916-2918 m. NOTIFICATION TO NEXT OF KIN 2921-2924 IV. PREPARATION OF REMAINS 29S1-2941 V. TRANSPORTATION OF REMAINS.. 2951-2961 VI. CORPSE ESCORT 2966-2978 VH. FUNERAL EXPENSES. 2975-2998 Vm. FUNERALS AND FUNERAL FLAGS 2998-2999 SECTION L RECORDING AND REPORTING OF DEATH Paragraph Reporting of Death to Department 2901 Report of Disposition of Remains 2902 Recording of Death 2903 Form N 2904 Death Occurring While on Leave, etc 2905 Death of Retired and Fleet Reserve Personnel 2906 Payment for Civil Death Certificate 2908 Death of Personnel at St. Elizabeths Hospital 2909 Life Insurance Report 2910 Death of Reservist Following Release from Active Duty 2911 2901. Reporting of Death to Department.—(a) When a death occurs an immediate report by dispatch shall be made to the Secretary of the Navy, giving the following information: (1) Full name; (2) rank or rating and service number; (3) branch of service; (4) in the case of a reservist, whether or not on active duty; (5) date, place, and cause of death; (6) line of duty and misconduct status; (7) full name and relationship of next of kin; (8) address of next of kin; (9) whether or not next of kin has been notified; (10) what disposition has been or will be made of remains, or where the remains are being held; (11) pay per month; (12) full name and address of beneficiary; (13) whether or not the deceased carried United States Government life insurance and date to which premiums have been paid. In case full information under any of the foregoing headings must await later investigation or determination, the dispatch shall be sent with what- ever data are available, and supplemented with complete information at the earliest possible date (art. 908 (2), N. R„). 365 2902-2905 ch. 19.—deaths and resulting duties (b) Hospitals.—As article 1513, Navy Regulations, provides that the commandant shall report to the Secretary of the Navy, by dis- patch, the death of any officer or enlisted person that may occur at the station under his command, in order to prevent unnecessary dupli- cation of dispatches reporting deaths, arrangements should be made with the commandant so that but one dispatch, either from the hos- pital or the commandant and directed to the Secretary of the Navy, shall be sent to the Navy Department. Such dispatch, when received by the communication office, Navy Department, will be copied and copies Bent to the Bureau, the Bureau of Supplies and Accounts, and to the Bureau of Navigation or the Commandant, United States Marine Corps. (c) Ships and stations.—When a death occurs at a naval activity, other than a naval hospital, the medical officer or in his absence a rep- resentative of the medical department shall furnish the proper official with a memorandum report containing the information required in subparagraph (a) above. 2902. Report of Disposition of Remains.—(a) A letter report of the disposition of remains of all deceased members of the naval service, including retired and reserve (and of any other deceased person for whom an expense chargeable to Medical Department funds has been incurred), shall be made to the Bureau by the medical officer of the activity having cognizance of the case. (b) A report also shall be submitted by the medical officer of any activity which has received such remains for any purpose. (c) See Circular Letter F in appendix D of this manual for the form of this report and instructions for its preparation. 2903. Recording of Death.—Accurate recording of death on vessels of the Navy is required by articles 20 (3) and 908 (1), Navy Regu- lations. The medical officer of each ship and shore station shall furnish the proper official with a memorandum report of each death in the command for entry in the official log. Such report shall include the name, rank or rating, and the exact time and cause of death, when they can be determined. At naval hospitals such entry shall be made in the journal of the officer of the day. 2904. Form N.—Certificate of death (Form N) shall in each in- stance be made out in accordance with instructions printed on the form and a copy shall accompany the body on each transfer. 2905. Death Occurring While on Leave, etc.—(a) When an officer, nurse, or enlisted man of the Navy or Marine Corps dies while on leave, or in a civilian hospital at home or abroad, or under other circumstances where the services of a medical officer of the Navy were not available, the medical officer of the ship or station to which 366 SEC. I. RECORDING AND REPORTING 2906-2909 the deceased was attached shall obtain a certificate of death from the proper civil authorities. The medical officer shall then prepare Form N and forward it to the Bureau, together with the supporting papers. (b) For persons on waiting orders, on detached or independent duty, or not directly attached to any command, the medical officer of the naval district within which the individual dies shall comply with the above instructions. (c) It is the duty of any medical officer having knowledge of a death which appears not to have been reported as above provided, to notify the Bureau, giving such facts as may be in his possession. 2906. Death of Retired and Fleet Reserve Personnel.—(a) Certificates of death in the cases of officers and enlisted men on the retired list of the Navy and Marine Corps shall be prepared and forwarded by the medical officer having cognizance of the case. In the event that such officer or man was not under the professional care of a medical officer of the Navy at the time of his death, the medical officer of the district within which the individual died shall obtain a certificate of death from the proper civil authorities, and shall prepare and forward Form N to the Bureau, together with the supporting papers. (b) Official reports of death shall be prepared for transferred members of the Fleet Reserve (16- and 20-year men) in the same manner as for personnel on the retired list. Official reports of death shall not be prepared for other members of the United States Reserve on inactive duty, but when information is received concerning such a death, the information obtainable shall be forwarded to the Bureau (par. 2911). 2908. Payment for Civil Death Certificate.—Under authority of a decision of the Comptroller General (No. A-39800, Dec. 17, 1931) when fees for civil death certificates are required to be paid in advance, such payments may be made from personal funds and reimbursement obtained from Navy disbursing officers on Sundry Expense Account (S. & A. Form 326) showing the name, rank, or rating of the deceased person, date of death, and a statement that the copy of death certifi- cate was required for official use, and accompanied with receipt for the expenditure or statement that the certificate bears a notation of the amount paid, date of payment, and signature of the issuing officer. The appropriation chargeable is Medical Department, Navy. 2909. Death of Service Personnel at St. Elizabeths Hospital.— Upon the death of an officer or enlisted man of the Navy or Marine Corps in St. Elizabeths Hospital for the Insane, a report of death shall, be prepared by the medical officer of the Navy assigned to duty in that institution, or in the absence of such medical officer a report of death 367 2910-2917 CH. 19.—DEATHS AND RESULTING DUTIES will be prepared and signed by the Surgeon General of the Navy upon information supplied by that institution. 2910. Life Insurance Report.—All mortuary reports (life insurance) are prepared by the Bureau (par. 741). 2911. Death of Reservist Following Release from Active Duty.—(a) From other than injury.—Should the disability of a reservist (other than injury), incurred while on active duty, result in death after the expiration of the period of active duty, but before release from hospital or the care of the Navy, the facts in the case shall be reported to the Bureau, by dispatch, in the following form: To Bureau of Medicine and Surgery, Navy Department, Washington, D. C.: (name) (rating) Naval (or Marine Corps) Reserve died this hospital (date) after expiration period of active duty but as a result of disease incurred while on active duty next of kin notified and directed to telegraph Bureau of Medicine and Surgery instructions for disposition of remains. (b) From injury.—Should death result from physical injury in- curred while on active duty, but after the expiration of the period of active duty and while the case is still under Navy care, the facts in the case shall be reported to the Bureau and to the Employees’ Compensation Committee, Washington, D. C., by dispatch, using the following form in both dispatches: To Bureau of Medicine and Surgery and to U. S. Employees' Compensation Com- mission: (name) (rating) Naval (or Marine Corps) Reserve died this hospital (date) after expiration period of active duty as result of injury (or injuries) received while on active duty next of kin notified and directed to telegraph Bureau of Medicine and Surgery instructions for disposition of remains. SECTION II. INVESTIGATION OF DEATH Paragraph Court of Inquiry or Board of Investigation 2916 Identification Tag; Fingerprint 2917 Postmortem Examination and Autopsy 2918 2916. Court of Inquiry or Board of Investigation.—Whenever loss of life occurs from accident or under peculiar or doubtful circum- stances, a court of inquiry or a board of investigation should be ordered to investigate fully and report on the circumstances and facts, and also to give an opinion and to make such recommendation as may be appro- priate. The court of inquiry or board of investigation is held in accord- ance with the provisions of chapter X, Naval Courts and Boards. 2917. Identification Tag; Fingerprint.—(a) Whenever a body is found with an identification tag on it, a rolled impression of the right index finger shall be taken and compared with the impression on 368 SBC. m. NOTIFICATION TO NEXT OF KIN 2918-2921 the tag, in order that the identity of the body may be positively established. The skin on the finger tips of the bodies of men which have been recovered from water will be greatly wrinkled or shriveled, so that without some treatment the making of satisfactory finger- prints may be difficult and even impossible. This may be overcome by injecting water with a hypodermic syringe beneath the skin of the bulb of the finger. This will smooth out the skin for the impression (par. 1573). (b) Cases have occurred in which, by reason of similarity of names and resultant transfer with wrong service records, the identity of a deceased person has been erroneously established. Fingerprints shall be invariably taken in the maimer prescribed above and com- pared with the prints found in the service record. 2918. Postmortem Examination and Autopsy.—In all cases of death occurring in the Navy under unnatural or suspicious circum- stances, or where the cause of death is obscure or not apparent and a decision as to origin affecting pension or gratuity is involved, the medical officer shall recommend to the commanding officer such post- mortem examination or autopsy as may be required in determining the exact cause of death. In all such cases the autopsy must be per- formed in a manner requiring no more disfigurement of the body than is necessary to obtain the evidence necessary (art. 1841 (5), N. R.). The results of all autopsies shall be fully recorded in the reports of death and health records. SECTION HI. NOTIFICATION TO NEXT OF KIN Paragraph Hospital Within the Continental United States 2921 Hospital Outside the Continental United States 2922 Ship or Station Within the Continental United States 2923 Ship or Station Outside the Continental United States 2924 2921. Hospital Within the Continental United States.—(a) When a death occurs in a naval hospital within the continental United States, or when such hospital has taken charge of the remains, the hospital shall notify, by dispatch, the next of kin or legal representa- tive of the deceased, if residing within the United States, and make disposition of the remains as may be requested, without reference to the Bureau, unless transportation beyond the continental limits of the United States, is involved, or the deceased is not entitled by law to burial or transportation at public expense. Where the address of the next of kin is outside of continental United States, the next of ldn will be notified by the Navy Department on receipt of the dispatch addressed to the Secretary of the Navy required by paragraph 2901. Disposition of remains in such cases shall await the instructions of the 369 2921 CH. 19.—DEATHS AND RESULTING DUTIES Bureau or the Commandant, Marine Corps, as the case may be. The following form of dispatch shall be employed for notification of next of kin of deaths of officers, nurses, reserve nurses, and enlisted men on active duty in the Navy; of officers, nurses, and enlisted men on the retired list of the Navy who were on active duty at the time of their death; and of officers and enlisted men of the Naval or Marine Corps Reserve who were on active duty at the time of their death: To next of kin: Deeply regret to advise that your (relationship) (name) U. S. died (date and cause). Telegraph naval hospital immediately whether you desire body buried locally or sent home. Burial can be made by Navy with military honors in (name of cemetery used by hospital) or forwarded to any national cemetery you designate. If interred locally by Navy all expenses will be paid. If sent home expenses of prepararion, encasement, and transportation will be prepaid and reasonable necessary funeral expenses not exceeding $50 reimbursed on application to Bureau of Medicine and Surgery, Navy Department. Escort of one person will accom- pany remains home if requested. (b) The following form of dispatch will be employed for notifica- tion of next of kin of deaths of officers and enlisted men on active duty in the Marine Corps; of officers and enlisted men on the retired list of the Marine Corps who were on active duty at the time of their death; and of accepted applicants for enlistment in the Marine Corps: Deeply regret to advise that your (relationship) (name) U. S. Marine Corps died (date and cause). Telegraph naval hospital immediately whether you desire body buried locally or sent home. Burial can be made by Navy with military honors in (name of cemetery used by hospital) or forwarded to any national cemetery you designate. If interred locally by Navy all expenses will be paid. If sent home expenses of preparation, encasement, and transportation will be prepaid and reasonable necessary funeral expenses not exceeding $50 reimbursed on application to Head- quarters, Marine Corps. Escort of one person will accompany remains home if requested. (c) The following form of dispatch shall be employed for notifica- tion of next of kin of deaths of retired officers, nurses, and enlisted men of the Navy and Marine Corps, who were on inactive duty at the time of their death; of officers and enlisted men of the Naval and Marine Corps Reserves (including transferred men of the Fleet Re- serves) on inactive duty (except those retained for treatment follow- ing expiration of active duty period); and of destitute patients: 370 SEC. III.—NOTIFICATION TO NEXT OF KIN 2921 Deeply regret to advise that your (relationship) (name) died (date and cause). Please telegraph naval hospital immediately what dispo- sition you desire made of remains. Regret Navy cannot defray any expense of preparation, encasement, or transportation. (d) The following form of dispatch will be employed for notifi- cation of next of kin of deaths of officers and enlisted men of the Naval or Marine Corps Reserve, who were transferred to a naval hospital during a period of active or training duty, but whose deaths occurred in hospital after expiration thereof: Deeply regret to advise that your (relationship) (name) Naval (or Marine Corps) Reserve died (date and cause). Telegraph immediately Bureau of Medicine and Surgery, Navy Department, Washington, D. C., whether you desire body buried locally or sent home. Burial can be made by Navy in (name of cemetery used by hospital) or forwarded to any national cemetery you designate. If interred locally by Navy all expenses will be paid. If sent home expenses of preparation, encasement, and transportation will be prepaid and reasonable necessary funeral expenses not exceeding $50 reimbursed on ap- plication to Bureau of Medicine and Surgery, Navy Department. Regret escort cannot be sent with body. (e) The following form of dispatch shall be employed for notifica- tion of next of kin of deaths of former enlisted men of the Navy or Marine Corps retained in a naval hospital for treatment after discharge from the service: Deeply regret to advise that your (relationship) (name) (former rating) died (date and cause). Telegraph naval hospital immediately whether you desire body buried locally or sent home. Burial can be made by Navy with military honors in (name of cemetery used by hospital) or forwarded to any national cemetery you desig- nate. If interred locally by Navy all expenses will be paid. If sent home ex- penses of preparation, encasement, and transportation will be prepaid and reasonable necessary funeral expenses not exceeding $50 reimbursed on application to Bureau of Medicine and Surgery, Navy Department. Regret escort cannot be sent with body. (f) The following form of dispatch shall be employed for notifica- tion of next of kin of deaths of Veterans’ Administration patients: Deeply regret to advise that your (relationship) * (name) a Veterans’ Administration patient, died (date). Please telegraph naval hospital immediately whether you desire body interred in national cemetery or sent home. If interred in national cemetery all expenses will be paid by Government. If sent home all expenses of preparation and transporta- tion will be prepaid and a small amount may be allowed by Veterans’ Administra- tion for burial expenses. (Note.—Ascertain from regional director which national cemetery to desig- nate.) 371 2922-2924 ch. 19.—deaths and resulting duties (g) The following form of dispatch shall be employed for notifica- tion of next of kin of deaths of pensioners: Deeply regret to advise that your (relationship) (name) died (date and cause). Please telegraph naval hospital immediately what disposition you desire made of remains. Interment can be made by Navy in (name of cemetery used by hospital) at Government expense but law prohibits payment of expenses for transportation home or to another locality. 2922.. Hospital Outside the Continental United States.—Wffien a death occurs in a naval hospital outside the continental United States the Navy Department will notify the next of kin, if residing in the continental United States or elsewhere than in the locality where death occurs, on receipt of the dispatch notification of death addressed to the Secretary of the Navy, and disposition of remains shall await the instructions of the Bureau or the Commandant, Marine Corps, as the case may be. However, should the address of the next of kin be local to the hospital, the hospital then shall notify the next of kin, inform the Secretary of the Navy by dispatch as to dis- position of remains desired, and await instructions. 2923. Ship or Station Within the Continental United States.—When a death occurs on board a ship in a port within the continental United States, or at a station (other than a hospital) within the continental United States, the medical officer shall prepare a dis- patch as indicated below for delivery to the proper authority for transmittal to the next of kin or legal representative of the deceased: Deeply regret to advise that your (relationship) (name) U. S. Navy (or Marine Corps) died — (date and cause). Telegraph Bureau of Medicine and Surgery (or Commandant, Marine Corps), Navy Department, Washington, D. C., immedi- ately whether you desire remains interred in naval or national cemetery or sent home. If interred by Navy all expenses will be paid. If sent home expenses of preparation, encasement, and transportation will be prepaid and reasonable necessary funeral expenses not exceeding $50 reimbursed on appli- cation to Bureau of Medicine and Surgery, Navy Department (or Head- When remains have been transferred to a naval hospital the above dispatch shall be modified to request the next of kin to communicate directly with the commanding officer of such hospital. 2924. Ship or Station Outside the Continental United States.—Wlien death occurs on board a ship in a port outside the continental 372 SEC. IV. PREPARATION OF REMAINS 2931 United States, or at sea, or at a station outside the continental United States, the Navy Department will notify the next of kin upon receipt of the dispatch notification of the death addressed to the Secretary of the Navy. SECTION IV. PREPARATION OF REMAINS Paragraph Inspection of Remains 2931 Necessity for Embalming 2932 Method of Embalming 2933 Brachial-femoral-carotid Method of Arterial Injection 2934 Cavity Injection 2935 Aortic Method of Arterial Injection 2936 Pickling, Injection of Full-strength Formaldehyde Solution, Etc 2937 Embalming Fluid 2938 Overseas Shipment, Additional Preparation for 2939 Clothlng___ 2940 Encasement _ 2941 2931. Inspection of Remains.—(a) The remains of the dead shall, whenever practicable, be prepared for interment or for shipment under the supervision of a medical officer of the Navy, who shall determine by final inspection in each instance that embalming, cleansing, shaving, and dressing of the body have been properly per- formed, and that the clothing and encasement meet the requirements of the occasion (par. 2940 and art. 1841 (3), N. R.). If practi- cable, there should be two inspections: The first, after embalming has been completed, but before the body has been clothed, as to the efficacy of the embalming process; the second, after the body has been clothed and encased, as to general appearance, completeness, correctness and condition of uniform and clothing, position in casket and condition of casket. The conditions noted on such inspection should be made the subject of a memorandum report for file with the record of the deceased. New clothing shall be obtained, if neces- sary, and charged to the appropriation care of the dead (art. 1841 (5), N. R.). (b) In no instance should a body be released for shipment until the inspecting officer is satisfied it is so preserved that it may be reasonably expected to reach its destination in proper condition. Whenever necessary, the body should be held for repeated attention until its condition is satisfactory, as it is better that there should be complaints regarding delays in shipment than of faulty embalm- ing or improper encasement. If for any unusual reasons, such as long immersion in cases of drowning, or where the body has reached the undertaker after long delay, satisfactory results cannot be ob- 373 2932-2933 ch. 19.—deaths and resulting duties tained, the relatives should be informed of the circumstances in advance, and the casket should be sealed and plainly marked “Not to be opened.” 2932. Necessity for Embalming.—(a) The regulations adopted in in May 1915, by the Conference of State and Provincial Boards of Health do not require embalming bodies where the destination or place of final interment will be reached within 24 hours after death, unless dead of certain communicable diseases hereinafter mentioned. Nevertheless, all bodies prepared for interment or for shipment under the supervision of a medical officer of the Navy shall be thoroughly and completely embalmed by the method described below, and the embalming fluid described in paragraph 2938 shall be used in all cases, in order that the body may be able to withstand unusually high temperatures or delays in transportation and arrive at its des- tination, after weeks or months, in good condition. However, when the embalming is done in the United States by a licensed undertaker, he may be allowed to use the standard embalming fluid with which he is familiar. (b) It is incumbent on all Navy embalmers to exercise great care in the preservation of bodies and their preparation for the casket, so that they may reach relatives without signs of decomposition, showing evidence of respectful and careful handling, and with the so-called natural appearance well preserved. Service embalmers who may be acquainted with civilian practice should remember that methods which have proved equal to preserving remains for a few days in temperate regions may be entirely inadequate to preserve bodies for months in the Tropics. (c) Before beginning the injection, complete the shaving and modeling of the features. Vaseline, to which has been added and thoroughly triturated, 10 percent of eugenol and 10 percent of thymol, will prevent drying and tend to prevent the growth of molds on exposed skin, an important matter in respect to the face and hands. The face and hands should be thoroughly massaged and the excess removed. The embalmer should take care that the ointment made of eugenol, thymol, and vaseline does not get on his hands as it is very irritating to living skin, and may be escharotic. 2933. Method of Embalming.—Satisfactory embalming requires both arterial and cavity injection. It is not necessary to drain the veins of contained blood, although that procedure is recommended as tending to produce a more pleasing appearance of the body and to lessen the liability to the development of discolored spots and local- ized collections of gas. Injection by the brachial-femoral-carotid method avoids opening the abdominal cavity, a procedure which may 374 SEC. IV.—PREPARATION OF REMAINS 2934 be objectionable. Injection into the aorta is an alternative method, but if injection by the aortic method fails to produce successful injection of the extremities it must be supplemented with brachial, femoral, or carotid injection. 2934. Brachial-femoral-carotid Method of Arterial Injection.—(a) The arterial system shall be injected with an amount of the prescribed embalming fluid equal to 15 percent of the body weight, estimating 450 cubic centimeters of fluid as 1 pound. Inject each femoral artery toward toes with 2 percent of body weight. Inject each brachial artery toward fingers with 1 percent of body weight. Inject one common carotid artery toward head with 2 percent of body weight. Inject same common carotid artery toward heart with 7 percent of body weight. Total amount of fluid, including both femorals and both brachials, 15 percent of body weight. (b) The technique of injection is important, because prolonged preservation will depend upon saturation of every tissue of the body with embalming fluid. To insure uniform distribution it is usually necessary to make all six injections. The return of fluid through the veins while the extremities are being injected will indi- cate saturation of the extremities, and the return of fluid during the carotid injection upward will indicate that sufficient fluid has been injected into the head. Penetration is promoted by repeated flexion and extension of the limbs and by massage of the soft parts. An advancing line of firmness of the tissues may be taken as an indi- cation of the progress of the fluid. It is an easy matter to overinject so that the face and hands are puffy and unnatural. Two signs may be accepted as indicating that sufficient fluid has been used, regardless of the actual amount injected: First, if the eyes, lips, or one side of the face become overdistended or, in the case of an extrem- ity, when it is apparent that the fluid has circulated from the smaller arteries through capillaries into the veins; and, second, when the tissues of a region are uniformly firm, with no soft areas remaining. Over- injection, however, is not objectionable, if a long time is to elapse before the remains are to be viewed, since a slow shrinkage of the body usually takes place. (c) When the carotids are being injected, massage of the face and adjacent parts is important, it being especially necessary to make sure that the fluid reaches less vascular parts such as the tip of the nose and margins of the ears. Here, as elsewhere, palpable firmness 375 2935 CH. 19.—DEATHS AND RESULTING DUTIES of the tissues is the indication of successful injection. If any of these parts remain soft after completion of the arterial injection and show signs of skin slipping, fluid should be introduced by means of a hypodermic syringe, the point of the needle being inserted through the ear, hair line, nostril, or mouth so that the puncture may be invisible. When, as sometimes happens, it is impossible to attain uniform firmness at the first injection, a second injection under- taken the next day often reaches the soft areas. 2935. Cavity Injection.—(a) Besides injection of the arterial sys- tem, cavity injection should be performed, as much additional fluid being used for this purpose as may be required. When circumstances permit delay, it is well to postpone cavity injection until several hours have elapsed after the arterial injection has been completed. By that time, if a second arterial injection is to be required, the necessity for it will be apparent, and it can then be undertaken prior to introducing the breaks in the arterial system entailed by cavity injection. (b) Thorax.—By means of aspiration at several points, remove all body fluids and inject each pleural cavity with embalming fluid under moderate pressure until a slight epigastric fullness becomes apparent. (c) Abdomen.—By means of aspiration, the point of the needle being extensively moved about, remove as far as possible all gas, liquid intestinal contents, and pathological fluids. Then inject em- balming fluid, again moving the needle point about extensively, until slight distention is apparent. Kneading of the abdomen favors diffusion of the fluid. (d) Treatment of cavities after autopsy.—After autopsy, bodies are to be embalmed in the same way, but in such cases the cavities of the abdomen, chest, and skull, after complete removal of all vis- cera, shall be packed with absorbent cotton saturated with embalm- ing fluid. Hardening compound may be used. Especial care shall be exercised that the evidences of autopsies shall not cause unneces- sary distress to the relatives, that the wounds so made shall be neatly closed, and that packings and dressings employed shall be of clean and suitable material. (e) Multiple injections into tissue.—If fluid can not be forced into an artery because of clots, or for other reasons, such as mutila- tion or advanced decomposition, multiple injections may be made into the tissues, which should then be wrapped in cotton saturated in embalming fluid. In such a case, the anus, mouth, and nostrils shall be plugged with cotton soaked in embalming fluid, and the 376 SEC. IV.—preparation of remains 2936 entire body, including the face, ears, and hair shall be washed with the fluid. (f) Special precautions in the presence of certain communi- cable diseases.—In the case of a body dead of smallpox, plague, cholera, typhus fever, diphtheria, or scarlet fever, the remains, after being washed and after completion of the procedures described, shall be bandaged completely, excepting the head, with muslin soaked in embalming fluid. The hands and face shall be enveloped in a suit- able cloth saturated with embalming fluid. 2936. Aortic Method of Arterial Injection.—(a) This method is ap- plicable to two classes of cases: (1) Those in which there is no objection to merely exposing the aorta by an abdominal incision. (2) Cases in which a partial or complete autopsy has been per- formed. (b) The method is as follows: (1) Make an incision through the abdominal wall from the ensi- form cartilage to the pubes. Hold the abdominal walls forcibly apart so as to expose the abdominal aorta freely. Draw the intes- tines aside and raise the aorta. (2) Insert two cannulas into the aorta, one pointing toward the head and the other toward the feet. (3) Inject the standard embalming fluid toward the head and toward the feet, using an amount equal to 15 percent of the body weight. (4) Tie off the aorta above and below the puncture openings and close the abdominal incision by suture, tightly enough to prevent leakage. (c) The method in autopsy cases.—(1) Tie the ends of any large vessels that have been severed. If the innominate, left common carotid, or left subclavian arteries are to be severed at autopsy they should be tied before they are cut to prevent them from retracting beyond reach. (2) If injection into the aorta alone will not suffice, insert cannulas into as many divided arteries as will insure delivery of the fluid to the extremities and head. Inject into the aorta downward and into the aorta upward, or into the innominate, left common carotid, and left subclavian arteries. (3) Inject the prescribed amount of the standard fluid. (4) Clean the exposed cavities; dry them, sprinkle with harden- ing compound, and fill with cotton, or fill with cotton soaked in embalming fluid. If it be desirable to return the viscera, they should 377 2937-2938 ch. 19.—deaths and resulting duties be partially sectioned upon removal, washed, immersed in the fluid, dried, dusted with hardening compound, and placed in their respec- tive cavities. 2937. Pickling, Injection of Full-strength Formaldehyde Solution, Etc.—(a) In some cases ordinary or standard methods of embalming are inapplicable or inadequate to preserve a body. The following conditions require unusual procedures: (1) Dismemberment by explosion or crushing. (2) Decay due to lapse of time since death from drowning or to lapse of too much time since death in the Tropics. (3) Failure from any cause to obtain successful arterial injection. (b) Pickling.—Complete pickling may be accomplished by put- ting the body into a tank or vat of formaldehyde solution for a sufficient length of time to allow diffusion of the fluid to all parts of the body. Local pickling is accomplished by wrapping the ex- tremity or other part with cotton soaked in formaldehyde solution and keeping it wet sufficiently long to insure penetration. (c) Multiple hypodermic injections.—Penetration of the fluid into areas not otherwise reached may be brought about by multiple in- jections under the skin and deep into the muscles through hypodermic needles. (d) Arterial injection of full-strength formaldehyde solu- tion.—The use of full-strength formaldehyde solution is advocated by embalmers who have had much experience in the Tropics. The aortic method of arterial injection is recommended. Standard em- balming fluid should be used in standard amount but with an opening in the vena cava to permit the escape of blood and embalming fluid. When a quantity of the embalming fluid equivalent to 15 percent of the body weight has been injected, and as much as will, allowed to escape, the vena cava should be tied off and the aortic injection continued with full-strength formaldehyde solution until the vascular system is refilled. The openings in the aorta are then to be tied off. 2938. Embalming Fluid.—(a) The following is the formula for the embalming fluid to be used: cc or grams Liquid formaldehyde (U. S. P. solution of formaldehyde) — 13. 5 Sodium borate (borax) 5. 0 Glycerin (this is optional) 5. 0 Water, sufficient to make.. 100. 0 Should the liquid formaldehyde contain less than 37 percent of formaldehyde gas, the amount used should be increased pro- portionately. (b) This solution is irritating to many skins, and some form of protection is advisable. Gloves may be worn in special cases, but 378 SEC. IV.—PREPARATION OF REMAINS 2938 in general it will be found more convenient, and equally safe, to anoint the hands prior to beginning work with a heavy protective unguent. (c) While technic of injection is perhaps of prime importance, the fluid used should represent a thoroughly tested formula. Fluid made by the above formula will retain its stability for more than 2% years. It has proved effective in preserving human subjects exposed for 2 months to a temperature of 98° F., and the property of formaldehyde in acid solution of bleaching muscular tissue to an ashy gray is overcome by the addition of borax, which furnishes the de- sired alkalinity without causing deterioration of the solution. This formula shall be used, therefore, in all cases. (d) The pressure essential to successful injection may be obtained either by elevating the container to a height of 6 or more feet, or by means of a bicycle foot pump. The details requiring attention in employing either method will suggest themselves. (e) The fluid may harden tissue so rapidly as to hinder penetra- tion to more remote parts. For this reason, once the injection is begun the introduction of fluid should be continuous. It is well to start the injection at each site with half-strength solution. When the return flow is established, the full-strength solution should then be used as directed in the preceding paragraph. 2939. Overseas Shipment, Additional Preparation for.—At stations beyond the continental limits or aboard ships in distant waters and when the body is to be returned to a naval activity in the United States, or within the United States when the body is to be shipped to a naval activity abroad, after completion of the embalming as directed in preceding paragraphs, the following additional pro- cedures shall be followed in preparing the body for shipment, using either method A or method B as may be more practicable: (1) When time permits, the body shall lie for several days to permit drying out, the escape of fluids, and discovery of imperfectly hard- ened areas. Repeated sponging with alcohol will assist dehydration. (2) Method A. Pickling. Do not clothe the body, but wrap in absorbent cotton dripping wet with 10 percent formalin, and then snugly bandage the whole body. (3) Method B. Spraying. Do not clothe the body. Spray body and casket fabrics with suitable fungicide dissolved in a volatile solvent as follows: Remove any mold already in evidence with a weak solution of ammonia in alcohol. Wipe over skin surfaces with the thymol solution given below. Using an insecticide spray or atomizer, spray skin surfaces with same solution. (It is advised that operators wear respiratory masks.) Wrap body in dry absorbent 379 2940-2941 ch. 19.—deaths and resulting duties cotton, secured by bandages. When placed in casket, spray wrapped body and all casket fabrics. The following formula will be found suitable for this method as a fungicide and for preservation of skin, while having little effect on appearance and no action on fabric or dyes. ee or grams Thymol 5. 0 Eugenol 2. 0 Petrolatum 5. 0 Chloroform (sufficient to make) „ 100. 0 (4) Wrap clothing in an impervious, waxed paper, and pack securely on top of casket inside shipping case (par. 2940). (5) If funeral services are to be held prior to shipment, the above procedures will be carried into effect after the services. (6) If, for any reason, the remains are not to be handled by a naval activity at port of arrival, method B will be followed, except that the body shall be fully dressed (par. 2940), and, as a final step, the spray applied to the clothed body in the same manner as to a bandaged body. 2940. Clothing.—Except as directed in paragraph 2939, each body shall be dressed in a clean, presentable, and complete (except for cap and shoes) uniform of the proper rank or rating. A cap may be placed inside the casket. When a body is sent to a hospital or hospital ship for embalming and further disposition, suitable uniform for burial shall be sent with it. 2941. Encasement.—Navy (or Army) standard caskets, when available, shall be used for transportation of remains of officers and enlisted men (art. 1841, N. R.). This requirement of the Navy Regulations is not construed to prevent the use of caskets supplied by contractors, under the annual contracts of hospitals and stations, for local burial or transportation of remains within the continental limits of the United States, where the use of contract caskets is economically justified. SECTION V. TRANSPORTATION OF REMAINS Paragraph Rules Regarding Transportation of Remains 2951 Method of Transportation 2952 When Accompanied by Escort 2953 Arrangements To Be Made at Transfer Points 2954 Express Shipment 2955 Special Label 2956 Express Charges 2957 Shipment of Personal Effects 2958 Information for Next of Kin or Consignee 2959 Transportation of Remains to Arlington National Cemetery 2960 Forwarding Remains to the Philippine Islands 2961 SEC. V. TRANSPORTATION OF REMAINS 2951-2953 2951. Rules Regarding Transportation of Remains.—Rules regarding transportation of the dead, adopted by Conference of State and Pro- vincial Boards of Health, May 1915, require: (a) That bodies dead of smallpox, plague, Asiatic cholera, typhus fever, diphtheria, and scarlet fever shall be placed at once in a metal- lined casket, which shall be hermetically and permanently sealed. (b) Rule 4 provides that no disinterred body dead from any disease or cause shall be transported by common carrier unless approved by the health authorities having jurisdiction at the place of disinterment, and that transit permit and transit label shall be required. Disinterment and transportation of bodies dead of the above-mentioned communicable diseases shall not be allowed except by special permission of the health authorities at both the place of disinterment and the point of destination. All disinterred remains shall be inclosed in metal or metal-lined boxes, hermetically sealed, provided that bodies in a receiving vault, when prepared by licensed embalmers, shall not be regarded as disinterred bodies until after the expiration of 30 days. (c) Rule 1 provides that— A transit permit and transit label issued by the proper health authorities shall be required for each dead body transported by common carrier. The transit permit shall state the name, sex, color, and age of the deceased, the cause and date of death, the initial and terminal points, the date and route of shipments, a statement as to the method of preparation of the body, the date of issuance, the signature of the undertaker, the signature and the official title of the officer issuing the permit. The transit label shall state the place and date of death, the name of the deceased, the name of the escort or consignee, the initial and terminal points, the date of issuance, the signature and official title of the officer issuing the permit, which label shall be attached to the outside case. (d) Rules 5 and 6 provide that the outside case may be omitted in all instances when the coffin or casket is transported in hearse or undertaker’s wagon, and that every outside case shall bear at least four handles, and when over 5 feet 6 inches in length shall bear six handles. 2952. Method of Transportation.—When transportation of remains of naval or Marine Corps personnel is to be effected, the shipment if by rail will be either on tickets procured by transportation request or by express on Government bill of lading; and if by commercial steamship, on minimum first-class fare. When remains have been cremated, and no escort is to accompany them, shipment will be by mail or by express at the usual rate according to weight; if an escort is to carry them, only the ticket for the escort is required (par. 2971). 2953. When Accompanied by Escort.—If the body is to be shipped by rail on transportation request, an escort must accompany the re- 381 2954-2955 ch. 19.—deaths and resulting duties mains. The transportation request issued for the shipment of the corpse will call for a one-way, first-class adult ticket. When the weight is in excess of 500 pounds the officer issuing the transportation request will enter on the face thereof the total weight of the encased remains, and the carrier will bill the Navy Department for the excess weight. The transportation request issued for the escort will call for the class of ticket determined by the status of the traveler as provided by the United States Navy Travel Instructions. The corpse will be trans- ported by baggage service. One escort may accompany more than one corpse. 2954. Arrangements To Be Made at Transfer Points.—(a) Express shipments.—Arrangements now in effect provide for the handling of bodies by wagon transfer at junction points where transfer is neces- sary, permitting the through handling of bodies by the carriers from point of origin to final destination. The parties performing the final transfer by wagon are to bill against the carrier, whose baggage agent arranges for the services, and the carriers will present the bill to the Department in the usual manner, accompanied by the transfer certificate. (b) Shipment under escort.—When shipment is by transportation requests, the issuing officer shall advance cash to the escort to cover transfer of remains between railroad stations and from railroad station to home or place of final delivery, as follows: In cases where only one transfer is necessary, $5 shall be advanced; if more than one transfer is required, $5 additional shall be advanced for each such transfer. Escorts shall be instructed to secure receipts from the transfer com- pany to cover the transfer of the corpse, and on return to station these receipts, together with unused cash, shall be turned in to the issuing officer. Civilian escorts shall be similarly instructed. 2955. Express Shipment.—When remains are not to be accompanied by an escort, shipment shall be effected by express on Government bill of lading (NMS Hospital Form 60). This form shall be prepared in septuplicate and the original and copies shall be disposed of as indicated below: Original.—To be delivered to undertaker for immediate return to the hospital by the undertaker after express agent has affixed his signature. The hospital shall then send the original and the sixth copy, accompanied by the following form letter, to consignee under special-delivery stamp, enclosing an addressed and franked envelope for return of the receipted sixth copy: Dear Sir: There are enclosed herewith two copies of the Government bill of lading covering transportation of the remains of , which went forward on train No. , (R. R.). (Date and hour.) The white copy is the original and should be carefully preserved by you until the remains are delivered, at which time please fill in consignee’s certification of 382 SEC. V. TRANSPORTATION OF REMAINS 2956-2957 delivery appearing near the bottom of the form, sign and surrender to transpor- tation company. Please note the instructions printed in red on the face of the form directing that you pay no charges. When delivery has been made, please also sign the blue copy of the bill of lading and return it to this hospital in the enclosed addressed envelope, which requires no postage. Very truly yours, First copy: To be delivered to undertaker for further delivery to the agent of the express company. This copy is for the files of the express company. Second copy: Hold in hospital files until weight and cost of ship- ment are obtained from the express company. When this information is received, fill in weight and cost of shipment and mail to the Bureau of Supplies and Accounts or the Quartermaster, U. S. Marine Corps, as the case may be. There should be no delay in forwarding this copy. Third copy: Enter weight and cost of shipment and file in case paper jacket of deceased. Fourth copy: Enter weight and cost of shipment and file in Prop- erty and Accounting Office files. Fifth copy: This copy must be securely pasted on shipping case to indicate to transportation company that transportation charges are payable by Government and must not be collected from consignee. Sixth copy: This copy shall be mailed, with original, to consignee. Seventh copy: To be delivered to undertaker together with the original and first copy. The express company will fill in weight and cost of shipment and return this (seventh) copy to the hospi- tal. If this copy is not returned within reasonable time a tracer should be instituted as it is necessary to have this copy completed before the second, third, and fourth copies can be completed and the case closed. 2956. Special label.—A special label, prohibiting cohection of ex- press charges from consignee, should be obtained from the local express agent and attached to the outside case, in addition to the copy of the bill of lading. 2957. Express Charges.—On express shipments, when weight of en- cased remains does not exceed 500 pounds, corpse transportation will be double the regular standard one-way, first-class passenger rate, but never less than $3.30 for any distance. When the weight exceeds 500 pounds, either by express or on two first-class tickets, the excess is charged for at the regular first-class rate. Land-grant deductions are not applicable to transportation of remains nor to the travel per- formed by the escort (1 Comp. Gen. 288). 383 2958-2959 ch. 19.—deaths and resulting duties 2958. Shipment of Personal Effects.—(a) Personal effects of active duty personnel not to exceed 150 pounds, may be forwarded with the body when shipped either by express or on transportation request without additional charge. When personal effects exceed 150 pounds, any excess should be delivered to the supply officer for shipment, such excess being chargeable to the appropriation instruments and supplies, bureau of navigation, for Navy personnel and general expenses, marine corps, for Marine Corps personnel. (b) The personal effects of former enlisted men, discharged in naval hospitals and remaining as inmates until death, may not be shipped at Government expense. However, when the remains ol such patients are to be shipped home, personal effects to the weight carried free may accompany the remains. The effects so forwarded should be those articles of greatest value, money, papers, keepsakes, jewelry, etc. The next of kin shall be informed of the character and cost of shipment of the remaining effects and required to advance transportation charges. If unclaimed, the effects shall be held for a period of 3 months and then destroyed or suitably disposed of as the commanding officer may direct. (c) The effects (including safekeeping deposits) of Veterans’ Ad- ministration patients who die in naval hospitals shall be turned over to the Veterans’ Administration regional manager having jurisdiction in the case for disposition in accordance with the prescribed regulations of the Veterans’ Administration. Receipt, in duplicate, shall be ob- tained in each case from the authorized representatives of the Veterans’ Administration to whom the effects are delivered. The duplicate of the receipt shall be retained in the files of the nkval hospital. The original shall be disposed of as follows: (1) For former members of the Navy or Naval Reserve, mail to the Bureau of Navigation. (2) For former members of the Marine Corps or Marine Corps Reserve, mail to Major General Commandant, Marine Corps. (3) All other receipts, mail to the Secretary of the Navy (Judge Advocate General). 2959. Information for Next of Kin or Consignee.—The next of kin, family, legal representative of the deceased, or the consignee, should the body be sent to other than the preceding, shall be informed by telegram of the time and method of forwarding, and, if practicable, the routing and scheduled time of arrival at destination; also of any special attending circumstances, such as communicable disease and the advisability or inadvisability of opening the casket for the pur- pose of viewing the remains. Copy of the bill of lading will be promptly forwarded to the consignee, under special delivery stamp, and ac- 2960 SEC. V.—TRANSPORTATION OF REMAINS companied by an explanatory memorandum (par. 2955). Investiga- tion has determined that in most instances where the express company attempts to collect express charges from consignee, the difficulty has been due to failure of the bill of lading to arrive in advance of the body, or to a misunderstanding on the part of consignee as to its purpose. 2960. Transportation of Remains to Arlington Cemetery.—Trans- portation of Navy and Marine Corps dead to Arlington National Cemetery will be governed by the following provisions: (a) The shipping case shall be marked “Officer in Charge, Arlington National Cemetery, Fort Myer, Va.,” and the remains billed to Washington, D. C. This will avoid the necessity and delay of obtain- ing a permit for the transfer of the body through the District of Columbia. (b) A telegram shall be sent at the earliest possible moment to the officer in charge, as above, giving the date and place of death, dimen- sions of outside box, and the date, hour, and number of the train on which the body will reach Washington. Whenever practicable, the shipment of the remains should be so timed as to arrive in Washington between the hours of 8 a. m. and 2 p. m. of week days. Arrival on Sundays or holidays should be avoided. If received after 2 o’clock p. m., they will be placed in the receiving vault at Arlington. (c) Upon receipt of the telegram above referred to, the officer in charge will give instructions to have the remains met at the railroad station by the department hearse, conveyed to Arlington, and placed in the receiving vault pending subsequent arrangements for interment. The services of an undertaker in Washington are not required in these cases, nor is there any expense attached to the opening and closing of the grave in Arlington. (d) Should it be impracticable for relatives or friends to accompany the remains to this city, the body will be received, conveyed to Arlington, and interred with the same respect and careful attention to every detail as though an attendant accompanied the remains. (e) Interment will not be made in Arlington National Cemetery on Sundays, holidays, after 11 a. m. on Saturdays, or after 3 p. m. on other week days. (f) As military honors are provided at every burial, an additional telegram shall be addressed to the Bureau of Navigation or the Major General Commandant, as the case may be, giving the full name, rank or rating, time of arrival of the body, stating whether or not relatives accompany the body, and the date on which it is desired that the services shall be held. At least 24 hours are required to complete funeral arrangements. If relatives are to be in attendance, they 385 2961-2967 ch. 19.—deaths and resulting duties should be instructed, upon arrival in Washington, to communicate immediately with the Aide to the Chief of the Bureau, of Navigation, Navy Department, or the Major General Commandant, as may be appropriate. 2961. Forwarding Remains to the Philippine Islands.—In forward- ing bodies for transportation to the Philippine Islands, the transit permit, certificate of death, and other necessary papers should be placed in a heavy envelope and securely attached to the shipping case. Paragraph Authority for 2965 Must Be Requested 2966 Selection and Detail of 2967 Travel Instructions 2968 Appropriation Chargeable 2969 Civilian as Escort 2970 Escort for Cremated Remains of Naval Dead 2971 Naval Reservist as Escort 2972 Escort Not Authorized 2973 SECTION VI. CORPSE ESCORT 2965. Authority for.—(a) The act of May 26, 1928, provides— That the Secretary of the Navy, in his discretion, is hereby authorized to furnish an escort not to exceed one person to the place of burial for the bodies of officers, «enlisted men, or nurses who have lost their lives in the naval service. Suoh expenses as are incurred for this purpose shall be paid from the proper appropriation. (b) Article 1513 (5), Navy Regulations, provides for a service or civilian escort to accompany to place of burial the remains of officers, enlisted men, or nurses who have lost their lives in the naval service. As the law provides for an escort of one person only, when a civilian accompanies the remains as escort a service escort may not be detailed. 2966. Must Be Requested.—Upon request of the next of kin or family of the deceased, a service or civilian escort of one person may be assigned to accompany the remains to place of burial. 2967. Selection and Detail of.—The escort, if of the service, shall be of the equivalent rank or rate of the deceased so nearly as may be practicable and, when possible, a friend or associate. The escort will be detailed and the necessary orders issued by the commandant of the navy yard or station when shipment of the remains is made from a naval hospital. If the remains have been transferred to the hospital from a ship in port, the commanding officer should, when practicable, detail the escort to report to the commandant for this duty. When shipment of remains is made from a ship, the detail of escort shall be made by the senior officer present afloat; and from activities not 386 SEC. VI.—CORPSE ESCORT 2968-2970 under the immediate jurisdiction of a commandant, the detail shall be made by the senior officer present ashore. 2968. Travel Instructions.—(a) U. S. Navy Travel Instructions con- tain full instructions relative to travel allowances and outline the de- tails to be followed in sending an escort to accompany, to place of burial, the remains of officers, enlisted men, and nurses who have lost their lives in the naval service. (b) Provided the cost of such travel does not exceed the cost of a round trip from the place from which the remains are to be escorted to the place of burial, the travel of the escort may be: (1) From point of shipment to place of burial and return. (2) From the place of prospective burial to the point of shipment and return. (3) From the point of shipment or port of entry to place of burial, thence to point selected by the escort. (4) From other than point of shipment or port of entry to the point of shipment or port of entry thence to starting point or to any other point selected by the escort. (c) When remains are returned to the United States from points outside the continental limits, escort may not be authorized to point of reshipment within the United States, except a dependent who may be otherwise legally entitled to transportation under the provisions of Navy Travel Instructions. From the point of reshipment the com- mandant of the yard or station shall, if authorized, arrange for escort to final destination of remains as in other cases. 2969. Appropriation Chargeable.—(a) Specific provision therefor be- ing contained in the appropriation pay, subsistence, and transpor- tation, the expenses of funeral escorts for deceased naval personnel are properly payable only under that appropriation (Comp. Gen. A-29117, Oct. 22, 1929). (b) All transportation and travel expenses of the escort to the pro- spective place of burial and return therefrom will be a charge to pay, SUBSISTENCE, AND TRANSPORTATION Or GENERAL EXPENSES, MARINE Corps, as the case may be. The only charge to be lodged against the appropriation care of the dead, when remains of naval dead are shipped on transportation requests is for the cost of the corpse ticket. In the case of Marine Corps dead, the cost of both escort and corpse ticket is a charge to general expenses, Marine Corps. 2970. Civilian as Escort.—The act of May 26, 1928, authorizing the Secretary of the Navy to furnish an escort to place of burial for the naval dead who have lost their lives in the naval service, permits the selection of a relative or other person not a member of the Navy or Marine Corps to be sent as such escort at Government expense. The expenses so authorized include subsistence en route and sleeping- 387 2971-2973 ch. 19.—deaths and resulting duties car accommodations to place of burial and return therefrom when necessary (Comp. Gen. A-24108, Sept. 19, 1928). 2971. Escort for Cremated Remains of Naval Dead.—The act of May 26, 1928, authorizes the furnishing of an escort for the cremated remains of officers, enlisted men, and nurses who have lost their lives in the naval service, if the escort actually carries with him on the trip the receptacle containing the ashes and personally delivers it to a mem- ber of the family or other proper person at the authorized destination (Comp. Gen. A-27358, June 29, 1929). 2972. Naval Reservist as Escort.—Under the act of May 26, 1928, a member of the Naval Reserve not on active duty may act as a civil- ian escort and while acting in that capacity is entitled to such travel and subsistence expenses as may be authorized by the Secretary of the Navy. An assignment to active duty for the purpose of acting as escort for the body of a naval reservist who died while on active duty is not training duty, but duty for that purpose may be author- ized by the Secretary of the Navy as “other duty” without pay, and the member so acting is entitled to mileage (Comp. Gen. A-29117, Oct. 22, 1929). 2973. Escort Not Authorized.—As the act of May 26, 1928, spe- cifically authorizes an escort “for the bodies of officers, enlisted men, or nurses who have lost their lives in the naval service,” an escort for personnel not on active duty in the Navy at the time of death is not authorized. An escort, therefore, will not be furnished for remains of the following personnel who die in a naval hospital, even though transportation home or to designated cemeteries is authorized at Government expense: (1) Naval and Marine Corps Reserve retained for treatment after expiration of active-duty period for injury or disease incurred on active duty; (2) enlisted men retained for treatment after expiration of enlistment. SECTION VII. FUNERAL EXPENSES When Authorized 2975 Specific Provisions for 2976 Appropriation Chargeable. 2977 Funeral Expenses of Personnel on Active List 2978 Disposition of Remains at a Naval Hospital 2979 Funeral Expenses Distinct from Transportation Expenses 2980 Limitation of Expenses 2981 Where Government Services Are Refused 2982 Funeral Expenses at Home Allowed 2986 Cremation of Remains 2987 Burial Prior to Ascertaining Wishes of Next of Kin 2988 Transportation to a Place Outside the United States 2989 Coroner’s Inquest 2990 Funeral and Burial Expenses of Destitute Patients 2991 Burial of Unclaimed Bodies 2992 Burial at Sea. 2993 Paragraph 388 SEC. VII.—FUNERAL EXPENSES 2975-2977 2975. When Authorized.—Funeral expenses of persons who die in the service of the Government, either in the civil branches or in the Army, Navy, or Marine Corps, active or retired, are payable by the Government only when specific provision is made therefor by law (1 Comp. Gen. 284, Nov. 25, 1921). 2976. Specific Provision for.—The language of the Annual Appro- priation Act for care of the dead, Navy, and other appropriations pertaining to care of the dead, enumerates the purposes for which expenditures may be made. (See Circular Letter C for language of current appropriations.) 2977. Appropriation Chargeable.—In connection with the prepara- tion, shipment, and burial of deceased members of the naval service, and the disposition of their effects, one or more of the above appro- priations are applicable. It is essential, therefore, that the scope of each appropriation be fully understood and that the proper appro- priation be charged as indicated below: (a) Local burial or shipment.—The appropriation care of the dead is chargeable with the cost of recovery of bodies; cremation, but only on request of the relatives of the deceased; embalming, clothing, and encasement; transportation to the home of the deceased, or to a national or other cemetery designated by proper authority, and interment, of the following deceased persons: (1) Officers, nurses, and enlisted men, Navy, active; (2) officers, nurses, and enlisted men, Navy, retired, on active duty at the time of their death; (3) officers and enlisted men, Marine Corps, active (or retired, on active duty) who die in or whose remains are transferred to naval hospitals (see note); (4) members of the Naval Reserve and Marine Corps Reserve who die while on active duty or training duty, or while performing authorized travel to or from such duty; (5) accepted applicants for enlistment; (6) former enlisted men of the Navy and Marine Corps who were discharged while patients in hospitals and who remain as patients in such hospitals to the day of their death; (7) civilian employees of the Navy Department or the Naval Establishment who have been ordered away from their homes in the United States to duty outside the continental limits of the United States and who die while on such duty or while performing authorized travel to or from such duty; and (8) officers and enlisted men of the Naval and Marine Corps Reserve who are retained in a naval hospital for treatment after expiration of active duty period for disease incurred on active duty and who die while patients in said hospital. (Note.—Expenses for transportation of Marine Corps dead are chargeable to general expenses, Marine Corps, in all cases except retired enlisted men, Marine Corps, on active duty, or when transportation away from the United States is involved.) 389 2977 CH. 19.—DEATHS AND RESULTING DUTIES (b) Local burial only.—The appropriation care of the dead is chargeable with the cost of embalming, clothing, funeral, and local burial only, of the following deceased personnel: (1) Pensioners who die in a naval hospital; and (2) destitute patients who die in a naval hospital. (c) Marine Corps.—The appropriation general expenses, Ma- rine Corps, is chargeable with the cost of embalming, clothing, and encasement; funeral and local burial; and transportation to their homes or designated cemeteries in the United States, of the following deceased persons: (1) Officers and enlisted men, Marine Corps, active; (2) officers, Marine Corps, retired, on active duty at time of death; and (3) accepted applicants for enlistment in the Marine Corps. (Note.—At stations or hospitals having an annual contract for care of the dead, expenses of preparation and local burial are charged, under the contract, to caee of the dead. Transportation is always chargeable to general ex- penses, Marine Corps, unless shipment to a foreign country is involved.) (d) Expenses not authorized.—No appropriation is available to pay the cost of embalming, clothing, or encasement; funeral or local burial; or transportation to their homes or designated cemeteries, of the following deceased personnel: (1) Officers, nurses, and enlisted men of the Navy and Marine Corps, retired, who were on inactive duty at the time of their death; (2) officers and enlisted men of the Naval or Marine Corps Reserve (except those retained for treatment for disease or injury incurred while on active duty) on inactive duty at time of death; (3) reserve nurses on inactive duty at the time of their death; and except as noted in paragraph 2992. (e) Reservists, death from injury.—(1) Funds under the con- trol of the Employees’ Compensation Commission are available to pay the cost of embalming, clothing, and encasement, and funeral and local burial, or transportation to their homes or designated ceme- teries, of officers and enlisted men of the Naval or Marine Corps Reserves who die after expiration of active duty period, as the result of injury incurred on active duty. (2) Expenses, how covered.—When the remains of such inactive reservists are cared for under the annual contract of a naval hospital or station, public voucher in favor of the contractor shall be prepared on the usual form and forwarded to the Bureau for transmission to the United States Employees’ Compensation Commission. Where no annual contract is available, dealer’s bills, itemized and in dupli- cate, properly certified, and with certificate from the officer author- izing the services that the same have been satisfactorily rendered, shall be submitted to the Bureau for transmission to the Employees’ Compensation Commission for settlement. 390 SEC. VII.—FUNERAL EXPENSES 2977 (3) Shipment of remains.—Shipment of remains, when directed by the Bureau, shall be by express on Government bill of lading or by tickets procured on transportation request. When bill of lading is used, the full name and rating of the deceased shall be specified and there shall be typed across the face of the bill, on all copies, “Charges Payable by United States Employees’ Compensation Commission.” The bill shall then be handled in the usual manner. When transpor- tation request is used, the name and rating of the deceased shall be similarly noted, and entry as to appropriation chargeable shall be United States Employees’ Compensation Commission. (f) Veterans’ Administration patients.—Funds under the con- trol of the Veterans’ Administration are available to pay the cost of embalming, clothing, and encasement; funeral and local burial; transportation to their homes or designated cemeteries; and a small amount for funeral expenses after arrival of body at destination, of Veterans’ Administration patients who die in a naval hospital. Vet- erans’ Administration patients who die in naval hospitals shall be transferred to the custody of the Veterans’ Administration regional director who will assume full charge of all arrangements for the preparation and disposition of the remains. (g) The appropriation chargeable with each of the several items of expense involved in disposition of remains of service personnel is shown in the following table: Class of personnel Preparation of remains Transportation of remains Funeral escort Care of the dead- Care of the dead Pay, subsistence, and transportation. Do. General expenses, Ma- rine Corps. Do. Do. P. S. and T., or general expenses, Marine Corps. Not authorized. Do. Do. Do. Do. Do. Navy personnel, retired, on active duty. Marine Corps, active _do General expenses, Ma- rine Corp.1 do General expenses, Ma- rine Corps, do - Officers, Marine Corps, retired, on active duty. Enlisted men, Marine Corps, retired, on active duty. Naval or Marine Corps Reserve, active or training duty. Accepted applicants for enlist- ment, Marine Corps. Former enlisted men retained in naval hospitals. Civilian employees beyond continental limits. Naval or Marine Corps Re- serve, retained in naval hos- pital after active duty, for disease. Naval or Marine Corps Re- serve, retained in hospital after active duty, for injury. Naval pensioners, death in naval hospital Care of the dead _ do General expenses, Ma- rine Corps.1 General expenses, Ma- rine Corps. Care of the dead do do do do Employees’ Compen- sation Commission. Employees’ Compen- sation Commission. Not authorized 1 Except at hospitals or stations having an annual contract for care of the dead, where the appropriation care of the dead is chargeable. Appropriation Chargeable (Note.—For expenses in connection with burial of remains after delivery at Government expense to the place designated by next of kin, see par. 2986.) 391 2178-2979 ch. 19.—deaths and resulting duties 2978. Funeral Expenses of Personnel on Active List.—(a) The necessary and proper funeral expenses of officers and enlisted men of the Navy and Marine Corps at naval stations within the United States shall be provided for by annual contracts, and elsewhere within the United States will be allowed when approved by the Bureau, or by such officers as may be designated by the Commandant, Marine Corps, respectively. Such expenses will be allowed only when authorized by law and shall in no instance exceed $200 (exclusive of the allowance for interment after delivery of the body to the place designated), unless due regard for decent burial renders greater expense necessary, which fact must be certified on all copies of the public voucher by the officer ordering the payment of the bill (art. 1841 (2), N. R.). No expenses for travel to attend the funeral of an officer who dies within the United States shall be allowed except as provided for in paragraph 2965 of this manual (art. 1841 (1), N. R.). (b) Whenever practicable, bodies of deceased persons shall be sent from naval ships and stations to the nearest naval hospital or hospital ship. A copy of Form N shall accompany each body so transferred. When such transfer is not practicable, bodies shall be embalmed and retained awaiting instructions from the Bureau. Burial shall not be made in a foreign port or at sea, in advance of receipt of such instructions, except when preservation or retention of the body is impossible. (c) At recruiting stations or other posts at a considerable dis- tance from a naval hospital or navy yard, or where there is no annual contract for care of the dead, the body shall be placed in the care of an undertaker for embalming and held until instructions arc received from the Bureau. 2979. Disposition of Remains at a Naval Hospital.—(a) Before making disposition of remains in any case, the hospital shall deter- mine definitely the status of the deceased in relation to the laws governing funeral and burial expenses, and that the instructions for disposition come from the designated next of kin or legal represent- ative of the deceased, or are given by some person acting in accordance with their wishes. (b) Whenever practicable a copy of NMS-Hospital Form No. 61, or, in the case of marines, NMC—Form 817 QM., information for next of kin, shall be sent to the next of kin or consignee so as to arrive in advance of the remains. (c) When the next of kin cannot be located, when the body is not claimed by the next of kin or legal representative, when there are con- flicting claims, or when, for any reason, there is doubt as to the proper 392 SEC. VII.—FUNERAL EXPENSES 2980-2888 disposition to be made of the body, the facts shall be reported by dispatch to the Bureau (or to Marine Corps Headquarters in cases of Marine Corps personnel) with request for instructions. 2980. Funeral Expenses Distinct from Transportation Expenses.— Funeral expenses or expenses of interment are distinct from expenses incurred in connection with transportation of remains (Comp. Dec. Aug. 21, 1908). The limitations as to amount to be expended for funeral expenses shall not be construed to affect the expenses for preparation and encasement incurred as a part of transportation. 2981. Limitation of Expenses.—In all cases expenses shall be held to the lowest amount consistent with decent preparation and encasement in accordance with Navy Regulations or to meet the requirements of laws governing transportation. 2982. Where Government Services Are Refused.—Where the services of the Government are refused and the remains of Naval or Marine Corps dead are taken charge of by relatives, the expenses of funeral, burial, or transportation may not be allowed by the Navy Department (Comp. Dec. Mar. 19, 1901). 2986. Funeral Expenses at Home Allowed.—After the body of an officer or enlisted man of the Navy or Marine Corps has been pre- pared and shipped or delivered at Government expense to the place designated by the relatives, further expenses of funeral and burial may be allowed not to exceed $50, applicable only to one or more of the following items: Hearse hire, transportation for immediate rela- tives to cemetery, undertaker’s services, clergyman’s services (not to exceed $5), cost of single grave site, opening and closing of grave. Claims may be submitted to the Bureau of Medicine and Surgery or to Headquarters Marine Corps, covering such expenses for burial of deceased personnel of the respective services. 2987. Cremation of Remains.—When requested by the next of kin and on prior authority of the Bureau, cremation will be permitted at Government expense, provided that the total cost of funeral, in- cluding preparation, encasement, and cremation, shall not be in excess of $200. The expenses of cremation, when authorized as above, will be covered by emergency requisition, approved in advance by the commandant (art. 1607 (5), N. R.) at shore stations, or by the senior officer present afloat (art. 1396 (3), N. R.). 2988. Burial Prior to Ascertaining Wishes of Next of Kin.—When a body has been buried prior to ascertaining the wishes of the next of kin, or if burial has been rendered necessary, for any reason, when the next of kin has requested shipment, the body may be later ex- humed and forwarded, at Government expense, to the place desig- 393 2988-2992 ch. 19.—deaths and resulting duties nated by the next of kin, but when burial has been made in compliance with request of the next of kin, the expenses of exhumation and trans- portation may not be defrayed by the Government. 2989. Transportation to a Place Outside the United States.—Trans- portation of remains may be allowed to a place not within the United States on the prior authority of the Bureau (Comp. Dec., Nov. 10, 1902). 2990. Coroner’s Inquest.—Expenses incident to a coroner’s inquest may not be paid by the Government, the Comptroller General (A- 16054, Nov. 15, 1926) having ruled that such expenses are not incident to funeral and burial of a person, but incident to the deter- mination by the civil authorities of the cause of death, and there- fore constitute no obligation against the United States. 2991. Funeral and Burial Expenses of Destitute Patients.—While the funeral and burial expenses of destitute patients who die in naval hospitals are authorized by the annual appropriation care of the dead, in view of the Comptroller General’s decision (Mar. 19, 1925) that no person in receipt of retired or retainer pay to date of death can be considered as having died destitute, and of other provision for care of the remains of those classes of personnel whose admission to naval hospitals is authorized by law, the Bureau reserves deter- mination of the meaning of the word destitute appearing in the appropriation. No expenses shall be incurred for care of remains of destitute patients without the prior approval of the Bureau except as a sanitary measure (Comp. Dec., July 24, 1914.) Moneys found among the effects of deceased persons cannot be used to defray funeral expenses (art. 908, N. R.). 2992. Burial of Unclaimed Bodies.—No person in "receipt of retired or retainer pay to date of death can be considered as having died destitute and the Government, therefore, is not required to assume the funeral and burial expenses of such persons (Comp. Gen., Mar. 19, 1925). When the remains of a retired officer or enlisted man, or inactive member of the Fleet Reserve (16 or 20 years, transferred classes) who has died in a naval hospital are unclaimed, burial shall be made under the annual contract of the hospital, chargeable to the appropriation, care of the dead, but the supply officer making pay- ment shall be advised immediately as to the facts in the case, and directed to forward checkage request to the Bureau of Supplies and Accounts (or Quartermaster, Marine Corps) for transmittal to the officer carrying the retired or retainer pay accounts and lodgment against any pay due the deceased at date of death, with consequent reimbursement to care of the dead (S. & A. and M. & S. joint letter, M. & S. No. 127492 (51), Aug. 24, 1925). 394 SEC. VIII.—FUNERALS 2993-2999 2993. Burial at Sea.—(a) Requests to conduct burials at sea of the remains of inactive personnel or civilians should be referred by the senior officer present to the Chief of Naval Operations for au- thorization, with a statement as to the practicability of complying with the request. (b) If authority is granted, arrangements for the burial then will be made directly with authorized persons having charge of the re- mains. The date of burial will be determined by the availability of the naval vessel concerned. (c) The following papers shall be presented to the commanding officer concerned before the remains-are taken into the custody of the Navy; and appropriate entry regarding presentation of such papers, together with specific identifying data regarding them, shall be entered in the log: (1) The request and authorization from the authorized person having charge of the remains. (2) A transit permit or burial permit issued by the responsible civil authorities at the place of death, whether or not the remains are cremated. (d) After the burial the above-mentioned papers shall be appro- priately endorsed by the commanding officer of the ship concerned as to the fact of the burial, and forwarded to the Secretary of the Navy. (e) There is no authority for the actual expenditure of Govern- ment funds or materials in connection with disposition of remains in these cases. SECTION VIII. FUNERALS AND FUNERAL FLAGS Paragraph Funeral Ceremonies - 2998 National Flag 2999 2998. Funeral Ceremonies.—Funeral ceremonies are conducted in accordance with the provisions of chapter 5, Navy Regulations. 2999. National Flag.—(a) Commandants of navy yards, command- ing officers of vessels, or senior officers present, and commanding officers of naval hospitals are authorized to issue the national flag (United States national ensign No. 7) to accompany all bodies of naval or Marine Corps personnel forwarded or delivered to the next of kin or relatives for private interment, in order that the flags may be available for use at the time of burial. Request for such issue shall be construed as included in, application for the body. The flag shall be inclosed in a suitable canvas bag or sack and securely at- tached to the casket, or placed inside the shipping box, in which case the box shall be labeled “‘flag inside” or the consignee otherwise notified. 395 2999 CH. 19.—DEATHS AND RESULTING DUTIES (b) Flags used for draping coffins of officers and enlisted men of the Navy or Marine Corps, which are issued to relatives, schools, patriotic orders, or societies, in accordance with the Naval Appro- priation Act of June 30, 1914, shall, when issued, be expended by the issuing supply officer on an invoice (S. & A. Form 71) as a charge to the current appropriation, bureau of ships the issuing yard or station’s ships and miscellaneous, allotment, and to title V, accout 44—Funeral flags (Bureau of Supplies and Accounts Manual, art. 1149-9). (c) (Laws Relating to the Navy (Supplement, 1929), p. 451): Retired officers and enlisted men of the Navy or Marine Corps are officers and enlisted men in the service of the United States Navy and Marine Corps, respectively, within the meaning of the act of June 30, 1914. Assigned and transferred members of the Fleet Naval Reserve and other members of the Naval Reserve, when on active duty in time of peace, are officers and enlisted men in the service of the United States Navy or Marine Corps within said act. Assigned and transferred members of the Fleet Naval Reserve and other members of the Naval Reserve, when on inactive duty, are not officers and enlisted men in the service of the United States Navy or Marine Corps, within the meaning of said act, but are only officers and enlisted men in the service of the Naval Reserve or Marine Corps Reserve (citing file 3768-635: 1, Dec. 9, 1925). Members of the Naval Reserve called to active duty in time of war or emergency are officers and enlisted men in the service of the United States Navy within the meaning of this act. CHAPTER 20 FINANCE AND PROPERTY Paragraphs Section I. ANNUAL APPROPRIATIONS AND BUREAU FUND 3001-3005 II. ESTIMATES OF EXPENDITURES 8011-3016 m. ALLOTMENTS, OBLIGATIONS, AND EXPENDITURES 3022-3024 IV. PROCUREMENT METHODS 3030-3059 V. PROPERTY: CUSTODY, ISSUE, DISPOSITION 3062-3081 VI. ACCOUNTING RECORDS: SHIPS, SHORE STATIONS 3086-3088 Vn. ACCOUNTING RECORDS, NAVAL HOSPITALS 3094^3117 VIH. MEDICAL STORES, NAVAL MEDICAL SUPPLY DEPOTS... 3142-3155 SECTION I. ANNUAL APPROPRIATIONS AND BUREAU FUND Paragraphs Annual Appropriations 3001-3002 Naval Hospital Fund 3003-3004 Bureau Financial Duties 3005 3001. Annual Appropriations.—The annual appropriations in- cluded in the naval appropriation bill that pertain to the Bureau are as follows: Medical Department, Navy. Care of the Dead, Navy. Salaries, Bureau of Medicine and Surgery. The exact wording of each Navy Department appropriation will be found in the act making appropriations for the Navy Department for the fiscal year concerned. Copies of the Appropriation Bulletin and the Annual Appropriation Act are furnished all activities by the Bureau of Supplies and Accounts. 3002. Medical Department and Care of the Dead Expendi- tures.—The language of the annual appropriation act enumerates the purposes for which expenditures may be made. 3003. Naval Hospital Fund—Revenue.—The naval hospital fund, created by the act of February 26, 1811 (24 U. S. C. 14) is a trust fund which derives its revenues from within the naval service and is admin- istered by the Secretary of the Navy, the trustee of the fund, subject to the control of Congress. Its revenues are derived from the follow- ing sources: 397 3004-3011 CH. 20. FINANCE AND PROPERTY (1) By the deduction of 20 cents per month from the pay of each officer, seaman, and marine (24 U. S. C. 3). (2) By fines imposed on officers, seamen, and marines (24 U. S. C. 4). (3) By the value of one ration per day allowed for each officer, sea- man, and marine, during his continuance in hospital (24 U. S. C. 16). (4) By the relinquishment of pensions due officers, seamen, and marines (other than Veterans’ Administration beneficiaries), while inmates of naval hospitals (24 U. S. C. 6.) (5) By forfeitures on account of desertion (24 U. S. C. 5). 3004. Naval Hospital Fund—Expenditures.—Every expense for the maintenance of a naval hospital may be paid from the naval hospital fund, except as Congress may provide for certain expenses by specific language in annual appropriation acts. 3005. Bureau Financial Duties.—The Bureau is charged with the accountability of funds provided to carry out its duties. This accountability is imposed by Title 5, Section 430, U. S. C., which states: The several Bureaus shall retain the charge and custody of the books of records and accounts pertaining to their respective duties; and all of the duties of the Bureaus shall be performed under the authority of the Secretary of the Navy, and their orders shall be considered as emanating from him and shall have full force and effect as such. Responsibility for proper expenditures of appropriations and ex- penditures in excess of any appropriation is established by 31 U. S. C. 665. Article 396, Navy Regulations, restates the provisions of sec- tion 665 and places similar responsibility on the activities of the Naval Establishment for proper expenditure of allotments granted by the respective Bureaus. Appropriational expenditures may be made only for the purposes authorized in the appropriation acts. Obliga- tions in excess of an appropriation may not be made unless such con- tract or obligation is authorized by law. SECTION II. ESTIMATES OF EXPENDITURES Paragraphs Bureau Estimates of Expenditures 3011 Annual Estimates of Expenditures, Field Activities 3012-3015 Tentative Estimates of Expenditures, Advance Years 3016 3011. Bureau Estimates of Expenditures.—The Chief of the Bureau is charged with the preparation of estimates for funds to carry out the duties of the Bureau, by Title 5, U. S. C. 431, which reads: All estimates for specific, general, and contingent expenses of the Department, and of the several Bureaus, shall be furnished to the Secretary of the Navy by the chiefs of the respective Bureaus. 398 sec. n.—estimates of expenditures 3012-3013 The estimates for the Bureau, hereinafter referred to as bureau estimates, are based upon: (1) Naval policy. (2) Current operating, development and personnel plans, approved by the Secretary of the Navy, annually. (3) Records of past requirements and expenditures. (4) Annual estimates of expenditures and tentative estimates for advance fiscal years submitted by field activities. 3012. Annual Estimates of Expenditures, Field Activities.—The estimates of expenditures for a fiscal year shall be prepared annually by— Naval hospitals. Hospital ships. All shore stations which are required to submit Medical Department financial reports, except recruiting stations and naval radio stations. (1) Annual estimates of expenditures (in duplicate) and necessary annual requisitions shall be forwarded in time to reach the Bureau prior to March 1. No letter of transmittal is required. (2) Ships and other activities which are not required to submit annual estimates shall forward necessary annual local purchase requisitions in time to reach the Bureau prior to March 1. (3) Estimated expenditures for normal operating purposes shall be evenly distributed as nearly as practicable over the year. Procure- ment of special items and completion of projects shall be planned for accomplishment during the first three-quarters with due regard to consolidating procurement. Unusually large expenditures for projects shall be distributed, if practicable, over a period of 2 or more years. 3013. Annual Estimates of Expenditures, Basis for.—Annual esti- mates of expenditures shall be based upon the following factors: (a) For ALL ACTIVITIES REQUIRED TO SUBMIT ESTIMATES. (1) Mis- sion of the activity, as prescribed by approved naval policy, Navy Regulations, general orders, Bureau manuals, and district, fleet, or station organization instructions. (2) Current operating, development, and personnel plans for the activities served by the Medical Department. (3) Past expenditures. (4) Continuous maintenance of essential equipment by a planned program of repair or replacement. (5) Provisions to correct material deficiencies noted in the most recent Bureau, fleet, or district inspection reports, unless approved for correction during the current fiscal year. 399 3014 CH. 20.—FINANCE AND PROPERTY (b) Additional factors for hospitals, medical supply depots, and medical schools.—(1) Work beyond the capacity of the force employed shall be performed by additional temporary labor unless such work is required by Navy Regulations or other instructions to be accomplished under the supervision of the Bureau of Yards and Docks (public works officer). (2) Maintenance of permanent buildings, service utilities, and non- structural improvements, essential to efficient operation and in conformity with a planned program of repair or replacement of unserviceable items. In connection with this planned program, records of inspection, operation, and repair shall be maintained on NMS—Form W or Wa, for each building and appurtenance, service utility, nonstructural improvement, machine, or other important plant and equipment items. (3) Minimum maintenance of temporary buildings required for operation of the activity. (4) Provisions to correct material deficiencies noted in latest report of annual inspection of public works and public utilities, if such defects have not been corrected, or definite plans approved to correct them, during the current fiscal year. 3014. Annual Estimates of Expenditures, Form.—Annual estimates of expenditures shall be prepared on 8 by 13 inches standard weight typewriter paper, written lengthwise, assembled in standard filing folders and secured at the left side by bar-type paper fasteners, and shall include the required schedules assembled in the folders in the following order, from top to bottom: Schedule A—Summary of estimates. Medical Department allotment estimates (if required): Schedule B—Analysis of estimates by subheads. Schedule C—Schedule of expenditures. Schedule D—Summary statement of estimates. Schedule E—Itemized estimates, for each subhead. Naval hospital fund allotment estimates (if required): Schedule B—Analysis of estimates by subheads. Schedule C—Schedule of expenditures. Schedule D—Summary statement of estimates. Schedule E—Itemized estimates, for each subhead. Care of the dead allotment estimates (if required): Schedule G—Care of the dead estimates. Supply depot allotment estimates: Schedule H—Analysis of expenditures by classes and subheads. Schedule D—Summary statement of estimates. Project estimates: Schedule J—Project estimates (in numerical order). 400 SEC. 11. ESTIMATES OF EXPENDITURES 3015 3015. Annual Estimates of Expenditures, Preparation of.—Current instructions will be furnished Medical Department activities routinely each year by circular letter. Necessary blank forms for schedules, etc., shall be prepared by the activity. (See par. 3014.) In addition to the annual instructions, the following general directives shall obtain: (1) In order to understand the purposes and details of the field requests for funds, it is necessary that field estimates be prepared in full detail and that the presentation adhere to standard schedule and justification forms. (2) The annual estimates of expenditures (financial plan) will be predicated upon the past expenditures and proposed future program. Past performance establishes a hypothetical base and, since all condi- tions are rarely duplicated, it is only through consideration of current conditions in connection with this base that the past can be used to estimate future needs. A financial plan and control will necessitate keeping estimate data, day by day, in order to formulate the next annual estimate and the tentative estimates required for advance years. (3) Field estimates are divided into three parts, viz: Base sum. Recurring items. Nonrecurring items. (a) Base sum.—The base sum is the least amount required for normal maintenance of an activity at the current work load. (b) Recurring items.—Proposed increases to meet additional work load are itemized as recurring items. Recurring items, when approved by the Bureau, automatically increase the base sum for an activity, unless plans and programs of a future fiscal year eliminate or cancel items of expenditure. (c) Nonrecurring items.—Items or projects not of a continuing nature, and additional items, are termed nonrecurring items. (4) The tabular arrangement of the base sum, the recurring items, and the nonrecurring items, on schedule D, together with the sum- maries, details, and justifications required on other schedules, furnish the activity and the Bureau with a complete financial plan. (5) The various schedules permit each item of an estimate to be judged entirely by the soundness of the supporting justification. Allotments can then be made on a maximum basis to carry out a planned and orderly program of repair, replacement, and development of plant. If it is found necessary, due to lack of funds, to make reduc- 401 3016-3022 CH. 2 0. FINANCE AND PROPERTY tions in estimates, this is accomplished in the Bureau by elimination of the least urgent items. 3016. Tentative Estimates of Expenditures, Advance Years.— Estimates of expenditures for the 2 fiscal years beginning next after the end of the ensuing fiscal year shall be prepared and forwarded, in duplicate, to reach the Bureau prior to April 1, annually, by— Naval hospitals. Hospital ships. All shore stations which are required to submit Medical Depart- ment financial reports, except recruiting stations and naval radio stations. Tentative estimates, advance fiscal years, shall be based upon the factors enumerated in paragraph 3013. Estimates shall be prepared on 8- by 13-inch standard weight typewriter paper, written lengthwise, assembled in standard filing folders and secured at the left side by bar-type paper fasteners and shall include the required schedules, assembled in the folders in the following order, from top to bottom: Schedule A-l—Summary of estimates. Schedule D—Summary statement of estimates for: Medical Department allotment estimates (if required)— both years. Naval Hospital Fund allotment estimates (if required)— both years. Supply Depot allotment estimates—both years. Schedule J—Project Estimates—in numerical order. SECTION III. ALLOTMENTS, OBLIGATIONS AND EXPENDITURES Paragraph Allotments 3022 Allotment Reports 3023 Allotment Expenditures. Objects and Subheads for 3024 3022. Allotments.—(a) Authority for obligation of funds is usually granted by allotments. No obligation shall be incurred against any appropriation, unless sufficient funds are available under an allotment granted for the purpose, except when such obligation is authorized by Navy Regulations or by the manual of the Medical Department. In the event it becomes necessary to obligate funds in excess of an existing allotment, or in the absence of an allotment, a report of the 402 sec. hi.—allotments, obligations, expenditures 3022 circumstances shall be made to the Bureau, accompanied by a request for allotment or increase of an existing allotment. (b) Annual estimates of expenditures, approved by the Bureau, provide the basic financial plan of the activity for the fiscal year. Allotments are forwarded to the activity to cover the sums approved. The allotment indicates the allotment number, the appropriation, the purpose, the quarterly or other apportionment, and the total sum granted. (c) Annual allotments, based on average expenditures, are granted to ships without request. Commissioning allotments, together with prorated annual allotments, are granted to ships, without request, to cover cost of original outfits when ships are placed in commission. (See par. 3058.) (d) Allotments granted under the appropriations, Medical De- partment and care of the dead and under the trust account, naval hospital fund, are allocations of funds available for obligation by the activity. Supply depot allotments are credits only which authorize withdrawal of material from medical supply depots on approved NMS-—Form 4 requisitions to the value of the amount allotted. Annual allotments under the appropriation, fund, and medical supply depot stores are based on the maximum funds available to the Bureau. Requests for additional funds, or modification of quarterly apportion- ments, will be submitted only when circumstances beyond the control of the activity have made such increases or modifications necessary. (e) The total amount allotted for supplies subheads, 01 to 59, as indicated by the approved estimates shall not be exceeded. Funds allocated for a particular supplies subhead, may be exceeded, provided an equivalent reduction is made in the allocation for other supplies subheads of the same allotment, except as restricted by subpara- graph (g). (f) Items and funds under the equipment subheads, 60 to 79, and as approved in annual estimates shall not be modified materially. It is the item that is approved as well as the estimate for funds. If conditions necessitate reallocation of funds to procure an approved item, or to procure an item not included in the estimate, savings from other equipment items may be utilized and details given in explana- tory letter accompanying requisition. (g) Funds allocated for salaries and wages, for provisions, and for land and buildings subheads, shall be expended only for the purpose allocated. 403 3023 CH. 20. FINANCE AND PROPERTY (h) In the event a change in allotment becomes necessary, a letter request, containing the following information, shall be submitted to the Bureau: A statement indicating the circumstances requiring the change. A report of the existing allotment, at date of the request, in the following form: Allotment number Expended to date, this quarter (year) $— Obligated to date, this quarter (year) $ Amount normally required, balance of quarter (year) $ Total $ Amount available quarter (year if SD allot.) $ Increase (or Decrease) required - $— Request for change shall be restricted to one allotment. Dispatch request for allotment change shall be submitted in the following form: * * * request allotment (indicate letter and numeral designation of allotment) be increased (or decreased) (state amount) (indicate quarter or year) period increase (or decrease) required due to (state briefly circumstances requiring change) * * *. A confirmatory letter in the form indicated in this subparagraph shall be submitted concurrently with the dispatch. 3023. Allotment Reports.—(a) Report of allotment expendi- tures and obligations, NMS—Form B, shall be prepared and sub- mitted in accordance with the detailed instructions contained in Circular Letter F, appendix D. Each allotment should be closed at the end of the fiscal year, if possible. In the event it is impossible to close an allotment at the end of the fiscal year for which it was granted, every effort shall be made to liquidate such outstanding obligations at the earliest practi- cable date. Obligations against an allotment are: Specific purchase requisitions approved by the Bureau; Bureau or local work requests; orders actu- ally placed with dealers under authority of a continuing contract or an annual requisition; or commitments under local authority. The transactions incident to liquidation of obligations outstanding at the end of a previous fiscal year shall be taken up by ships and stations in the journal of receipts and expenditures of Medical Depart- ment property and reported in NMS—Form E, and at naval hospitals shall be entered in the appropriate financial records during the quarter in which liquidated. (b) Monthly reports of expenditures (S. & A. Form 280) and statement of charges and credits (S. & A. Form 126) are furnished the Bureau by officers of the Supply Department. However, these SEC. m. ALLOTMENTS, OBLIGATIONS, EXPENDITURES 3023 reports do not include current expenditures authorized by public voucher. In order that expenditures may be correctly reported, it is necessary that the amount indicated on NMS—Form B during any period, include the appropriational expenditures reported by supply officers on S. & A. Forms 126 and 280 for labor, material, and indeter- minate, as well as expenditures authorized by public vouchers or other vouchers. (c) The amounts granted by allotment, or other Bureau authority, control the sum available for obligation. Every expenditure of funds under cognizance of the Bureau shall be charged to the appro- priate object and subhead and reported as an expenditure under a local allotment or under one maintained in the Bureau. The Bureau maintains allotments to which are charged expenditures as follows: For recruiting stations; For civilian medical, dental, hospital, and nursing services, for active naval personnel; and For care of the dead on ships and at certain shore stations. (d) Every appropriational expenditure reported on NMS—Form B must be supported by a voucher substantiating the transaction, as follows: Item No. Source of supply Substantiating voucher When reported as ex- penditure on N. M. S. Form B 1 Property purchased by contracts authorized Standard Forms 1034 Date voucher is prepared by purchase requisitions or obtained from other Government departments. and 1034a (public voucher). (typed). 2 Labor — Standard form pay roll— Last day of period. 3 Naval supply account material Stub requisition or ex- penditure invoice (S. & A. Form 71). Month appearing on summary. 4 Clothing and small store account material Expenditure invoice When charged by supply officer. 5 A. P. A. material, when an appropriational allotment charge. Stub requisition or ex- penditure invoice. Do. 6 Job orders (Bureau work requests) S. & A. Form 280; other statement or invoice. Last day of month. 7 Material obtained from Marine Corps quarter- masters. Invoice and receipt (N. M. C. Form 24-Qm). Date invoice is receipted. 8 Transportation of remains Copy of bill of lading or order for transporta- tion. Date remains are deliv- ered to carrier. The following paragraphs are in explanation of the above items: (1) Payment for property purchased under contracts is authorized by public voucher, the appropriational expenditure being made by the local disbursing officer issuing the check in payment. (2) Payment for labor is made by the local disbursing officers under authority of approved pay rolls, expenditure being made by him at date of payment. (3) 1. Expenditures for naval supply account (NSA) material issued by the supply officer on stub requisitions are made by the local 405 3023 CH. 2 0.—FINANCE AND PROPERTY accounting (supply) officer of the issuing ship, yard, or station. Stub requisitions are local memoranda invoices, the total value of which, at shore activities, is included in the monthly summary of stub requisi- tions (S. & A. Form 178) covering NSA and appropriation purchases account (APA) material separately. Expenditures are made in the amount indicated by Form 178 covering NSA stub requisitions charged during the month. The summary, or equivalent voucher on board ship, is signed by the commanding officer or head of depart- ment who received the material (par. 3096 (3)). 2. Expenditures covering NSA material issued on expenditure invoices (S. & A. Form 71) are not included in the summary of stub requisitions, the receipted expenditure invoice substantiating the charge. Provisions are issued to naval hospitals on expenditure invoices. (4) Expenditures for clothing and small stores material received are made by the local accounting (supply) officer, the substantiating voucher being the receipted expenditure invoice (S. & A. Form 71). (5) Appropriation purchases account material, as defined by article 1865, Navy Regulations, is not usually an appropriations 1 expendi- ture. Several types of transactions, however, invoiced as APA items, are evidence that appropriational expenditures have been made by the supply officer and indicate inclusion of those items as an allot- ment expenditure, as follows: Transportation charges on material purchased f. o. b., contractor’s plant, ship- ment authorized on Government bill of lading. Purchases liquidated by public vouchers under title 13-X-2, directly charge- able to Bureau appropriations (ambulances, typewriters on exchange, etc.), are abstracted by the Bureau of Supplies and Accounts to the nearest stores activity (as indicated by article 1100, Bureau of Supplies and Accounts Manual), and cleared as APA material. The APA stub requisition shall be used as an appropriational expenditure voucher only when a copy of the title 13-X-2 public voucher has not been previously furnished. (6) Expenditures for work performed by yard labor under au- thority of Bureau or local work requests, are made by the accounting (supply) officer of the yard or station performing the work. Cost charges are recorded in a job order account (usually title Z) and include as appropriational expenditures the value of NSA material used, the value of labor consumed, and the indeterminate charges applicable to the specific work, and, as nonappropriational expendi- tures, the value of APA material used and estimated statistical overhead. The value of statistical overhead shall not be included in 406 SEC. III.—ALLOTMENTS, OBLIGATIONS, EXPENDITURES 3023 computing total cost of work performed. An invoice or a statement of expenditures charged against job orders is furnished monthly to the activity for which the work is performed, indicating the value of NSA material, APA material, labor and indeterminate, and the value of public vouchers drawn directly against Bureau funds. The value of appropriational expenditures made during a period, as fur- nished to the activity, shall be included with other expenditures reported on NMS—Form B for the same period. The value of the APA material used shall be taken up as a transfer voucher received. When a job order is completed, the activity performing the work will furnish a copy of NSO—106 (job order charges) indicating total expenditures. When received the report shall be checked against the total monthly job order charges to insure that all appropria- tional expenditures will be reported appropriately on NMS—Form B. If through oversight, an expenditure has not been reported to the Bureau, it will be reported on the current NMS—Form B with an explanatory note. Expenditures for work performed by public works contracts are authorized by public vouchers and paid by disbursing officers in the same manner as other purchases. A copy of such public vouchers, usually prepared by the public works officer supervising the work, is furnished the activity for which the work is performed. The amount of these public vouchers shall be reported as an expendi- ture on NMS—Form B during the period in which the copy of the public voucher is received, unless previously reported from an APA stub. (7) Expenditures for material obtained from Marine Corps quarter- masters are made by the Marine Corps Quartermaster on the au- thority of the receipted NMC—Form 24-Qm. The amount of these expenditures shall be reported during the period in which the invoice is receipted. (8) Charges for transportation of remains, authorized by Govern- ment bill of lading or transportation request, are ultimately liquidated by public vouchers. Expenditures for transportation are made by disbursing officers in the same manner as other expenditures on public vouchers. In view of the long period of time which elapses between the obligation and recording the actual expenditure for transportation of remains, and since a very accurate estimate is obtainable from the initial carrier, the estimated cost of transportation of remains shall be obtained from the carrier and reported as an expenditure by the activity shipping remains, on the NMS—Form B prepared for the period in which shipment is made. Adjustment of expenditures re- ported by the activity is made in the Bureau when charges are 407 3024 CH. 20.—FINANCE AND PROPERTY liquidated. Obligations for transportation of remains in foreign countries, when liquidated locally by authority of public vouchers, shall be reported as an expenditure on NMS—Form B for the period in which the public voucher is dated. (e) In event an activity should incur charges (or be invoiced charges) against Bureau funds which are not covered by paragraph 3023 (d), a notation or letter shall accompany NMS—Form B for the period in which the charge occurred, fully explaining the transac- tion in order that the Bureau may reconcile the charges with other reports. (f) The date public vouchers are paid need not be considered in reporting expenditures on NMS—Form B. (g) Each Medical Department activity preparing public vouchers shall indicate in the space captioned “Additional Statement by Depart- ment, Bureau, or Establishment, if deemed necessary,” the month in which charged to the allotment as an appropriational expenditure, the allotment number, and expenditure object and subhead to which the items enumerated on the voucher apply. As an example, a voucher is prepared in payment for a drug during July, fiscal year 1939; the data to be inserted would be: “7/9243/1406”— 7, representing the month (July), 9243, representing the allotment number, and 1406, representing the object and subhead numbers. In the space “No. ,” below “D. O. Vou. No. each preparing activity shall number public vouchers in the following manner: First, the number of the purchase requisition followed by a dash and the serial number of the voucher prepared in payment for material procured under the requisition. The letter P shall precede the NSA or Bureau purchase requisition number on vouchers prepared by hospitals and hospital ships in payment for provisions. (h) Public vouchers prepared by medical supply depots, covering medical stores, shall modify the above so as to indicate the month in which charges to the allotment as an appropriational expenditure will be made. The allotment number and the supply table class number by which the items on the voucher will be taken into store follow: Supply table classes use numerals only. Supplementary supply table classes precede numeral by S. Non-listed classes precede numeral by NL. 3024. Allotment Expenditures, Objects, and Subheads for.—Ex- penditures of funds are classified by object, by subhead groups, and by subhead. Expenditures of funds shall be charged to one of the following objects: 408 sec. hi.—allotments, obligations, expenditures 3024 (a) Object 14—Maintenance and operation of shore sta- tions.—Expenditures for supplies and services consumed in the opera- tion of the medical department of shore stations (except expenditures specifically chargeable to objects 16 and 22) including expenditures for personal services, consumable supplies for the sick, dental supplies, maintenance supplies, and repair supplies and services. (b) Object 15—Maintenance and operation of the fleet.— Expenditures for supplies and services consumed in the operation of the medical department of ships (except expenditures specifically charge- able to objects 16 and 22) including consumable supplies for the sick, dental supplies, maintenance supplies, and repair supplies and services. (c) Object 16—Miscellaneous operating charges.—Expendi- tures made for the benefit of the naval service generally including services of blood donors, special instruction and hygienic investiga- tion, and miscellaneous charges. (d) Object 22—Burial expense.—Expenditures for the care of the dead, including care and preparation of remains, transportation of remains, caskets, and mortuary supplies; care of cemeteries and graves; and mortuary equipment. (e) Object 30—Equipage of naval vessels.—Expenditures for medical department equipment outfits for ships and subsequent addi- tions and replacements, including medical, dental, and surgical equipment and medical books. (f) Object 32—Additions and improvements to shore sta- tions.—Expenditures for medical department equipment outfits for shore stations and subsequent additions and replacements, including medical, dental, and surgical equipment, vehicular equipment, and maintenance equipment. The classification by objects does not furnish sufficient detail for administrative purposes. Therefore, it is necessary to reclassify expenditures by subhead groups and subheads. Subhead groups include subheads recording expenditures for similar general purposes, i. e.: (1) Personal services—Subheads Nos. 01 and 02. (2) Supplies and services for the sick—Subheads Nos. 04, 05, 06, 07, 08, 13, and 59. (3) Dental supplies—Subhead No. 10. (4) Maintenance supplies—Subheads Nos. 11, 12, 16, 18, 19, 20, 21, 22, 23, 24, 26, 27, 42, and 43. (5) Repair supplies and services—Subheads Nos. 35, 36, 37, and 40. (6) Services of blood donors—Subhead No. 09. (7) Special instruction and hygienic investigation—Subhead No. 57. (8) Miscellaneous charges—Subheads Nos. 56 and 58. (9) Care of the dead—Subheads Nos. 50, 51, 52, 53, and 73. 409 3024 CH. 2 0.—FINANCE AND PROPERTY (10) Hospital, medical, and surgical equipment—Subheads Nos. 60 and 74. (11) Dental equipment—Subhead No. 64. (12) Vehicular equipment—Subhead No. 68. (13) Maintenance equipment—Subheads Nos. 62, 63, 65, 66, 69, 70, 71, 72, and 79. (14) Land and Building Additions and Improvements—Subheads Nos. 80, 81, 82, and 83. (g) In general, the purpose or use for which an item is intended shall control the selection of the subhead against which the expenditure shall be reported. (h) Expenditures under an object shall be further analyzed by one or more of the following subheads: OBJECT 14—MAINTENANCE AND OPERATION OF SHORE STATIONS AND OBJECT 15—MAINTENANCE AND OPERATION OF THE FLEET [Appropriation chargeable key: MD = medical department; HF«= naval hospital fund; CD—care of the dead] Appropriation chargeable Hospi- tals Other shore stations Ships Sub- head No. Subhead group (1) Personal services Salaries (clerical) MD MD 01 Salaries of civil employees assigned to group IV (b) and those per- forming similar services carried under native and alien schedules in the “schedule of wages for civil employees in the field service of the Navy Department,” who are carried on pay roll as a direct charge to the appropriation Medical Department, including retirement fund deductions, but excluding special duty service and part compensa- tion. Wages MD MD 02 Pay of all civil employees who are carried on pay roll as a direct charge to the appropriation Medical Department, and not designated under 01, including retirement fund deductions, but excluding special duty service and part compensation. (2) Supplies and services for the sick Civilian medical, dental, and nursing services - HF HF HF 04 Payment of civilian medical, dental, and nursing services, includ- ing special examinations for patients not admitted to civilian hospi- tals, when authorized. Care of sick in other than naval hospitals HF HF HF 05 Hospitalization of naval personnel in other than naval hospitals. Includes charges for X-ray, laboratory or other special examinations when patient is admitted to such hospital; otherwise charge to 04. Medicines, tablets, and biologicals HF MD MD 00 Drugs; medicinal preparations; tablets; biologicals; anesthesia gases; alcohol; antiseptics; medicinal agents or vehicles such as yeast, ginger ale, etc. Surgical dressings, hospital and nursing supplies HF MD MD 07 Surgical dressings; splints; minor, inexpensive surgical instru- ments; expendable surgical, hospital and nursing supplies; expenda- ble bedding and linen; curtain material; needles; thread; thimbles; and similar linen room supplies; canvas, grommets and small tools for manufacturing shower curtains; bedside screens; etc. Special department supplies HF MD MD 08 Expendable dispensary, laboratory, X-ray, electrocardiographic, basal metabolism, physical therapy and hydrotherapy apparatus and supplies, including cost of, and feed for, laboratory animals. 410 SEC. III.—ALLOTMENTS, OBLIGATIONS, EXPENDITURES 3024 OBJECT 14—MAINTENANCE AND OPERATION OF SHORE STATIONS AND OBJECT 15—MAINTENANCE AND OPERATION OF THE FLEET [Appropriation chargeable key: MD=medical department; HF-=naval hospital fund; CD«=care of the dead] Appropriation chargeable Hospi- tals Other shore stations Ships Sub- head No. Subhead group (2) Supplies and services for the sick—Continued Provisions and items of special diets HF MD MD 13 At hospitals, provisions for the general mess or for special diet. On board hospital ships, provisions to be used by the medical depart- ment for the requirements of the sick. Items somtimes classified as provisions, such as yeast, ginger ale, grape juice, mineral water and alcoholic beverages, which are required for use as medicinal agents or vehicles, shall be charged to subhead 06. Items of special diet re- quired for the sick on board ship and at other shore stations. Field supplies - MD MD MD 59 Special supplies for Navy and Marine Corps expeditionary and ilanding force units. (3) Dental supplies Dental supplies MD MD MD 10 Including artificial teeth. (4) Maintenance supplies Stationery, library and office supplies MD MD MD 11 12 Writing paper; envelopes; carbon paper; stencils; printed forms; mailing tubes; file guides and folders; index guides; blotting paper; blotter holder; blank books; desk shears; paper fasteners; labels; seals; pencils; leads; pens; ink eradicators; erasers; typewriter and adding machine ribbons and paper; inking pads; metal seals; inks; calendar pads; pencil sharpeners; sponges and sponge cups; special forms for temperature and time recorders and diagnostic apparatus; revised and reprinted replacement sheets for books (equipment) of the “loose- leaf” types and similar expendable supplies. Printed forms and instructions for diagnostic examinations, educa- tional classification, etc. Copies of death certificates. Cleaning, toilet and sanitation supplies __ HF MD Soap; soap powder; detergents; steel wool (when used for general cleaning purposes); phosphate cleanser; sponges; brooms; brushes; dust pans; swabs; dust mops; toilet paper; floor wax; furniture polish; and similar cleaning and toilet supplies. Disinfectants for general cleaning and sanitary use within the medical department; insecticides and animal poisons, except those used for care of grounds, trees, shrubs, etc. Trash and garbage cans. Laundry supplies shall be charged to subhead 16. Laundry supplies and services __ HF MD MD 16 Laundry supplies such as soap; soda; washing powder; bleach; starch; sizing; bluing; wax; wash bags; linen marking supplies; canvas for rollers, tables, ironer aprons, etc. Prorated cost of laundry supplies for laundering medical depart- ment linen by ship or station laundries. Cost of laundry services obtained under purchase contracts. Transportation supplies and services - MD MD MD 18 Gasoline; motor fuel; oil; grease; spark plugs; tires; tubes; valve caps; automobile wax; sponges; chamois skins; antifreeze solutions; auto- mobile lamp bulbs; automobile overhaul and repair services; replace- ment parts; inexpensive automobile tools; paints; painting; and simi- lar consumable supplies and accessories for automotive equipment. Maintenance supplies; feed; grain; bedding; shoeing; repair of har- ness and wagons; veterinary services and medicine; and incidental supplies for draft animals. Transportation supplies and services, passenger-carrying ve- hicles MD 19 Cost of maintenance, operation and repair of passenger-carrying automobiles, including items as indicated under subhead 18, at activi- ties where such passenger-carrying vehicles are authorized by the an- nual Naval Appropriation Act. Fuel, except gas HF MD 20 (Hospitals, medical supply depots, and Naval Medical Center.) Coal; coke; fuel oil; wood; etc., except gas. 411 3024 CH. 20.—FINANCE AND PROPERTY OBJECT 14—MAINTENANCE AND OPERATION OF SHORE STATIONS AND OBJECT 15—MAINTENANCE AND OPERATION OF THE FLEET [Appropriation chargeable key: MD=medical department; HF=naval hospital fund; CD=care of the deadj Appropriation chargeable Hospi- tals Other shore stations Ships Sub- head No. Subhead group (4) Maintenance supplies—Continued Gas service HF MD 21 (Hospitals, medical supply depots, and Naval Medical Center.) At other shore activities, only gas used in connection with care of the sick is chargeable to Medical Department funds (laboratory, dental, etc.). Heating service HF MD 22 Steam or hot water heat at hospitals, medical supply depots, and Naval Medical Center. Electric light and power service HF MD 23 Electric service at hospitals, medical supply depots, and Naval Med- ical Center. Water service HF MD 24 Water service at hospitals, medical supply depots, and Naval Med- ical Center. Commissary supplies, except provisions HF 26 Kitchen utensils (except the more expensive items) such as frying pans; pie pans; paring knives; cooks’, butchers’, and boning knives; steels; whips; spoons; saucepans; funnels; strainers; ladles; mixing bowls; dredges; condiment cans; cleavers; meat and bone saws; rock salt (for freezing foods), and similar kitchen supplies. Dining room china and glass ware; serving utensils; replacement containers for steam tables and food carts; Navy standard knives, forks, and spoons, except silverware; and similar supplies. Special cleaning agents purchased exclusively for dishwashing pur- poses. Ice and mechanical refrigeration supplies (except repairs) required for preservation and preparation of foods. Refrigeration thermom- eters. Mess attendants’ jackets, aprons, dish towels. Artificers’, fire protection and general supplies _ HF MD MD 27 Artificers’ loose and hand tools, minor equipment; supplies and expendable materials procured for general use. Items purchased for stores replenishment which will eventually be used for one specific type of repair or purpose shall be charged to the appropriate subhead. Fire protection supplies and replacement parts, such as fire hose, nozzles, spanner wrenches, chemical extinguisher materials. Ice procured for purposes other than food preservation and prepara- tion. Safety matches for general use. (Transportation charges on f. o. b. and f. a. s. purchase contract de- liveries, as invoiced by the supply officer, for both supplies and equip- ment, shall be added to the cost of the material and charged to the respective subheads to which the material is allocated.) Maintenance of grounds, roads, and walks MD MD 42 (Hospitals, medical supply depots, and Naval Medical Center.) Repair, maintenance and minor improvements of grounds, roads, and walks; material for such repair. Repair of equipment for care of grounds, such as mowers, road equip- ment, rollers, watering equipment, garden tools, road cleaning equip- ment, etc. Cost of trees, including services of tree surgeons, procured under contract or job order; tree spraying; plants; seeds; fertilizer; minor tools, such as rakes, shovels, hoes, street brooms, snow shovels, hand lawn mowers, sprinklers, garden nose, hedge and grass trimmers, and similar items used for care of grounds. Waste removal service _ HF MD 43 (Hospitals, medical supply depots, and Naval Medical Center.) Expenditures for removal of rubbish, ashes, garbage, etc., including fuel used in incinerator. 412 SEC. III. ALLOTMENTS, OBLIGATIONS, EXPENDITURES 3024 OBJECT 14—MAINTENANCE AND OPERATION OF SHORE STATIONS AND OBJECT 15—MAINTENANCE AND OPERATION OF THE FLEET [Appropriation chargeable key: MD=medical department; IIF=naval hospital fund; CD=care of the dead] Appropriation chargeable Hospi- tals Other shore stations Ships Sub- head No. Subhead group (5) Repair supplies and services HF MD 35 (Hospitals, medical supply depots, and Naval Medical Center.) Cost of material, supplies and replacement parts, purchased for im- mediate or deferred (stores) use in the repair or maintenance of build- ings and appurtenances. Cost of all repair work, including minor ad- ditions or extensions whether performed by yard labor or public works contracts under authority of job orders, or by hospital maintenance force. Buildings and appurtenances include the structure; electric, heating, plumbing, water, sewer, etc., systems located inside the building (see subhead 80): Awnings; screens; fire-escapes, porches; elevators; plumbing and toilet fixtures; lighting fixtures, lamps, shades, and sockets; and built-in shelving, cupboards, ventilation fans, blowers, etc., permanently attached to and part of the building. Metal products, lumber, linoleum, paints and preservatives and other materials and supplies, when purchased for building repair, maintenance or preservation, whether for immediate or deferred use, shall be charged to this subhead. Elevator inspection service and repair. Window shade replacements. Repair and maintenance of service utilities _ HF MD 36 (Hospitals, medical supply depots, and Naval Medical Center.) Minor repair and maintenance of heat, steam, electric, gas, water (including water tanks, artesian wells, and reservoirs) brine, fuel oil, telephone, sewer, compressed air, street lighting, and fire protec- tion lines and distribution systems, including tunnels, conduits, poles, etc., carrying such lines, which are located outside of build- ings (see subhead 83) whether performed by yard labor, public works contract under authority of job orders, or by hospital maintenance force. Materials and supplies such as, pipe; pipe fittings; cable; wire; dis- tributing panels; street lighting standards or poles, fixtures, lamps, and globes; replacement meters; valves; gutter grates (surface drains); and similar replacement parts, material, and maintenance supplies. Where fire protection, compressed air, sewer services, etc., main- tained by yard or station and used by hospital, the prorata invoiced cost shall be charged to subhead 36. Repair and maintenance of nonstructural improvements HF MD 37 (Hospitals, medical supply depots, and Naval Medical Center.) Minor repair and maintenance of railway spurs; bridges; piers; wharves; fences; sea walls; retaining walls; ditches; flag poles; tennis and handball courts; baseball backstops; commemorative structures; monuments, etc. (except in cemetery lots); and like improvements, not classified as buildings (see subhead 82) whether performed by yard labor or public works contract under authority of job orders, or by hospital maintenance force. (Minor repair and maintenance of grounds, roads, walks, etc., shall be charged to subhead 42.) Repair of equipment __ _ HF MD 40 Repair and minor improvement of all equipment, except motor vehicles and horse drawn equipment (subheads 18 and 19) and main- tenance of equipment for grounds (subhead 42). Repair of power plant equipment (including the periodical inspec- tion service of boilers); fireboxes; engines; generators; pumps; motors; fuel oil tanks; coal bunkers; gauges and other recording instruments; etc. Replacement of parts of units, when survey has not been (and will not be) held, shall be charged to subhead 40. For example: An electric motor, part of an air compressor, is burned out and exam- ination reveals that a new motor of tho same type would cost less than repair of the old. Replacement without survey should be made and the cost charged to subhead 40. When survey has been held and approved, cost of replacement unit shall be charged to the appropriate equipment subhead. Repair and minor improvement of telephone, fire protection, laun- dry, cleaning, sterilizing, commissary, X-ray, hospital and special equipment, and machinery and tools. 413 3024 CH. 20.—FINANCE AND PROPERTY OBJECT 16—MISCELLANEOUS OPERATING CHARGES [Appropriation chargeable key: MD=medical department; HF=naval hospital fund; CD *= care of the dead] Appropriation chargeable Hospi- tals Other shore stations Ships Sub- head No. Subhead group (6) Services of blood donors Services of blood donors Services of blood donors. No other item shall be charged to this subhead. (7) Special instruction and hygienic investigation MD MD MD 09 Special instruction and hygienic investigation (Naval Medical Center only, except when specifically authorized.) Expenditures in connection with post-graduate and special courses of instruction of medical and dental officers, pharmacists, nurses, and Hospital Corps men, at other than Army or Navy activities; expendi- tures in connection with hygienic and sanitary investigation. (8) Miscellaneous charges MD MD MD 57 Orthopedic and prosthetic appliance Appliances for correcting or preventing deformity of the body and artificial parts (except artificial teeth) fitted to the body, such as arti- ficial limbs, eyes, braces, etc. MD MD MD 56 Tolls and ferriages Toll and ferry charges for Medical Department vehicles and driver, properly chargeable to funds of the Bureau. (Toll and ferry charges for patients and other passengers are not chargeable to Medical De- partment funds.) MD MD MD 58 OBJECT 22—BURIAL EXPENSES (9) Care of the dead Bubial expense CD CD CD 50 Expenditures in connection with burial of the dead (except caskets) such as embalming, clothing, hearse and carriages, opening and clos- ing grave, permits, cost of grave, local transportation incident to preparation and funeral, or shipment. Caskets purchased under local care of the dead contracts shall be charged to subhead 52. CD CD CD 51 Estimated cost of transportation of remains on Government bill of lading, transportation requests or by other authorized means, when chargeable to funds of the Bureau. A very accurate estimate is usually obtainable from the agent of the carrier at point of shipment. Final adjustment of cost of transportation will be made by the Bureau. (Since payment for all transportation is made by the Bureau of Supplies and Accounts, except under most unusual circumstances, the best estimate obtainable shall be reported as an expenditure by the field activity.) CD CD CD 52 Caskets and supplies for general use, including caskets purchased under local care of the dead contracts. CD CD CD 53 Expenditures in connection with care, maintenance and preserva- tion of naval cemeteries and isolated graves, including erecting of headstones, monuments, flagpoles, fences, walks, and roadways. (Headstones, including transportation thereof to designated point, are supplied by the War Department, without charge, upon request submitted as prescribed by par. 3059. CD CD CD 73 Mortuary equipment such as: Tables, necroscopic instruments, embalming apparatus, carriers for removal of bodies, and similar equipment for exclusive use in connection with the care of the dead. 414 SEC. III.—ALLOTMENTS, OBLIGATIONS, EXPENDITURES 3024 OBJECT 30—EQUIPAGE OF THE FLEET AND OBJECT 32—ADDITIONS AND IMPROVEMENTS TO SHORE STATIONS [Appropriation chargeable key: MD=medical department; HF=naval hospital fund; CD=care of the dead] Appropriation chargeable Hospi- tals Other shore stations Ships Sub- head No. Subhead group (10) Hospital, medical, and surgical equipment Hospital, medical, and subgical equipment HF MD MD 60 Expenditures for equipment peculiar to hospitals, such as: Hos- pital, surgical and fracture beds; mattresses, pillows, bedding, and linen (except dining room linen and dental linen); ward desks, cabi- nets, lockers, screens, stands, tables, stretchers, and wheeled litters; S. 0. Q. furniture; furnishings; operating room furniture; sterilizing apparatus; surgical instruments and appliances; X-ray equipment; hydrotherapy and physical therapy equipment; special diagnostic equipment; laboratory equipment; ward clocks; physicians’ scales; and other special medical, surgical, and hospital equipment. (Transportation charges on f. o. b. and f. a. s. purchase contract deliveries for both supplies and equipment shall be added to the cost of the material and charged to the respective subheads to which the material is allocated.) MD MD MD 74 Special equipment for Naval and Marine Corps expeditionary and landing force units. (Applicable chiefly at medical supply depots.) (11) Dental equipment MD MD MD 64 Expenditures for dental equipment. Items of linen procured for exclusive use of the dental office shall be charged to this subhead. (12) Vehicular equipment Vehiculab equipment MD MD MD 68 Expenditures for motor ambulances and trucks, including motor- ized fire trucks; horse-drawn wagons and carts; harness; bicycles; and other vehicles. (13) Maintenance equipment HF 62 Expenditures for equipment peculiar to the commissary depart- ment, diet kitchens, etc., such as: Ranges, cookers, steam kettles; mixing machines; bake ovens; vegetable peelers and cutters; ice- cream freezers; platform (inspection), butchers’, bakers’, cooks’ and dieticians’ scales; butchers’ and cooks’ tables; meat blocks; portable refrigerators, except for laboratory (biological storage), or staff quar- ters; power meat and bonesaws; meat slicers; bread cutting machines; dishwashing machines; coffee urns; portable food serving carts; dish trucks; serving and steam tables; kitchen and serving utensils of long life; silverware; damask table cloths and napkins; and other special commissary equipment. HF MD 63 (Hospitals, medical supply depots, and Naval Medical Center.) Expenditures for furniture, furnishings, and fixtures for use in hos- pital offices; reception room; libraries; lobby; staff quarters; equipment for other spaces not used primarily for the care and treatment of the sick, including desks, chairs, tables, filing cabinets, safes, bookcases, clocks, setees; rugs and floor coverings; portiers, drapes, curtains, mirrors; all furniture, furnishings, including portable refrigerators, and fixtures for use in staff quarters (officers’, nurses’, Hospital Corps, and civilian); storeroom fixtures, such as steel shelving, bins, hand trucks, scales, etc.; recreation room furniture, furnishings and fix- tures; porch and lawn gliders; portable ventilating equipment (fans, etc.); chairs; benches; and similar equipment. Original purchase of window shades and additional shades shall be charged to subhead 63; replacements to subhead 35. 415 3024 CH. 20.—FINANCE AND PROPERTY OBJECT 14-MAINTENANCE AND OPERATION OF SHORE STATIONS AND OBJECT 15-MAINTENANCE AND OPERATION OF THE FLEET [Appropriation chargeable key: MD=medical department; HF=naval hospital fund; CD =care of the dead Appropriation chargeable Hospi- tals Other shore stations Ships Sub- head No. Subhead group (13) Maintenance equipment—Continued Office machines and devices... HF MD 65 Expenditures for typewriters; adding machines; calculators; book- keeping machines; addressographs; billing machines; blueprint ma- chines; dictating and transcribing equipment; duplicating machines; mimeographs; multigraphs; time recording stamps; and other office machines and devices. Plant equipment, machinery, and tools HF MD 66 Expenditures for heat, light, power, water, refrigeration and electrical equipment, machinery and tools, such as: Boilers and power house equipment; engines; generators; motors; pumps; transformers; switchboards and panels; refrigerator equipment (built-in); and other plant equipment. Expenditures for machinery, and power tools, such as: Drill presses; lathes; millers; pipe cutting and threading machines; power saws; woodworking machines; grinding machines; portable power tools; welding outfits; and similar machinery and tools. (Machine tools, jigs, and fixtures, not of a consumable nature shall be carried as a part of the machine with which they are most used. Consumable machine tools such as drills, reamers, taps, dies, etc., shall be charged to subhead 27.) The costly and durable hand tools such as micrometers; verniers; tachometers; vices; anvils and adjustable squares, shall be charged to subhead 66; small, inexpensive, and consumable hand tools shall be charged to subhead 27. Fire protection equipment HF MD 69 (Hospitals, medical supply depots, and Naval Medical Center.) Expenditures for hand-drawn chemical engines and trucks; hook and ladder trucks; hose carts; wheeled chemical extinguishers; special fire-protection equipment. Value of initial outfits and additional items of hose, hand extin- guishers, fire hooks, axes, nozzles, etc., are properly chargeable to this subhead; charge replacements to subhead 27. Laundry and cleaning equipment HF MD 70 (Hospitals, medical supply depots, and Naval Medical Center.) Laundry machinery and equipment; vacuum cleaners; and floor polishers, etc. Equipment for maintenance of grounds MD MD 71 (Hospitals, medical supply depots, and Naval Medical Center.) Motor and horse-drawn lawn mowers; lawn and road rollers; power hedge clippers; power-driven street cleaning equipment; automotive snow-plow attachments; plows; cultivators and similar durable equipment for repair and maintenance of grounds, roads, walks, trees, shrubbery, etc. Library and reference books MD MD MD 72 (The purchase of all books is made by medical supply depots twice annually.) Medical, technical, and reference books. (Revised replacement sheets for books of the loose-leaf type and printed forms and instructions for use in connection with diagnostic and educational classification examinations, etc., shall be charged to subhead 11.) Sundry equipment HF MD 79 (Hospitals, medical supply depots, and Naval Medical Center.) National ensigns; red cross flags; mail bags (for use by mail orderly); and special testing equipment at supply depots and the Medical School. No other items shall be charged to this subhead except when specifically directed by the Bureau. 416 SEC. III.—ALLOTMENTS, OBLIGATIONS, EXPENDITURES 3024 OBJECT 14—MAINTENANCE AND OPERATION OF SHORE STATIONS AND OBJECT 15-MAINTENANCE AND OPERATION OF THE FLEET [Appropriation chargeable key: MD=medical department; HF=naval hospital fund; CD=careof the dead] Appropriation chargeable Hospi- tals Other shore stations Ships Sub- head No. Subhead group (14) Land and buildings, additions and improvements Buildings and appurtenances HF HF HF HF MD MD MD MD 80 81 82 83 (Hospitals, medical supply depots, and Naval Medical Center.) First cost of buildings and appurtenances; thereafter, only cost of major additions or extensions which materially add to the original value. Appurtenances include building equipment located within or permanently attached to and part of, the structure, such as: Fire escapes; elevators; plumbing and fixtures; electric, heating, water, steam, gas, telephone, ventilation, fuel oil, fire protection, refrigeration (brine, etc.), and compressed air systems; built-in fixtures; porches; awnings; door and window screens; lighting fixtures; and similar items. (Repairs and minor additions, extensions or improvements are considered to restore depreciation and shall be charged to subhead 35.) Land Purchases of land when title is transferred by deed to the United States. (Contract for such purchases are made by the Judge Advocate General. Appropriation chargeable as indicated in each specific authorization.) Improvements to land, other than buildings _ (Hospitals, medical supply depots, and Naval Medical Center.) First cost of improvements, thereafter, only cost of major additions or extensions which materially add to original value. Improvements to land include railway tracks, bridges, piers, wharves, sea walls, fences, drainage ditches, terracing walls; flag poles, tennis and hand ball courts, baseball backstops, commemora- tive structures, retaining walls, embankments, grading, roads, walks, or other improvements. (Repairs and minor additions, extensions, or improvements are con- sidered to restore depreciation and shall be charged to subhead 37.) Service utilities (Hospitals, medical supply depots, and Naval Medical Center.) First cost of service utilities, thereafter, only cost of major additions or extensions which materially add to original value. Service utilities include, heat, steam, electric, gas, water (including water tanks, wells, cisterns), brine, fuel oil, telephone, sewer, com- pressed air, street lighting, and fire-protection systems, including tunnels, conduits, poles, etc., carrying such lines, which are located OUTSIDE OP BUILDINGS. (Repairs, minor additions, extensions, or improvements are con- sidered to restore depreciation and shall be charged to subhead 36.) (i) When an item, carried in the land and buildings account at an estimated value, is wholly replaced, the old item shall be surveyed and the new item taken up at the actual cost. (See par. 3099 (d).) (j) Estimates or reports of expenditures shall indicate the object and subhead numbers in combination of four numerals, the first two numerals designating the object and the second two designating the subhead; for example: 1401 represents object No. 14 and subhead 01—salaries (clerical); 3260 represents object No. 32 and subhead 60—hospital, medical, and surgical equipment. 417 3030-3031 CH. 2 0.—FINANCE AND PROPERTY SECTION IV. PROCUREMENT METHODS Paragraphs Property: Procurement Under Allotment, Requisition, Contract, NMSD—Requisition, Etc 3030-3042 Property: Procurement Without Allotment, Local Procurement, Transfer 3043-3048 Special Items, Procurement of 3043-3057 Alcohol 3049 Blood Donors 3050 Surgical Instruments, X-ray Equipment, Medical Books 3051 Biologicals: Antigens, Bacterial Cultures, Etc 3052 Stationery and Printing 3053 Furniture, Etc., Staff Quarters 3054 Motor Vehicles 3055 Orthopedic and Prosthetic Appliances 3056 Medical Supplies, Local Purchase — 3057 Commissioning Outfit 3058 Headstones, Naval Cemeteries 3059 3030. Authority for Procurement Under Allotment.—Materials and services, required for maintenance of the Medical Department and chargeable to Bureau funds, may be procured by the following methods when an allotment for the purpose has been granted by the Bureau: Purchase requisitions (S. & A. Form 44, afloat, and Form 76, ashore). Stub requisitions (S. & A. Form). Expenditure invoices (S. & A. Form 71) (when used as a requisition). Marine Corps invoices (NMC—Form 24r-Qm.) (when used as a requi- sition) . Requisitions for labor (NYO—Form 6). Work requests (job order). Medical supply depot requisitions and invoices (NMS—Form 4). 3031. Purchase Requisitions, General Information.—(a) General instructions for preparing purchase requisitions are contained in articles 1395 to 1400, Navy Regulations, for activities afloat and in articles 1604 to 1610, Navy Regulations, for activities ashore. De- tailed instructions for preparing and submitting purchase requisitions, ashore, and afloat, are contained in chapter 9, Bureau of Supplies and Accounts Manual. (b) Materials, not listed as Navy material in the Federal Standard Stock Catalog or carried in stock at medical supply depots or by a supply officer or Marine Corps quartermaster, may be obtained by purchase requisition. A purchase requisition is prepared by the requiring activity and submitted to the Bureau. Approval by the Bureau, except as noted under paragraph 3032, is required to authorize obligation against Bureau appropriations. After approval by the Bureau, purchase requisitions are forwarded to the Bureau of Supplies 418 SEC. IV.—PROCUREMENT METHODS 3032-3033 and Accounts for action as all purchase contracts (except contracts for purchase of land and public works contracts), and payments under all contracts, are made by that Bureau. If the contract is not made by the Bureau of Supplies and Accounts, a supply officer, usually in the same area as the requiring activity, is designated to make the purchase contract. (c) Purchase requisitions drawn under Bureau appropriations or fund shall be numbered in a separate series for each fiscal year. A two-group numbering system shall be used, the first group being the serial number followed by a dash and the second group consisting of the last two numbers of the fiscal year, i. e,, 1-39, 2-39, 3-39, etc. Serial numbers of requisitions cancelled or not approved shall not be used on a subsequent requisition except when specifically directed by the Bureau. (d) Purchase requisitions drawn under funds of other Bureaus shall be numbered in a separate series for each fiscal year. 3032. Local Approval in Emergency.—Requisitions for materials or services, required under circumstances not permitting sufficient time for submission of a purchase requisition to the Bureau for action, may be approved by local naval authority in the manner prescribed by article 1396, Navy Regulations, for activities afloat, or as provided by article 1607 (5), Navy Regulations, for activities ashore. In each instance of local approval, a copy of the requisition shall be promptly forwarded to the Bureau, accompanied by a letter stating the cir- cumstances. 3033. Annual Requisitions.—(a) Instructions relative to the prepa- ration and submission of annual requisitions are contained in article 921, Bureau of Supplies and Accounts Manual. (b) Annual requisitions shall be reduced to the least number con- sistent with the needs of the activity. (c) When an annual requisition, including provision for sundry items, is required, the following language shall be used: For hospitals, hospital ships, medical supply depots, Naval Medical Center, and naval dispensaries (broad form): Item 1. For sundry items of supplies, equipment, or services, including serv- ices of blood donors, in such quantities and at such times as may be required during the fiscal year 19-_. (Omit words in italics from requisitions drawn under naval hospital fund.) For other ships and stations (restricted form): Item 1. For sundry items of medical and dental supplies; special diet for the sick; laundry supplies and services; services of blood donors; repair of and parts for medical department equipment; repair of and parts for motor vehicles; in such quantities and at such times as may be required during the fiscal year 19-(Omit words in italics if not required.) 419 3034-3035 CH. 2 0. FINANCE AND PROPERTY All annual requisitions under “care of the dead” appropriation: Item 1. For sundry items of supplies and services, in such quantities and at such times as may be required for the care of remains of deceased naval personnel during the fiscal year, 19. _. (d) Items for which annual more or less quantity contracts are required to meet varying demands during the year, such as prosthetic dental items; electric, gas, or water services; mortician services, etc., shall be included in the appropriate annual requisition (immediately following the sundry item), as specifically numbered items with ap- propriate specifications, estimated quantities, unit cost, and total cost. 3034. Annual Requisitions, for Civilian Medical, Dental, Nursing, and Hospital Services.—(a) Ships normally operating beyond the con- tinental limits of the United States, and detachments on foreign shore stations, including Alaska, shall submit annual requisitions, drawn under the naval hospital fund., for procurement of civilian medical, dental, nursing, and hospital services as may be required for treatment of naval personnel on duty. Such requisitions shall be worded as follows: Item 1. For sundry items of medical, dental, nursing, and hospital services, including incidental ambulance service when furnished as part of the above services, for members of the naval service on duty beyond the continental limits of the United States or in Alaska, in such quantities and at such times as may be required during the fiscal year 19—. (b) The purposes of the requisition are to provide authority for the supply officer to make contracts for such services as may be required and to permit prompt payment of bills incurred in Alaska and beyond the continental limits of the United States (par. 3045). (c) Any expenditures for above services shall be reported on NMS—Form B and shown as a receipt and expenditure on NMS— Form E. Expenditures will be charged to an allotment maintained by the Bureau. (d) Report on NMS—Form U shall be made in each case in ac- cordance with instructions in paragraph 3162 of this manual. 3035. Purchase Contracts.—Purchase contracts are of two general types: (1) Formal contracts. Involving purchases in excess of $500. Bidders required to execute guarantee on Standard Form No. 31 or other acceptable form of bid bond. (2) Less formal contracts. Involving purchases of $500 or less. No guarantee or other form of bid bond required. When purchase contracts have been made, the purchasing supply officer informs the requiring activity, and the disbursing officer desig- nated to make payments under the contract, of the award by furnish- ing copies of the contract or order for delivery. 420 SEC. IV.—PROCUREMENT METHODS 3036-3039 3036. Payments.—After property has been delivered, inspected and accepted and the vendor’s bill received, a public voucher (Standard Form 1034) is prepared in accordance with instructions contained in articles 2130 to 2136, Bureau of Supplies and Accounts Manual, and paragraph 3023 (g) of this manual, and forwarded with the vendor’s bill to the disbursing officer designated to make payment under the purchase contract. 3037. Stub Requisitions.—(a) Supplies and equipment, listed in the Federal Standard Stock Catalog as Navy material, or carried in stock by the supply officer of a ship or shore station as naval supply account (NSA) or appropriation purchases account (APA) mate- rial, may be obtained on stub requisition. The supply officer shall be consulted as to the specific form of stub requisition, number of copies, etc., required by local procedure. (b) Naval supply account material (defined by art. 1865 (2) N. R.), issued by the supply officer on stub requisition, is chargeable to the maintenance allotment of the receiving activity or department. (c) Appropriation purchases account material (defined by art. 1865 (3), N. R.), is issued by the supply officer without appropria- tional charge. The value of APA material shall be taken up as a transfer voucher received in the property records (Form E and prop- erty ledgers) and accounted for in the same manner as material received on a purchase or other requisition, except that no allotment charge shall be made. (d) Material listed as Navy material in the Federal Standard Stock Catalog but not carried by the local supply officer, will generally be obtained by him when specifically requested. 3038. Expenditure Invoice (S. & A. Form 71).—(a) Supplies and equipment listed as Navy material in the Federal Standard Stock Catalog or carried in stock by the supply officer of a ship or shore station as naval supply account, clothing and small stores account (CSS), or appropriation purchases account material, may be obtained on expenditure invoice (S. & A. Form 71). The value of NSA and C&SS material so issued is chargeable to the maintenance allotment of the receiving activity or department. The particular procedure required shall be obtained from the supply officer. (b) Provisions for naval hospitals, except provisions obtained under monthly contracts, and items of clothing for use in preparation of remains, are issued by the supply officer on expenditure invoices. 3039. Marine Corps Invoices (NMC—Form 24-Qm.).—Supplies and equipment carried in stock by Marine Corps quartermasters may be obtained on invoice and receipt, USMC (NMC—Form 24-Qm.). 421 3040-3041 CH. 2 0. FINANCE AND PROPERTY The value of material invoiced is a charge to the maintenance allot- ment of the receiving activity or department. 3040. Requisition for labor (NYO—Form 6).—When employment of civil personnel is authorized by the Bureau, appointments shall be made in accordance with instructions contained in the regulations governing the employment of civil personnel under the naval service (Civil Service Commission Form 2009) and the schedule of wages for civil employees in the field service of the Navy Department and the Marine Corps. Labor required to be obtained through the local labor board shall be requested on requisition for labor (NYO—Form 6). 3041. Work Requests.—(a) A work request shall be submitted to the Bureau, in quadruplicate, by naval hospitals, medical supply depots, and the Naval Medical Center, for necessary work which is beyond the capacity of the force employed. (b) Routine work requests shall be forwarded in time to reach the Bureau 2 months prior to the date work is planned to start. Plans, sketches, copies of public works officer’s recommendations, etc., re- quired to support work requests, shall be submitted in duplicate. (c) When practicable, projects shall be accomplished by the force employed, supplemented by additional temporary labor if required. (See par. 3013.) (d) The public works officer’s recommendation shall be requested for projects to be accomplished under the supervision of the Bureau of Yards and Docks (art. 481 to 484, N. R.). The following questions should be referred to the public works officer for comment: (1) Feasibility of project, alternate suggestions. (2) Economy, or additional cost of subsequent maintenance. (3) Capacity to care for planned future expansions. (4) Description of work required. (5) Proposed manner of accomplishment (yard labor or public works con- tract) . (6) Most desirable period to accomplish work. (7) Specifications, blueprints, sketches, estimated cost. (e) In general, work requests shall be limited to projects including one building or one unit in order that costs may be allocated correctly. (f) Whenever the best interest of the Government will be served, the policy of replacing worn-out and inefficient units with modern units, rather than making extensive and costly repairs, shall be ob- served. (g) When immediate authorization for work, beyond the capacity of the force employed, is required to maintain essential services for the care of the sick or for the protection of Government property, and the 422 SEC. IV. PROCUREMENT METHODS 3042-3044 work is of a nature too urgent to permit delay incident to requesting Bureau approval by dispatch, a request shall be made of the com- mandant to authorize the work, as prescribed by articles 1489 and 1975, Navy Regulations. A report of the circumstances and a routine work request shall be forwarded to the Bureau at the earliest prac- ticable date. 3042. Medical Supply Depot Requisition and Invoice (NMS—Form 4).—(a) Material listed in the supply table and supplementary supply table is obtainable from medical supply depots on NMS— Form 4. (b) Items of material listed in the supply table and supple- mentary supply table shall not be purchased locally except when the need is immediate and will not permit delay incident to procurement from a medical supply depot or by transfer from another Medical De- partment activity. If purchased, a letter reporting the circumstan- ces shall be forwarded to the Bureau. 3043. Authority for Procurement, Without Allotment.—Materials and services required for maintenance of the Medical Department and chargeable to Bureau funds, may be obtained by the following methods, when no allotment for the purpose has been granted by the Bureau: Transfer invoice (S. & A. Form 71) from another Medical Department ac- tivity. Local purchase, medicines and civilian medical, dental, nursing, and hos- pital services. Local purchase, recruiting stations. Transfer from other Government agency. 3044. Transfer Invoice From Another Medical Department Activity.— (a) Material under cognizance of the Bureau may be obtained from other Medical Department activities upon the specific approval of the Bureau. (b) The senior officer present may authorize transfer of materials between ships, when the urgency will not permit sufficient delay to obtain Bureau approval (art. 1388, N. R.). (c) The commandant may authorize transfer of materials between shore stations and, when requested by the senior officer present afloat, between shore stations and ships, if the emergency will not permit sufficient delay to obtain Bureau approval. (d) Paragraph 3079 outlines the procedure for transfer invoices. (e) District craft and shore units which have no Bureau allotment, and are not assigned to a specific Medical Department activity for supplies and services, may submit letter request to the Bureau, through the commandant, for the necessary medical material. 423 3045-3046 CH. 20.—FINANCE AND PROPERTY 3045. Local Purchase, Medicines and Civilian Medical, Dental, Nursing, and Hospital Services.—(a) Medicines and civilian medical, dental, nursing, and hospital services, for Navy and Marine Corps personnel on duty, may be procured at the places and in the manner in which such articles are usually bought and sold, or services engaged, between individuals (41 U. S. C. 5), when all of the following conditions exist: (1) The member of the naval service for whom the medicine or service is required must be on duty. (2) When the material required is not available from naval or other stores owned by the United States, or when the services or facilities of phy- sicians, dental surgeons, nurses, or hospitals, employed or operated by the United States, are not available. (3) Immediate delivery or performance is required for the proper care and treatment of the patient. (4) Procurement must be authorized by the commanding officer or by the Navy Department. (b) Prompt report (NMS—Form U), in the manner prescribed by paragraph 3162, shall be made in each instance of local procurement of medicines or civilian medical, dental, nursing, or hospital services. (c) Bills for medicines or civilian medical, dental, nursing, or hos- pital services, incurred within the United States, in the manner author- ized, shall be forwarded to the Bureau for payment (par. 3167). (d) Bills for medicines or civilian medical, dental, nursing, or hos- pital services, incurred outside the United States, in the manner au- thorized, shall be paid by the local Navy activity when possible; other- wise, the bills shall be forwarded to the Bureau for payment. 3046. local Purchase, Recruiting Stations.—(a) Medical supply- table and supplementary supply table items, required for use at re- cruiting stations, shall be obtained from a medical supply depot on requisition (NMS—Form 4). (b) Medicines and civilian medical, dental, nursing, and hospital services, for Navy and Marine Corps personnel on duty, may be pro- cured subject to the enumerated conditions in paragraph 3045. (c) Public vouchers for medicines required in an emergency and ob- tained from local drug concerns without requisition shall be prepared at the end of each month and forwarded, accompanied by vendor’s bill, to the Bureau for payment. Such public vouchers shall bear the following certificate, immediately following the last item: The foregoing medicines were required for immediate use in the care and treatment of naval personnel on duty. Government-owned medical supplies were not available. Purchase was authorized by the officer in charge. (Signature and rank of medical officer.) 424 SEC. IV. PROCUREMENT METHODS 3047-3048 3047. Transfer from Another Government Agency.—When medical, dental, nursing, or hospital material or services, required for immediate use in the care and treatment of naval personnel on duty, are available from another Government agency, they shall be obtained from the agency by official letter request, a copy of which shall be furnished the Bureau by the requiring activity. The Government agency from which material or services are procured shall be requested to submit invoices, in triplicate, through their usual channels, to the Bureau for payment. 3048. Maintenance and Equipment Items Not Chargeable to Bureau Funds.—(a) Certain maintenance material and services, as listed under subparagraph (c), when required by Medical Department activities, are furnished by other Bureaus and are chargeable to other than Medical Department funds. (b) The proper procedure to procure such material or services is contained in the Bureau of Supplies and Accounts Manual, manuals of other bureaus, or ship or station regulations. (c) Material and services furnished by other bureaus include: (1) Secretary's Office.— Funeral expenses of interned persons or prisoners of war. Postage, except parcel post. Transportation for civil employees, under formal orders. Telephone and telegraph service. Periodicals. (2) Bureau of Navigation.— Athletic and recreational material. Library books, except medical books. Fingerprint and identification tag outfits. Medical supplies and equipment of Naval Reserve activities, except avia- tion units. Medical supplies and equipment for Naval and Marine Corps Reserve aviation units. Scales, physicians’, for recruiting purposes. (3) Bureau of Supplies and Accounts.— Fuel (or heat), electricity (lighting only) and gas, within allowances, for officers, residing in public quarters. (Note.—Any excess of allowances, all refrigeration, and all water consumed, are ultimately chargeable to the personal account of the individual officer.) Ice for cooling water, except at naval hospitals. Postage for parcel post. Rental of quarters for Navy Nurse Corps personnel. Services, supplies, and equipment for disbursing officers at naval hospitals. Street car tickets, ferry and toll bridge tickets for naval personnel, in- cluding patient passengers in Navy ambulances. Transportation for civil personnel, not under formal orders. 425 3049-3050 CH. 20.—FINANCE AND PROPERTY Transportation and expenses of funeral escorts, military or civilian, of deceased naval personnel. Transportation of personal effects of deceased naval personnel (chargeable to Bureau of Navigation funds). Typewriters on board ships. (4) Bureau of Construction and Repair.— Funeral flags for deceased naval personnel. On board ship: Furniture. Cleaning gear material. (5) Major General Commandant, United States Marine Corps.— Ambulances for Fleet Marine Force, Marine Corps expeditionary units. Medical supplies and equipment for Marine Corps Reserve activities, except aviation units. Preparation of remains of Marine Corps personnel at activities having no Bureau annual contract for care of the dead. Special field equipment. (See supply table.) Transportation of deceased Marine Corps personnel, and escorts, military or civil. Transportation of personal effects of deceased Marine Corps personnel. (6) At Shore activities, except naval hospitals, medical supply depots, and the Naval Medical Center.— The following maintenance items and equipment required by the Medical De- partment at shore stations are chargeable to maintenance allotments of other bureaus as specified by article 484, Navy Regulations: Supplies for maintenance of buildings and appurtenances, such as: Brooms, brushes, soaps, floor wax, paint brushes, etc. Lighting fixtures and lamps, electric, for general lighting. Repairs and alterations of partitions, doors, windows; heat, water, electric, and gas supply lines, including alterations and connections required to install Medical Department equipment (dental chairs, sterilizers, etc.). Furniture, except special medical apparatus. Floor polishers. Plumbing fixtures, except special hydrotherapeutic fixtures. 3049. Alcohol, Procurement of.—Alcohol used for medicinal pur- poses shall be obtained from the supply department on stub requisi- tions, approved by the commanding officer or from a medical supply depot on NMS—Form 4 requisition. Alcohol shall be obtained from the supply officer by Medical Department activities having an allotment for the purpose when alcohol meeting the requirements of Navy Department Specification No. 52A8a—grade A—is carried in stock for issue by the supply department. 3050. Blood Donors, Services of.—(a) Services of blood donors are chargeable to the appropriation Medical Department, Navy. All activities submitting annual requisitions under this appropriation shall include an item for services of blood donors. Other activities will submit purchase requisitions to the senior officer present afloat, 426 SEC. IV.—PROCUREMENT METHODS 3051-3053 or the commandant, for approval, when services of blood donors are required in emergency. (b) Payment for services of blood donors who are members or former members of the military or naval service shall be made at the rate of 5 cents for each cubic centimeter of blood donated; minimum payment $10; total payment not to exceed $50 for one transfusion. (See 24 U. S. C. 30.) 3051. Surgical Instruments, X-ray Equipment, and Medical Books.— (a) Surgical instruments shall be obtained from medical supply depots except when the exigencies of the service require immediate delivery. (b) X-ray equipment shall be obtained from medical supply depots except when otherwise directed by the Bureau. Activities requiring repairs to head or x-ray tube of dental x-ray unit will request replace- ment part by dispatch to the Bureau, stating the date of manufac- turers’ test (this date is noted on manufacturer’s test slip inside the cover of stabilizer); upon receipt of replacement head, the head re- quiring repairs is to be removed, together with its yoke, by unscrew- ing the retention nut attaching the yoke to the extension bracket. Place the old head, which will include the positioning cone, yoke, retention nut and washer, in the container in which replacement head was received, and return to the Naval Medical Supply Depot, Brook- lyn, N. Y., via express. The return of the old head shall be accom- plished on S. & A. Form 71 at the invoice value of the new head. (c) Medical books shall be obtained from the Naval Medical Sup- ply Depot, Brooklyn, N. Y. Requisitions for book requirements (NMS—Form 4) shall be submitted to reach the Bureau prior to August 1 and February 1, annually. Requisitions for books not listed in the current supplementary supply table shall be accompa- nied by a letter detailing justification for volumes requested. 3052. Biologicals: Antigens, Bacterial Cultures, Etc.—(a) Bio- logicals. (See list and instructions for procurement in supple- mentary SUPPLY TABLE.) (b) Antigens, bacterial cultures, etc. (See list and instructions in the supply table for procurement of supplies from the Naval Medical Center, Washington, D. C.) 3053. Stationery and Printing.—(a) Stationery shall be procured from the supply department by Medical Department activities hav- ing an allotment. Other activities shall procure necessary stationery from a medical supply depot. (b) No field printing, including binding, and blank-book work, shall be done wholly or in part at Government expense unless auth- orized by the Joint Committee on Printing. Refer to paragraph 427 3054-3057 CH. 20. FINANCE AND PROPERTY 940-29, S. & A. Manual, and regulations of the Joint Committee on Printing. (c) A copy of each printed form, except letterheads, obtained from local sources, shall be forwarded to the Bureau at the time it is received from the printer. 3054. Furniture and Furnishings for Staff Quarters.—Furniture and furnishings for staff quarters shall be procured by purchase requisitions prepared in accordance with the instructions contained in Bureau of Yards and Docks Manual, which are reprinted in the pamphlet Maintenance and Furnishing of Quarters, and pub- lished by the Bureau of Yards and Docks. These instructions shall be observed also as to marking, custody, and upkeep. 3055. Motor Vehicles.—Requirements for motor vehicles shall be included in annual estimates of expenditures. The Bureau will consolidate requirements and initiate purchase requisitions for procurement. 3056. Orthopedic and Prosthetic Appliances.—(a) Artificial eyes, supports and braces, eye glasses for general court-martial prisoners, artificial limbs and other orthopedic and prosthetic appliances required for naval personnel including Fleet Reserves regularly admitted to naval hospitals, are chargeable to the appropriation, Medical Department, Navy. (b) Orthopedic and prosthetic appliances required for patients of other Government agencies are not chargeable to Navy funds. Re- quest shall be made on the Government agency for which the patient is hospitalized for such appliances as may be required for the patient. (c) Replacements of orthopedic and prosthetic appliances, required for former members of the Military and Naval Establishments, are chargeable to funds of the Veterans’ Administration, and applications should be addressed to that office. These patients need not be admitted to a naval hospital (38 U. S. C. 241 to 250). (d) Artificial limbs, required for naval patients, shall be procured by a purchase requisition submitted to the Bureau in each specific case. This requisition shall include, in addition to the usual speci- cations and other data, the full name, grade, and diagnosis of the patient. 3057. Medical Supplies, Local Purchase of.—(a) Medical supplies, not on hand or available at other Government agencies, required for immediate use in the care of the sick or injured, may be procured from the nearest available source under authority of an annual or locally approved purchase requisition. 428 SEC. IV.—PROCUREMENT METHODS 3058-3059 (b) The Bureau approves procurement of any medicinal prepara- tion of established efficacy required for treatment of naval personnel. Instructions relative to allotments shall be observed in connection with such purchases. (c) The Bureau will approve procurement of new or improved medicinal agents for test purposes under the following conditions: (1) Approval of the Bureau shall be obtained prior to procurement. (2) When preparation has been accepted by the council on pharmacy and chemistry of the American Medical Association. (3) Adequate laboratory and other facilities are available at the activity and, in the opinion of the commanding officer, the study is of suffi- cient potential value to warrant procurement. (4) Sufficient clinical material to provide adequate control and study groups. (5) Sufficient funds are available under current allotments. (6) Result of study will be reported to the Bureau. 3058. Commissioning Outfits.—Prior to the commissioning date of ships and stations, medical outfits, except biologicals, will be issued by the nearest naval medical supply depot when directed by the Bureau. The material included in this outfit will be sufficient to adequately supply and equip the sick-bay and battle-dressing stations. The prospective medical officer shall submit NMS—Form 4 requisi- tion for required biologicals about 2 weeks prior to commissioning date. Deficiencies noted in the commissioning outfits furnished shall be reported to the Bureau. A special outfit will be issued when a medical officer is ordered aboard destroyers or other small craft for temporary duty incident to a shake-down or other short cruise. However, the commanding officer should request the Bureau to direct such issue well in advance of the sailing date. The special outfit, including unconsumed supplies, shall be returned to a naval medical supply depot or disposed of as directed by specific instruction of the Bureau, after completion of the cruise and before detachment of the medical officer. 3059. Headstones, Naval Cemeteries.—Headstones, required for graves of deceased members of the naval or military services interred in naval cemeteries or plots, shall be procured from the War Depart- ment. Requests for headstones shall be submitted to The Quarter- master General, United States Army, War Department, Washington, D. C., in the form prescribed. Forms for preparation of such requests may be obtained from that officer. Headstones will be delivered without charge to Navy funds, to the consignment address stated in the request. Erection of headstones and necessary bases in naval 429 3062-3065 CH. 20.—FINANCE AND PROPERTY cemeteries and naval plots are a charge to the appropriation care of the dead, Navy, except when such erection is included in the per- petual care clause of the title deed for naval plots in civil cemeteries. SECTION V. PROPERTY: CUSTODY, ISSUE, AND DISPOSITION Paragraph Medical Department Property 3062 Unnecessary Expenditure of Public Property 3063 Record of Public Property. 3064 Property Accountability 3065 Property and Accounting Officer 3066 Storerooms 3067 Equipment, Land and Buildings 3068 Required Quantities Supply Table Supplies 3069 Issue Voucher 3070 Inventory 3071 Unit Value 3072 Biologicals, Records of 3073 Survey of Property—General 3074 Request for Survey of Property 3075 Report of Survey of Property 3076 Disposition of Surveyed Property 3077 Disposition of Metal Scrap, X-ray Films, Etc 3078 Transfer of Medical Department Material 3079 Loan of Medical Department Material 3080 Medical Material, Disposition upon Decommissioning 3081 3062. Medical Department Property.—The medical officer in com- mand of each hospital, and the medical officer of each station and ship shall be held responsible and accountable for all public property under his control belonging to the Medical Department of the Navy (art. 1194, N. R.). 3063. Unnecessary Expenditure of Public Property.—Officers shall avoid any unnecessary expenditure of public money or stores and, so far as may be in their power, prevent the same in others. Officers shall be held accountable for any wasteful or improper expenditure that they may direct, authorize, or knowingly permit (art. 83 (1), N. R.). 3064. Record of Public Property.—Records shall be maintained by each Medical Department activity which will promptly disclose the source, date of receipt, book value and immediate responsibility or disposition data, when indicated, of each item of property invoiced to the activity. The term property embraces every item including services, supplies, equipment, and land and buildings. 3065. Property Accountability.—The medical officer will be held to a strict accountability for all items of public property placed in his 430 SEC. V.—PROPERTY : CUSTODY, ISSUE, AND DISPOSITION 3060-3069 charge, but for the purpose of inventory he may require a junior officer to supervise personally the inventory procedure and certify to that effect. Similarly, accountability for routine expenditures of services and supplies on issue vouchers may be delegated to a junior officer. In order to facilitate accountability and to fix responsibility, every item of Medical Department property is classified in one of four groups, viz, LAND AND BUILDINGS, EQUIPMENT, SUPPLIES, and SERVICES. 3066. Property and Accounting Officer.-—The officer so designated shall be accountable to the medical officer for all property placed in his charge, exercise personal supervision over its condition and the economical expenditure thereof. The officer so designated will cer- tify, or initial, all financial reports submitted to the Bureau. His duties are detailed elsewhere in this manual. 3067. Storerooms.—(a) The bulk of all medical material shall be kept in the medical storerooms. The quantities in the issue room, the dispensary, or sick bay shall be kept as low as may be consistent with current requirements. (b) Subject to the provisions of article 1145, Navy Regulations, the medical officer may place a competent hospital corpsman in charge of the storeroom, who shall make, on approved issue voucher, such issues as are required. 3068. Equipment and land and Buildings.—The accountability for this property can only be terminated by a receipted transfer invoice or by a property survey accomplished in the manner prescribed in this manual. 3069. Required Quantities Supply Table Supplies.—(a) It is impor- tant that the designated minimum quantity of medical supplies be maintained at each activity and that the Bureau may rely on mini- mum quantity being on hand at all times. The composition of items subject to the minimum quantity requirements is determined by consideration of: (1) Past records of issue for use, and (2) the type of medical services required by the individual activity; for example, larger stations and ship units require a greater variety of medical supplies than smaller units (art. 1380 (2), N. R.) (b) Hospitals, ships, and shore stations, except medical supply depots, recruiting stations, and activities to which no medical officer or hospital corpsman is regularly attached, shall establish, record on Form W, and revise annually, a minimum quantity, maximum quan- tity, ORDER POINT, AVERAGE ANNUAL RATE OF USE, and RESERVE quantity, for each supply table item of supplies, which is normally required for facilities maintained at the activity, and shall maintain, on hand, a quantity of supplies not less than the minimum quantity 431 3069 CH. 20.—FINANCE AND PROPERTY nor more than the maximum quantity. The minimum and maximum quantities shall be established as follows: O) Ships, except hospital ships.— 1. Minimum quantity.—Six months’ supply at the average annual rate of issue, plus reserve quantity indicated by paragraph 3069 (e). 2. Maximum quantity.—Twelve months’ supply at the average annual rate of issue, plus reserve quantity indicated by paragraph 3069 (e). (2) Hospital ships and shore stations.— 1. Minimum quantity.—Twelve months’ supply at the average annual rate of issue, plus reserve quantity indicated by paragraph 3069 (e). 2. Maximum quantity.—Twenty-four months’ supply at the average annual rate of issue, plus reserve quantity indicated by parabraph 3069 (e). (c) The average annual rate of use, revised annually at the close of a fiscal year, shall be calculated by the following method: Determine net expenditures to use by deducting transfers and surveys from total expenditures during the last completed 3-year period, then divide the result by three (ships and stations in commission less than 3 years shall modify the formula in such manner as to utilize the latest available data). (d) An order point shall be established for each item required. This amount shall be: Minimum quantity plus the quantity estimated to be consumed during the period of time that will elapse between submission of requisition and delivery of supplies from a supply depot. (e) Ships shall maintain as reserve quantity, unopened, original units of supplies stored at battle-dressing stations, battle stations, and in field medical units. Shore stations shall maintain as reserve quan- tity, only such items as may be specifically directed by the Bureau. Reserve quantity shall not be expended from the stock ledger, Form W. Items of this reserve that deteriorate shall be replaced by new issue at the time replenishment supplies are received. (f) Replenishment requisitions, except for items classed as perish- ables, or items required in an emergency, shall be planned for submis- sion quarterly, immediately following completion of the quarterly inventory, except when the operating schedule will bring ships in proximity to a medical supply depot in which case submission dates of requisitions may be slightly advanced or delayed to effect savings in transportation charges. Individual items shall be requisitioned once yearly for hospitals, hospital ships, and shore stations; twice yearly for ships except hospital ships. When the order point for an item is reached, the quantity ordered shall be minimum less reserve. Any deviation from this schedule shall be controlled by Circular Letter F. Requisitions for perishables are excepted from these schedule limitations to permit maintenance of fresh supplies. 432 sec. v.—property: custody, issue, and disposition 3070-3071 For calculation of items of supplies, other than perishable items, the following example is given: Item—8-005—Gauze, plain, 25-yard roll Rollt Total expenditures during 3 most recently completed fiscal years 200 Transferred to other activities 20 Net expenditures for use 180 180 divided by 3 equals 60, establishing the average annual rate of use at 60 rolls, or 5 rolls per month. A total of 25 rolls are required to be maintained intact at battle-dressing stations and in other emergency units (reserve quantity) . The time normally required to obtain supplies, after submission of requisition, is 2 months, during which period 10 rolls of gauze would normally be used. On the basis of the foregoing, the following data would be established and noted on Form W: For ships For shore stations 25 rolls. 85 rolls (60+25). 05 rolls (85+10). 145 rolls (120+25). 60 rolls. Minimum quantity 55 rolls (30+25) 65 rolls (55+10) - 85 rolls (60+25) - 30 rolls...-. 3070. Issue Voucher.—(a) Supplies shall be issued from the store- rooms only on issue vouchers approved by the medical officer or his delegate. The object of these vouchers is to keep the medical officer informed of supplies issued, to support bookkeeping entries, and to authorize the issue of the enumerated items by the storeroom keeper. (b) Form R (issue voucher) shall be used by the Medical Depart- ment activities, except destroyers or other vessels having small quanti- ties of medical supplies. When supplies are required from the store- room the form shall be prepared in duplicate and, when approved, both copies shall be delivered to the storeroom and shall be authority for issue of the supplies. A receipted copy shall be retained by the storeroom keeper as his receipt for supplies issued. 3071. Inventory.—(a) A physical inventory of supplies on hand and unexpended shall be made quarterly and the supplies ledger reconciled with inventory. Any adjustments that may be necessary shall be brought to the attention of the medical officer and his signa- ture affixed on a memorandum voucher to support the adjustment entry. 433 3072-3074 CH. 2 0.—FINANCE AND PROPERTY (b) A physical inventory of equipment shall be made annually and when the medical officer is relieved. Inventories of equipment should be completed annually and the quantities found on inventory veri- fied with the quantities recorded in the equipment ledger. (c) Receipts shall be exchanged on NMS—Form D (transfer of property) when the custodian of property is relieved. 3072. Unit Value.—When items of material are received, identical with items on hand but with different unit price, a new unit price shall be established as shown in the following example: On June 30 there were on hand 10 bottles of acacia, unit price $0.50 per bottle, making a total value of $5.00; on July 1, 10 additional bottles were received from the supply depot with a unit price of $1.00 per bottle, or a total value of $10.00; there are now 20 bottles with a total value of $15.00, making the new unit price of all acacia $0.75 per bottle. 3073. Biologicals, Record of.—Naval medical supply depots will maintain a biological ledger in which will be recorded the lot numbers, name of manufacturing laboratory, and potency dates of biologicals issued to the field service. This data will be entered on the original of each supply depot requisition and the receiving activity will enter this data on the copies. 3074. Survey of Property, General.—(a) See articles 393 (6), 458 (4), 1389, and 1906 to 1918, Navy Regulations. (b) In accordance with article 1909 Navy Regulations, formal investigation and survey shall be made in the following cases: (1) For classes of material or articles designated by the bureau concerned. (2) For lost or missing articles of ships’ equipage when the value of the articles or the total of identical articles exceeds $100. (3) When the head of the department concerned is not a commis- sioned officer, for articles of ships’ equipage lost or missing, or worn beyond serviceable repair and not covered by a repair letter. (4) When specifically directed by the commanding officer or commandant. (c) Pursuant to article 1909 (1) Navy Regulations, subparagraph (a), and supplemental to instructions contained in other articles, the Bureau requires formal survey and investigation for the following: (1) Items of property designated as equipment in the supply table and the supplementary supply table of the Medical Depart- ment, or carried as such on the books of record, and (2) items carried in the equipment and land and buildings accounts of naval hospitals, shall be subject to a formal investigation and survey, if the unit book value for a single item exceeds $25, or a total book value of a group of identical items exceeds $100. A formal survey of items of property 434 SEC. V. PROPERTY : CUSTODY, ISSUE, AND DISPOSITION 3075 may be dispensed with in accordance with article 1909 (2), Navy- Regulations. 3075. Request for Survey of Property.—(a) Requests for survey of Medical Department property shall originate with the head of the department charged with the custody of the property to be surveyed (par. 3076). (b) Request for a survey of property, formal or otherwise, either afloat or ashore, shall be prepared on S. & A. Form 154 (art. 1909 (1), Navy Regulations, and par. 3074 above.) This form may be obtained from the local supply officer. Each form shall be numbered (in the upper right hand corner), consecutively, regardless of class (formal or not), beginning a new series with each fiscal year. (c) If additional sheets are required, ordinary stock typewriting paper shall be used and clipped to the form. The upper portion of the sheet shall be used for listing the items for survey and the lower portion reserved for the report of the surveying officer for items appearing only on the upper portion of the sheet. This procedure, when followed, will have all data with respect to each item on one sheet. (d) The nomenclature and classification of items shall correspond with the Medical Department supply table and the latest inventory of property. (e) Each item shall be numbered consecutively, beginning with No. 1 on each survey. Also, for each item, the quantity, date of receipt, and book value, shall be indicated. The total value of all items shall be recorded. If partial contents of a case or an outfit are to be surveyed and an itemized book value of the contents is not a matter of record, an estimated value shall be assigned each item to be surveyed. This is essential for accounting purposes. All sheets of the request for survey shall be typewritten whenever practicable. Great care must be exercised to assure correctness of figures in order that the figures on approved survey will agree with the records on file in the Bureau. If such care is not exercised, the book of record may be out of balance and accounting difficulties may be encountered. (f) Requests for surveys may be initiated when necessary. Hos- pitals shall, however, request a survey on all equipment unfit for use, at least quarterly, before a commanding officer or property and ac- counting officer is detached, and before being decommissioned. Ships and stations shall request a survey at least every 6 months, before the medical officer or property and accounting officer, if there be one, is detached, and before being decommissioned. When property is lost or missing, a request for a survey shall be prepared immediately. 435 3076 CH. 20.—FINANCE AND PROPERTY Surveys for motor vehicles, typewriters, computing machines, or other labor-saving devices, shall include no dissimilar items. WTien typewriters, computing machines, and other labor-saving devices are to be exchanged and replaced the requisition for replacement shall accompany the survey. The survey and requisition shall state the condition of carriage and main frame, whether broken or not (arts. 940 (38) and 1905 (2), Bureau of Supplies and Accounts Manual). When property is damaged by fire or other unusual occurrence, a separate request for a survey shall be prepared, covering only the property so damaged. Property in excess of current and reasonable future requirements shall be the subject of a special survey. (g) The items on the form used for the request for survey of Medi- cal Department property shall be arranged in accordance with the following example to provide the information required by the Bureau: Item Quan- tity Article Identify- ing marks, etc. Date and from whom received Price at which carried Surgical instruments and appliances, class No. 7 1 4 1 4-10-30 $4.00 1.20 2 1 Force psj sponge-holding J 1- 6-28 3 1 Outfit, surgical instrument, items from: »1-10-29 1.60 4 1 > 1-10-29 .50 Dispensary and laboratory equipment, class No. IS 5 1 I 12-6-33 .17 Hospital and nursing appliances, class No. H 6 3 U. S. N. 1 1-13-30 .84 Total $8.31 1 MSD, Mare Island. > MSD, Brooklyn. 3076. Report of Survey of Property.—(a) For appointing a survey- ing officer, or a board of officers, for the investigation and survey of Medical Department property, instructions contained in article 1910, Navy Regulations, shall apply. (b) When formal survey is not required, the head of the depart- ment, and when formal survey is required, the surveying officer, shall make a thorough inspection of the items to determine their condition at time of survey, or, if missing, a thorough examination of the cir- cumstances attending the loss, and shall, if possible, fix the cause and responsibility for damaged or deteriorated condition, or for loss. He shall make a full report, on prescribed S. & A. Form of his findings as to condition, cause, and responsibility, together with his recom- mendation as to disposition, and whether replacement shall be re- 436 SEC. V. PROPERTY : CUSTODY, ISSUE, AND DISPOSITION 3076 quired (art. 1911 (1), N. R.). The head of the department shall be interpreted as the property and accounting officer at hospitals and on hospital ships, and the medical officer at stations and on ships. Items recommended for transfer to a naval medical supply depot for repair or further disposition, or to the supply officer for sale, shall be conservatively appraised (art. 1912 (3) (/), N. R.). (c) In addition to the necessary file copies required by the activity requesting the survey, by the commanding officer and by the com- mandant, or file copies required by fleet regulations, the following number of copies of the completed survey shall be submitted to the Bureau in each instance cited: (1) When items of equipment are recommended to be destroyed: Num- ber of copies required—original and two. (2) When items of equipment are recommended for sale or transfer to another activity, and when typewriters and other office labor-saving devices are recommended for replacement: Number of copies required— original and three. (3) When motor vehicles—ambulances, trucks, and tractors are surveyed for any cause: Number of copies required—original and four. (4) When items carried in the land and buildings account are surveyed for any cause: Number of copies required—original and seven. (d) The items and information on the form to be used for the re- port of the officer surveying the items listed under paragraph 3075 (g) or the head of the department requesting the survey as the case may be, shall be arranged in accordance with the following example, to provide the information required by Bureau. Report Item Condition, cause, responsibility, and recommendation Appraised value 1 Catch locks broken. Use. None. Destroy. $0.00 2 Rusted. Use. None. Repair. 1.20 3 & 4 Broken. Use. None. Destroy. 0.00 5 Blade pitted. Acid. None. Destroy. 0.00 6(1) Missing. Unknown. Cannot be fixed. To loss. Disciplinary action not indicated. 0.00 6(2) Good. In excess. None. To Naval Medical Supply 0.56 Depot. $1. 76 [To be prepared by head of Department or by surveying officer(s) if so directed below] Consecutive items may be grouped only when circumstances attend- ing the report of the condition, cause, responsibility, and recommen- dation for the group will permit a report as a single item. However, the report data for items on any one sheet shall be restricted to the items appearing in the request (upper) portion. (e) The surveying officer shall assign an appraised value to each item (including items in excess or items considered to be suitable for 437 3076 CH. 20.—FINANCE AND PROPERTY repair or adjustment) recommended to be turned in to the supply department for sale or other disposition, or to be transferred to another activity, including the medical supply depots. This appraised value shall be based upon (1) present condition, (2) probable future useful- ness, and (3) probable resale value, of each item considered. The surveying officer should be careful not to overestimate the appraised value assigned to any item. The appraised value assigned, when approved by the Bureau, shall be reflected in the records of account, NMS—Form E, and hospital recapitulation sheet. (f) Findings and recommendations of the surveying officer: In addi- tion to the required details outlined in subparagraph (d), above, the report shall be in accordance with article 1916, Navy Regulations. The recommendation should be restricted to one of the following: (1) To naval medical supply depot.—Items in excess shall be recom- mended to be turned in to the nearest naval medical supply depot. Items unfit for use in present condition but which can be economi- cally repaired, for example, microscopical outfits; x-ray machines, cassettes, and the target of tubes; dental cabinets, chairs, and engines; and field medical outfits, shall be recommended to be returned to a medical supply depot, or retain and repair on station. When survey reports on items in use at naval hospitals and larger shore stations, recommend repair, any repair or replacement parts required for surgical instruments, therapy emitters, units for electrical apparatus, x-ray, electrocardiographs, and similar equipment, shall be procured by the activity and charged to local allotment, rather than repair by trans- fer to a medical supply depot. (2) To supply department, for sale.—When a surveying officer recom- mends an item for sale he will be guided as follows: Items of a nature not warranting repairs, except as noted in the preceding para- graph, and which may have a resale value, should be condemned for sale and an appraised value assigned (art. 1912 (3) (/), N. R.). (3) To supply department, for yard scrap heap.—When a surveying officer recommends an item to yard scrap heap he will be guided as follows: Items of metal, unserviceable and not warranting repair, and which have no sale value, shall be condemned to the yard scrap heap. (4) To destroy, of no value.—This recommendation shall be made only when the items cannot be disposed of under any of the previous headings. (5) To loss.—The action of the surveying officer should be guided by articles 1909 (1) (6), 1910 (3), and 1916 (2), Navy Regulations, in the case of lost or missing items. If any item listed in the request for survey can be repaired economic- 438 sec. v.—property : custody, issue, and disposition 3077-3079 ally on the station, or is fit for use without repairs, the survey officer will so indicate by recommending to repair on station or retain, and recording the book value in the column headed, appraised value. When, in the opinion of the surveying officer, any item appearing on the list for survey is fit for use, it should be retained on the books of record and recommendation made accordingly. (g) It is not necessary to survey items that may be repaired on the ship or station. A requisition, or a Bureau work request, if repairs are to be made by a navy yard, will be submitted to the Bureau for approval. (h) Final disposition of surveyed property (formal or informal sur- veys) shall not be made prior to the approval of the Bureau, except that vessels of the Asiatic Fleet may make disposition if and when approved by the commander in chief. Sixteenth Naval District activities may carry out recommendation for disposition as approved by the commandant. 3077. Disposition of Surveyed Property.—(a) When a report of property survey is returned approved, the commanding officer will appoint an officer to personally supervise destruction of items of property approved to destroy, of no value. The officer appointed shall certify on the file copy of the approved survey that he has per- sonally supervised destruction of the items which shall be completely destroyed except that items of bedding and linen may be torn up and used for cleaning material. (b) When a report of property survey is returned approved all items having an appraised value shall be retained at appraised value or transferred as directed. Items for transfer shall be invoiced on S. & A. Form 71 which shall be forwarded in triplicate (at least) to the receiving activity making reference thereon to the approved survey. The transferring activity shall request the receiving activity to sign the original and one duplicate copy of the S. & A. Form 71, and return both copies to the transferring activity. The original shall be retained by the transferring activity as authority to charge off the property; the signed duplicate copy shall be forwarded with the financial reports to support entries appearing therein. 3078. Disposition of Metal Scrap, X-ray Films, Etc.—Metal scrap, used x-ray films, etc., have sale value. Accumulations of such ma- terial that is ready for disposition shall be transferred at no value to the supply officer for sale. 3079. Transfer of Medical Department Material.—Equipment and supplies under the cognizance of the Medical Department shall not be transferred except with the approval of the Bureau or other com- 439 3080-3086 CH. 2 0. FINANCE AND PROPERTY petent authority (art. 1388, N. R.). When transfer is authorized, it shall be accomplished on S. & A. Form 71 at book value, or appraised value, when appraised by a board of survey. The transferring activity shall request the receiving activity to sign the original and one du- plicate copy and return both to the transferring activity. The signed original shall be retained by the transferring activity as authority to charge off the material; the signed duplicate copy shall accompany the financial reports to support entries appearing therein. 3080. loan of Medical Department Material.—Equipment and sup- plies under the cognizance of the Bureau shall not be loaned except as provided in article 83 (3), Navy Regulations. 3081. Medical Material, Disposition Upon Decommissioning.—(a) Prior to decommissioning of a ship or station, unless otherwise directed by competent authority all Medical Department equipment unfit for further use shall be surveyed. The equipment not disposed of by survey and all unbroken packages of supplies shall be transferred to the nearest naval medical supply depot. The transfer shall be accomplished on S. & A. Form 71 at book value or, in the case of sur- veyed items recommended to be returned to the naval medical supply depot, at the appraised value. Broken packages, open bottles of medicinals, and other expended items may be transferred, at no cost, to the nearest Medical Department activity, afloat or ashore. (b) After disposing of Medical Department material as above outlined, final financial reports, NMS—Form E and NMS—Form B, together with other final M. & S. reports shall be accomplished and forwarded to the Bureau. SECTION VI. ACCOUNTING RECORDS: SHIPS, STATIONS Paragraph Journal of Receipts and Expenditures 3086 Statement of Receipts and Expenditures.. 3087 Report of Allotment Expenditures 3088 3086. Journal of Receipts and Expenditures.—Each ship and station (except naval hospitals) shall maintain a suitable blank book or loose- leaf sheets ruled to provide columns, in two sections, and captioned in the following numerical order: (a) Equipment section— (1) Equipment—receipts (left page): 1. Date. 2. Medical supply depot. 3. Supply department (NSA material). 4. Public vouchers. 5. TVR—other Medical Department activities. 6. TVR—APA material (no allotment charge). 7. Explanatory notes, when indicated. 440 SEC. VI.—ACCOUNTING RECORDS: SHIPS, STATIONS 3086 (2) Equipment—expenditures (right page): 8. Date. 9. Survey. 10. TVI—to supply officer for sale. 11. TVI—to other Medical Department activities. 12. Explanatory notes, when indicated (voucher number, balance, etc., as desired). (b) Supplies section— (1) Supplies■—receipts (left page): 1. Date. 2. Medical supply depot. 3. Supply department (NSA material). 4. Public vouchers. 5. Pay roll, civilian employees. 6. TVR—other Medical Department activities. 7. TVR—APA—material (no allotment charge). 8. Explanatory notes, when indicated. (2) Supplies■—expenditures (right page): 9. Date. 10. Supply table, medical, except care of the dead. 11. Supply table, dental. 12. Special diet. 13. Laundry. 14. Transportation service. 15. Miscellaneous dental supplies, other than supply table items. 16. Miscellaneous Medical Department supplies, other than supply table items. 17. Salaries. 18. Wages. 19. Care of the dead. 20. Survey of supplies. 21. TVI—to supply officer. 22. TVI—to other Medical Department activities. 23. Explanatory notes, when indicated (voucher number, balance, etc., as desired). This journal is used to record data relative to each financial transac- tion involving the receipt and disposition of Medical Department property. It should be posted daily, or as frequently as may be neces- sary to keep the record up to date. Each entry shall be substantiated by a duly authenticated voucher and the vouchers shall be preserved in such manner as to be readily accessible for reference or audit pur- poses (par. 3094 (b)). Activities that have numerous transactions may find it advantageous to employ a two column arrangement for several columns to provide space for collecting related information, such as the identification numbers of purchase and stub requisitions, public vouchers, and surveys. At the close of each quarter and upon decommissioning, each amount column of the journal shall be totaled and the sums entered on the 441 3087-3088 CH. 20. FINANCE AND PROPERTY statement of receipts and expenditures of Medical Department prop- erty, NMS—Form E. 3087. Statement of Receipts and Expenditures (NMS—Form E).— This is the principal financial report required from ships and stations (except hospitals) having custody of Medical Department property. It is prepared from information classified, recorded, and summarized in the journal of receipts and expenditures. Instructions covering the preparation and submission of NMS—Form E are contained in Circular Letter F, appendix D. 3088. Report of Allotment Expenditures and Obligations (NMS— Form B).—This report reflects the current status of allotments for a definite financial period, i. e., quarterly summaries of liquidated obli- gations, unliquidated obligations, and unobligated balances. It is the only report of allotment expenditures prepared by Medical Department activities. Instructions covering preparation of NMS— Form B are contained in Circular Letter F, appendix D. SECTION VII. ACCOUNTING RECORDS, NAVAL HOSPITALS Paragraph Accounting Records Maintained 3094 Journal 3095 Charge Register 3096 Quarterly Adjustment, Provisions and Fuel 3097 General Ledger 3098 Land and Buildings Ledger 3099 Equipment Ledger 3100 Supplies Ledger 3101 Provisions Ledger 3102 Expense Analysis Register 3103 Quarterly Expenditures, Provisions and Fuel __ 3104 Heat, Electric Current, Gas, and Water, Officers Quarters 3105 Part Compensation and Special Duty Services Allowances 3106 Special Depositors, Civil Employees... 3107 Services Furnished Ships Service 3108 Subsistence Checkages 3109 Services Furnished Other Medical Department Activities 3110 Material and Services Furnished Other Government Agencies 3111 Closing Receipt, Expenditure and Adjustment Account 3112 Balance Sheet 3113 Inventory, Land and Buildings 3114 Inventory, Equipment 3115 Register No. 3—Recapitulation of Ledger Accounts 3116 Quarterly Ration Return 3117 442 SEC. VII.—ACCOUNTING RECORDS, HOSPITALS 3094-3096 3094. Accounting Records Maintained.—(a). The following account- ing records shall be maintained permanently at naval hospitals: Journal. Charge register. General ledger. Land and buildings ledger. Equipment ledger. Supplies ledger. Commissary ledger. Expense analysis register. Recapitulation of ledger accounts. Quarterly ration return. (b) The following accounting vouchers shall be retained in the hospital files for the period indicated, prior to disposition in accordance with article 2047 (4), Navy Regulations. Vouchers Minimum period Civil pay rolls Permanently. Public vouchers or other invoices covering land and building item Do. Public vouchers, other 10 years. Medical supply depot invoices. Do. Stub requisitions 5 years Expenditure invoices Do. Transfer vouchers, issued or received Do. Issue vouchers Do. Receipt and expenditure vouchers (NMS—Form 37) Do. 3095. Journal.—The journal is a book of original entry in which is recorded, either in detail or in summary form, the debit and credit effect of financial transactions. (Postings to general ledger accounts shall be made only from entries in the journal.) The debit and credit effect of transactions shall be posted in the journal either from the substantiating voucher, or in summary, from the charge register or expense analysis register. The standard form of journal shall be used, either in bound-book or loose-leaf type. 3096. Charge Register.—(a) The charge register is a columnar sub- sidiary journal record in which is recorded the debit and credit effect of financial transactions involving the receipt of property, except that received by transfer from other activities. The debit and credit effect of such transactions shall be posted in the charge register from data contained in the voucher evidencing payment or settlement for the property received, except as noted under paragraph 3097. 443 3096 CH. 2 0. FINANCE AND PROPERTY (b) The following instructions shall be observed in determining when payment or settlement is made, and when the transaction shall be posted in the charge register. (1) Medical supply depot invoices, NMS—Form 4, shall be con- sidered as paid vouchers on the date the material is received and that date shall be entered on the invoice without regard to the fact that actual receipting and forwarding of the invoice copies is not accom- plished until after check of the material received with the invoice. After forwarding the invoices, the value of material received shall be posted in the charge register, debiting the value of equipment and sup- plies in the appropriate columns of the charge register as indicated, and crediting the total value of the invoice in the column headed amount from medical supply depot. The items, quantities, and values of material invoiced are then posted in the equipment and supplies ledgers as indicated. (2) Public vouchers, including those covering material or services received for work performed under public works contract, shall be considered as paid vouchers at the time the public voucher is prepared and dated. The value of material or services covered by the public voucher, except public vouchers drawn in payment of items previously taken up on memorandum voucher, shall be posted in the appropriate debit column, or columns, of the charge register as indicated by the property or expense classification of the material or services covered by the voucher, and credited in the column headed amount vouchers payable. The items, quantities, and values of material or services received are then posted in the appropriate property ledgers. In the case of debits to operating expense or Navy as a whole, the expen- diture is posted in the appropriate expense analysis register account. Public vouchers covering items previously taken up on memorandum vouchers shall be handled in accordance with paragraph 3097. (3) Stub requisitions covering material received shall be considered as a paid voucher during the month in which it appears on the sum- mary of stub requisitions. Most supply department activities furnish a memorandum copy of stubs with the material at time of delivery; in such cases the values indicated are subject to adjustment before charge is made. Some supply department activities mail the priced copies of stubs a few days after delivery of the material, and others not until the end of the month when a summary of stub requisitions, S. & A. Form 178, covering the total value of stubs charged during the month, is forwarded for receipt. Prior to receipting the summary of stub requisitions, careful verification of the appropriation chargeable and of the amount shall be made to insure the amount of the charge 444 SEC. VII.—ACCOUNTING RECORDS, HOSPITALS 3096 made by the supply department and the amount posted in the charge register agree. The value of material received on stub requisitions, except stub requisitions drawn in payment of items previously taken up on memorandum stub requisitions, shall be posted in the charge register, debiting the value of land and buildings, equipment, or sup- plies items in the appropriate columns of the charge register as indi- cated, respectively, and crediting the total value of the stub in the column headed amount from other naval supplies. The items, quantities, and values of property invoiced shall be posted in the appropriate property ledgers, as indicated. In the case of debits to operating expense or Navy as a whole, the expenditure is posted in the appropriate expense analysis register accounts. Stub requisi- tions covering items previously taken up on memorandum stub requisitions shall be handled as prescribed in paragraph 3097. (4) Expenditure invoices, S. & A. Form 71, covering material received from the supply department as an appropriational expendi- ture shall be considered as a paid voucher when charged by the supply officer. The value of material received on expenditure invoices shall be posted in the charge register, debiting the value of land and build- ings, equipment, or supplies items in the appropriate columns of the charge register as indicated, and crediting the total value of the invoice in the column headed amount from other naval supplies. The items, quantities, and values of material invoiced shall be posted in the appropriate property ledgers. In the case of debits to operat- ing expense or Navy as a whole, the expenditure is posted in the appropriate expense analysis register accounts. Expenditure invoices covering items previously taken up on memorandum expenditure invoices shall be handled as prescribed in paragraph 3097. (5) Civil pay rolls shall be considered as paid vouchers on the last day of the period covered by the pay roll. The value of services re- ceived, as evidenced by the pay roll (amount paid plus retirement fund deduction), shall be posted in the charge register, debiting the total value in the column headed operating expense and crediting the total value in the column headed amount from other naval sup- plies. An analysis of the value of services covered by the pay roll, showing the values applicable to the various hospital departments, shall be made and posted in the respective expense analysis register accounts. (6) Job order charges (except charges for APA material used in connection with the job order), for work performed by yard labor, 445 3096 OH. 20. FINANCE AND PROPERTY shall be considered as paid vouchers on the last day of the month during which the charges were made. A statement of charges made against each job order during the month is furnished; final invoice (APA stub) is usually deferred until the work is completed. The value of charges made (except charges for APA material used in connection with the job order), shall be posted in the charge register in accordance with the following tabulation: Nature of work Debit column in which posted Construction, or extensions, which have been designated by the Bureau to be taken up in the land and buildings ledger Land and buildings. Equipment manufactured under job order Equipment. Supplies manufactured under job order Stores. Repair of land and buildings, equipment, or supplies items Operating expense. Work in connection with cemeteries or care of remains Navy as a whole. The total value of the charges shall be credited in the column headed amount from other naval supplies. The items, quantities, and values of property invoiced shall be posted in the appropriate property ledgers. The value of charges posted in the operating expense or Navy as a whole columns, are posted in the appropriate expense analysis register account. The value of APA material used in connection with the job order shall be debited, by journal entry, to the appropriate general ledger account indicated by the nature of the work, crediting transfer vouchers received. The value of work performed under public works contracts, initiated by Bureau work request, shall be posted in the charge register as indicaetd under subparagraph (2). (7) Transportation requests or express bills of lading, showing estimated cost of transportation of remains, shall be considered a paid voucher on the date remains are delivered to the carrier. The esti- mated cost of transportation, obtained from the initial carrier, shall be posted in the charge register, debiting Navy as a whole and cred- iting amount from other naval supplies. An issue voucher (NMS—Form R) covering the estimated cost of transportation, is then prepared and posted in the appropriate expense analysis register account. (c) The charge register debit and credit columns shall be totaled monthly; the balance of the entries checked by verifying that the total of the three credit columns equal the total of the five debit 446 SEC. VII. ACCOUNTING RECORDS, HOSPITALS 3097-3098 columns and summary entry made in the journal, for posting to the corresponding general ledger accounts, as follows: Land and buildings , $_. Equipment Stores Operating expense Navy as a whole Medical supply depot $ Other naval supplies Vouchers payable To record summary of charge register entries during 19 (Month) 3097. Quarterly Adjustment, Provisions and Fuel.—An adjustment shall be made at the end of each quarter for items of provisions and fuel received during the quarter and wholly or partly expended prior to execution of a voucher in payment or settlement. This procedure is prescribed to eliminate credit balances in the stores (ledger sheet) account, due to expenditure by issue voucher of supplies received and wholly or partly consumed and which has not been taken up (debited) in the stores account until payment for the supplies is authorized by public voucher or stub requisition. Memorandum vouchers (public vouchers, stub requisitions, etc.) shall be prepared, listing the items, quantities, credit prices, extension, total cost, discount, and net total cost of supplies delivered, under each contract which has not been liquidated by public voucher or other settlement. The memorandum voucher shall be posted by journal entry, debiting the stores account and crediting inventory adjustment account. Other unliquidated receipts, such as electric, gas, and water service, shall not be taken up unless accurate calculation of the charge is practicable. Issue vouch- ers shall be prepared and posted to the appropriate expense analysis register accounts. This will automatically obtain the debit to oper- ating expense and the credit to stores (par. 3103 (1)). When vouchers are prepared m settlement of items so adjusted, during the succeeding quarter, they shall be posted by journal entry, debiting inventory adjustment account and crediting vouchers payable account. 3098. General ledger.—(a) The general ledger is the master or control ledger in which is recorded debit and credit value effect of every receipt and expenditure of property. Postings to the general ledger accounts shall be made only from journal entries. The net debits in the respective property accounts reflect the value of property on hand in the corresponding property ledgers. The net credits in the respective receipt accounts reflect the value of property received 447 3098 CH. 20.—FINANCE AND PROPERTY during the year while the net debits in the expenditure accounts reflect the value of property expended during the year. The capital and receipt accounts, less the debits in the expenditure accounts, after adjustments reflected in the inventory adjustment account, equals the totals of the property accounts. The receipt, expenditure, and adjustment accounts are set up to classify financial transactions and are closed to capital account at the end of the year (par. 3112). (b) General ledger accounts, instructions relative to their pur- pose and transactions applicable to each, are as follows: (1) Capital.—The capital account reflects the net investment in property carried in the land and buildings, equipment, supplies, and commissary ledgers. Changes are usually recorded only at the end of the fiscal year when the receipt, expenditure, and adjustment accounts are closed. (2) Land and buildings.—The land and buildings account is a control account reflecting the total value of items carried in the land and buildings ledger. Receipt and expenditure of land and buildings items are recorded as debits and credits in the control account, the details being posted in the appropriate item sheets of the land and buildings ledger. (3) Equipment.—The equipment account is a control account reflecting the total value of items carried in the equipment ledger. Receipt and expenditure of equipment items are recorded as debits and credits in the control account, the details being posted in the appropriate item sheets of the equipment ledger. (4) Stores.—The stores account is a control account reflecting the total value of items carried in the supplies and commissary ledgers. Receipt and expenditure of supplies and provisions are recorded as debits and credits in the control account, the details being posted in the appropriate item sheets of the supplies and commissary ledgers. (5) Medical supply depot.—The medical supply depot account is a receipt account designed to record the value of material received during the year from medical supply depots. The value of each invoice is posted as a credit. (6) Other naval supplies.—The other naval supplies account is a receipt account designed to record the value of material or services received during the year from the supply department and other sources. The value of material received on stub requisitions or ex- penditure invoices; services of civil employees carried on the pay roll; work performed by yard labor as evidenced by job order charges and the estimated cost of transportation of remains are posted as a credit. 448 SEC. VII.—ACCOUNTING RECORDS, HOSPITALS 3098 (7) Vouchers 'payable.—The vouchers payable account is a receipt account designed to record the value of material or services received during the year under purchase contracts, payment for which is author- ized by public voucher. The value of material or services approved for payment by public vouchers, including work under public works contracts, is posted as a credit. (8) Transfer vouchers issued.—The transfer vouchers issued account is an expenditure account designed to record the value of material or services transferred to other activities during the year. The value of material or services transferred to other activities is posted as a debit. (9) Transfer vouchers received.—The transfer vouchers received account is a receipt account designed to record the value of material or services received during the year by transfer from other activities. The value of material or services, including the value of APA material, received from the supply department at no appropriational charge, or used in connection with work performed by yard labor; material and services received from other activities and the value of pay and allowances of the military staff are posted as credits. (10) Operating expense.—The operating expense account is an expenditure account designed to record the value of material or serv- ices expended incident to the operation of the hospital, exclusive of: Material or services transferred to other activities; expenditure of land and buildings items; losses by fire, flood, etc.; expenditures incident to care of the dead, Hospital Corps schools, out-patient services fur- nished dependents, and subsistence sold to staff members. The value of expenditure, not properly chargeable to other expenditure accounts, is posted as a debit. Expenditures applicable to other accounts which cannot be allocated when original charge is made, such as fuel fur- nished staff quarters, subsistence, etc., shall be charged to operating expense and the prorated portion transferred at the end of the month or quarter, to the appropriate account by adjustment voucher. The net debit balance recorded in the operating expense account shall equal the total expenditures recorded in section 1 of the expense analysis register. (11) Inventory adjustments.—The inventory adjustment account is designed to record the value of inventory adjustments due to differ- ences between physical and book inventories and the adjustments at the end of the quarter, due to expenditure of items of provisions and fuel prior to settlement of dealer bills. (13) Navy as a whole.—The Navy as a whole account is an ex- penditure account designed to record the value of expenditures inci- 449 3099 CH. 2 0. FINANCE AND PROPERTY dent to care of the dead, Hospital Corps schools, losses by fire or other unusual occurrences, out-patient services furnished dependents, sub- sistence sold staff members, expenditure of land and buildings items, and similar expenditures not considered to be hospital operating ex- pense. The value of such expenditures are posted as debits. The net debit balance recorded in the Navy as a whole account shall equal the total expenditures recorded in section 3 of the expense analysis register. (14) Pay and allowances, military staff.—The pay and allowances, military staff account is an expenditure account designed to record the value of pay and allowances of members of the Navy and Marine Corps attached to the hospital for duty, except personnel assigned to Hospital Corps schools for duty or instruction. The value of allow- ances paid enlisted personnel in lieu of subsistence and quarters shall be included as an expenditure. The value of travel allowances of officer and nurse personnel, and allowances for quarters of officer per- sonnel furnished public quarters, shall not be included as an expendi- ture. The value of expenditures are posted as debits. 3099. Land and Buildings ledger.—(a) A land and buildings ledger shall be maintained at naval hospitals, medical supply depots, and the Naval Medical Center. A copy of the land and buildings ledger is maintained by the Bureau. The total value of items listed in the land and buildings ledger must equal the net debit balance of account 2—land and buildings in the general ledger. (b) A control ledger sheet (NMS—Form Wa) shall be main- tained for each complete unit and a separate ledger sheet shall be maintained for component parts of the complete unit. Similar control sheets may be maintained for each group, subdivision, and general division. All data indicated by NMS—Form Wa shall be recorded. A record of repairs, replacement of parts, alterations, and minor improvements shall be made on the reverse of the ledger sheets. A copy of additional ledger sheets, changes, repairs, etc., shall be for- warded annually on July 1 to the Bureau for insertion, or for entry, in the duplicate of the ledger maintained in the Bureau. (c) The land and buildings ledger shall be classified and arranged in the following general divisions, subdivisions, and groups: 450 SEC. VJI.—ACCOUNTING RECORDS, HOSPITALS 3100 Division Subdivision Group (2LI—Parcels of land 2L11—Hospital reservation. 2L12—Miscellaneous plots. 2L—Land 2L2—Improvements to land. 2L13—Cemetery plots. 2L21—Roadways. 2L22—Sidewalks. 2L23—Sea walls. 2L24—Retaining and restraining walls. 2L2-5—Piers and wharves. 2L26—Reservoir. ,2L27—Miscellaneous. 2L31—Sewer system. 2L32—Water-distributing system. 2L33—Fire-protection system. 2L34—Gas-distributing system. 2L35—Electric-distributing system. 2L36—Steam-distributing lines (outside of buildings). 2L37—Heat (hot water) distributing system (outside of buildings). ,2L38— Miscellaneous. '2B11—Granite. 2B12—Brick. 2B13—Concrete. 2B14—Composite (granite, stone, brick, concrete, etc. (specify combination)). 2B15—Wood. 2B16—Stucco. 2B.17—Composite (wood, galvanized iron, stucco, etc. (specify combination)). 2B18—Miscellaneous. 2B21—Concrete. 2B 22—Wood. 2B23—Stucco. 2B24—Composite (wood, galvanized iron, stucco, etc. (specify combination)). 2B25—M isceilaneous. ,2L3—Service utilities /2B1—Permanent 2B—Buildings... ,2B2—Temporarv (d) Additions and extensions or improvements which add to or increase the original usefulness of land and buildings’ items shall be taken up in the land and buildings’ ledger sheet. Authority to record changes in value of land and buildings’ items, due to acquisi- tions, expenditure, or other causes, shall be requested of the Bureau when indicated. 3100. Equipment ledger.—(a) An equipment ledger shall be maintained by all activities charged with accountability for Medical Department property and required to render financial reports to the Bureau. (b) An equipment ledger sheet (NMS—Form W) shall be main- tained for each identical item of equipment. All data indicated by the form shall be recorded. Additional descriptive data shall be added when necessary to accurately identify the item. Use of control sheets for the respective classes of equipment is recommended. The equipment location record on the reverse of the ledger sheets shall indicate the quantity of the item located in each department or unit, the quantity awaiting survey and the quantity in store. 451 3101 CH. 20. FINANCE AND PROPERTY (c) The equipment ledger items shall be arranged in the following order: Part 1—Supply table classes. Part 2—Supplementary supply table classes. Part 3—Federal Standard Stock Catalog classes. (d) Items not specifically listed in the foregoing supply tables or catalog shall be classified and carried under the appropriate Federal Standard Stock Catalog class listing similar equipment. (e) Receipt of equipment shall be posted to the equipment ledger from the data contained in the voucher evidencing payment or settle- ment for the equipment received. Items of equipment shall be carried at the invoiced value. (f) Expenditure of equipment shall be posted to the equipment ledger from the approved survey or transfer voucher. 3101. Supplies Ledger.—(a) A supplies ledger shall be main- tained by all activities, except recruiting stations, charged with ac- countability for Medical Department property and required to render financial reports to the Bureau. (b) A supplies ledger sheet (NMS—Form W) shall be main- tained for each identical item of supplies. All data indicated by the form shall be recorded. Additional descriptive data shall be added when necessary to accurately identify the item. The use of control sheets for the respective classes of supplies is recommended. The reverse of the ledger sheet may be adapted for desirable data. (c) The supplies ledger items shall be arranged in the following order: Part 1—Supply table classes. Part 2—Supplementary supply table classes. Part 3—Federal Standard Stock Catalog classes. (d) Items not listed in the foregoing supply tables or catalog shall be classified and carried under the appropriate Federal Stock Catalog class listing similar supplies. (e) Receipt of supplies shall be posted to the supplies ledger from the data contained in the voucher evidencing payment or settlement for the supplies received. Upon receipt of supplies at a unit cost differing from that of stock on hand, a new unit cost shall be calcu- lated by dividing the total value of old and new stock by the number of old and new units on hand. Subsequent issues shall be expended at the new unit cost. (f) Expenditure of supplies shall be posted to the supplies ledger from the issue voucher, transfer voucher or inventory adjustment voucher authorizing the expenditure. 452 SEC. VH.—ACCOUNTING RECORDS, HOSPITALS 3102 (g) Differences between physical inventory and the quantity on hand as- shown by the respective sheets shall be adjusted by an inventory adjustment voucher approved by the commanding officer, a copy of which shall be forwarded to the Bureau with the financial reports. (h) Inventory adjustment vouchers shall be prepared in the follow- ing form: (Name of activity) (Date) Inventory Adjustment Voucher 1. The following differences were found between the quantities shown as on hand by the supplies ledger and the actual count as determined by inventory: Stock No. Item Quantity on hand Value Supplies ledger Inven- tory count Over Under Unit price Over Under $ $ $ List items and data as indicated by column headings. 2. Authority is requested to adjust the differences listed. U. S. Navy, Property and accounting officer. Approved. (Date) U. S. Navy, Commanding. After approval suitable adjustment shall be made in the general ledger by debits or credits to the stores and inventory adjustment accounts. 3102. Provisions ledger.—(a) A provisions ledger shall be main- tained at naval hospitals. (b) A set of provisions ledger sheets, consisting of one cash values sheet, NMS—Form 35, and as many additional sheets, NMS— Form 35a, as may be required, shall be maintained to record receipts and expenditures during each calendar month. (c) Provision ledger sheets are ruled in columnar form, a pair of columns, one designated R (receipt) and the other E (expenditure) 453 3103 CH. 2 0.—FINANCE AND PROPERTY being provided for the items. Receipts are posted in black ink, expenditures are posted in red ink. The name and unit price of the items are shown at the top of the pair of columns. One line is assigned for each day of the month, the quantity only of receipts and expendi- tures of items being entered under the respective items. Cash value of total receipts and total expenditures are entered in the cash value columns of NMS—Form 35. Changes in unit price shall be made in the manner prescribed for supplies. (d) At the beginning of the month the quantities and values of items on hand at the end of the preceding month are brought forward to the top line of the sheets for the new month. Subsequent receipts, expenditures, and the respective values are posted to the ledger columns from the data contained in the receipt and expenditure voucher, NMS—Form 37, after approval of the voucher by the com- manding officer. (e) At the end of the month the respective R and E columns shall be totaled, the quantities on hand verified by physical inventory, and any differences between inventory quantities and the ledger quantities, and differences in value due to time payment discounts, if any, shall be adjusted. 3103. Expense Analysis Register.—(a) The expense analysis register is a loose-leaf ledger in which there is an account (separate sheet) maintained for the following departments and activities of the hospital: Section 1 Administration. Wards. Operating rooms. X-ray. Pharmacy. Laboratory. Laundry. Transportation. Maintenance, buildings and grounds. Commissary. Staff quarters. Surveys, supplies, and equipment. Hospitalization of dependents. Section 2 Pay and allowances, military staff Section 3 Care of the dead. Out-patient services, dependents. Hospital Corps schools. Contingencies and losses. Other nonhospital expense. (b) Section 1 of the expense analysis register is an analysis of the net debits to Account 10—operating expense. Section 2 of the expense analysis register is an analysis of the net debits to Account 14—pay and allowances, military staff. 454 SEC. VII.—ACCOUNTING RECORDS, HOSPITALS 3103 Section 3 of the expense analysis register is an analysis of the net debits to Account 13—Navy as a whole. (c) Each debit and credit to Accounts 10, 13, and 14, when made in the charge register or journal, shall be posted to the appropriate expense analysis register accounts and analyzed as appropriate for the department into the following: 01 Pay civil personnel. 05 Fuel gas, electricity, water, etc. 02 Supply table material. 06 Provisions. 03 Supplementary supply table mate- 07 Job order charges. rial. 08 Special material and services. 04 Federal Standard Stock Catalog 09 Pay, military staff. material. 10 Land and buildings. (d) Every voucher, authorizing expenditure of property except property transferred to other activities, shall be recorded in the ex- pense analysis register, either individually or in summary. Vouchers authorizing expenditure of property shall be approved as follows: Vouchers expending Approved by Land and building items Bureau. Equipment items Bureau or commandant. Supplies or provision items Commanding officer or executive officer. Material transferred Bureau or senior officer present. (e) Expense analysis register accounts, and instructions rela- tive to expenditures applicable to each, are as follows: (1) Section 1. Analysis of debits to Account 10—operating expense.— Administbation.—Expenditures for maintenance of general administrative offices and activities, including offices of the commanding and executive officers; officer of the day; chiefs of services; heads of departments and chief nurse; library; storeroom; and other similar units. Wards.—Expenditure for maintenance of wards (except commissary supplies and supplies utilized exclusively for hospitalization of dependents), including services of blood donors and maintenance of dressing rooms, splint rooms, physical therapy, dental offices, electrocardiograph and similar units serving two or more, wards. A separate account for each ward or unit may be maintained, if desired, provided a single control account is also maintained. Operating rooms.—Expenditures for the maintenance of operating rooms, except those utilized exclusively for hospitalization of dependents. X-ray.—Expenditures for maintenance of x-ray service. Pharmacy.—Expenditures for maintenance of the pharmacy, including the value of medicines, biologicals, and medical supplies issued to other units through the pharmacy. Laboratory.—Expenditures for maintenance of the laboratory. Laundry.—Expenditures for maintenance of the laundry or for laundry services. Transportation.—Expenditures for maintenance of transportation services. Maintenance, buildings and grounds.—Expenditures for maintenance of buildings (except staff quarters) and service utilities and grounds, including fuel; gas; heating; electric and water services; repair, alteration, and painting of build- 455 3103 CH. 2 0. FINANCE AND PROPERTY ings and appurtenances; cleaning services and supplies; elevator inspection services; lamps for general lighting; repair and maintenance of steam, heating, water, electric, and gas distributing systems located outside of buildings; outdoor il- luminating and sewer systems; waste removal services; roads; walks; trees; bridges; piers; sea walls; retaining walls; embankments; grading; flag poles; and similar maintenance and repair expenditures. Commissary.—Expenditures for maintenance of the commissary, including provisions; kitchen, dining room, diet kitchen, butcher shop, bake shop, scullery, and ward service supplies and services; refrigeration supplies required for preserva- tion of provisions or preparation of foods; and similar expenditures. Staff quarters.—Expenditures for repair and maintenance of quarters includ- ing survey of equipment assigned staff personnel, including officer, nurse, enlisted, and civil personnel. Surveys, supplies, and equipment.—Expenditures of supplies and equipment by authority of approved property survey, except when otherwise directed by the Bureau, and except survey of supplies and equipment assigned for use in Hospital Corps school, staff quarters, out patient service, and spaces utilized for hospitalization of dependents. Hospitalization of dependents.—Expenditures for hospitalization of de- pendents, including all supplies and services issued directly; repair, alteration, and painting of buildings or spaces assigned when the cost of the work can be apportioned, and other similar direct expenditures which can be definitely allo- cated as a cost of maintaining or operating the services and the buildings or spaces assigned for the purpose. The value of supplies and equipment, when surveyed, assigned for use in dependent wards, shall be charged to the account when ex- pended by survey. (2) Section 2. Analysis of debits to Account 14—Pay and allowances, military staff.— Pay and allowances, military staff.—Expenditures for pay and allowances of members of the Navy and Marine Corps on duty; the value of allowances paid enlisted personnel in lieu of subsistence and quarters. Expenditures for pay and allowances of personnel on duty or under training in Hospital Corps schools shall be allocated to Account IS—Navy as a whole (3) Section 3. Analysis of debits to Account IS—Navy as a whole.— Care of the dead.—Expenditures incident to care of the dead, including maintenance of the mortuary, cemeteries, and burial plots. Out-patient services, dependents.—Expenditures for supplies and main- tenance of buildings or spaces set aside for out-patient services to dependents. Expenditures include survey of equipment. Hospital Corps school.—Expenditures for supplies; maintenance of buildings or spaces set aside for use as Hospital Corps school and personnel; pay and allow- ances, including subsistence of personnel detailed as instructors or under instruc- tion; value of supplies and equipment, when surveyed, assigned for use of the Hospital Corps school, and similar-expenditures. Contingencies and losses.—Expenditure of supplies and equipment losses by fire or other unusual occurrence and land and building items, when expended by authority of approved surveys. Other nonhospital expense.—Expenditures for subsistence sold naval or civil staff personnel and other nonhospital expenditures not otherwise classified. (f) Expenditures recorded in the respective expense analysis ac- counts shall be posted according to classification. The expense 456 SEC. VII.—ACCOUNTING RECORDS, HOSPITALS 3103 analysis classifications and instructions as to expenditures appli- cable to each are as follows: Pay, civil personnel.—Expenditures for services of civil personnel. Supply table material.—Expenditure of items listed in the supply table. Supplementary supply table material.—Expenditure of items listed in the SUPPLEMENTARY SUPPLY TABLE. Federal Standard Stock Catalog material.—Expenditure of items listed in the Federal Standard Stock Catalog. Fuel, gas, electricity, water, etc.—Expenditures for fuel, gas, heating, electricity, and water. Provisions.—Expenditure of items listed in the provisions ledger. Job order charges.—Expenditures incurred by job orders. Special material and services.—Expenditure of material and services ex- pended immediately upon receipt, including services of blood donors, etc. Pay, military staff.—Expenditures for pay of naval personnel on duty, exclusive of patients. Land and buildings.—Expenditure of items listed in the land and buildings ledger. (g) Expenditures applicable to two or more expense analysis register accounts which cannot be allocated thereto, when original charge is made, such as fuel and subsistence, shall be charged to the usual expense analysis register account and, at the end of the month or quarter, the prorated portion transferred to the appropriate account by ADJUSTMENT VOUCHER. (h) Expenditures of a nature not specifically enumerated shall be allocated to the appropriate account after due consideration of the purpose of the expenditure. (i) Vouchers covering supplies, previously issued and charged to expenditure accounts, which are returned to the storeroom by issue vouchers (NMS—Form R), shall be entered in red ink indicating subtraction. Such supplies shall be taken up at current unit price. (j) Adjustment vouchers, transferring the value of expenditures originally charged to one expense analysis register account to another account, do not require adjustment of the general ledger accounts if made during the same month and before posting to general ledger accounts. When posting to general ledger accounts has been made during one month and transfer to another expense analysis register section is made during a subsequent month, corresponding adjustment of the general ledger accounts shall be made by journal entry. (k) The value of items carried in the stores account, including supplies and provisions, expended to the various expense analysis reg- ister accounts by approved issue vouchers, shall be posted in the re- spective expense analysis register sheet either individually by vouch- ers, or monthly, in summary form. The total value of supplies issued shall be posted in the column total of stores issued on issue 457 3104-3107 CH. 2 0.—FINANCE AND PROPERTY voucher, and the value of the various kinds of supplies expended classified as indicated under paragraph 3103 (f). Vouchers covering supplies or services expended immediately upon receipt, as indicated by debits in the columns headed operating expense and Navy as a whole, of the charge register and supplies expended by survey, shall be similarly posted. (1) Expenditures posted in the total of stores issued on issue vouchers columns of each section of the expense analysis register shall be totaled at the end of each month and journal entry made to record the expenditures in the general ledger accounts as follows: Operating expense — $ . Navy as a whole Stores $ To record stores expended during 19 Month 3104. Quarterly Expenditures, Provisions and Fuel.—Expenditure vouchers shall be prepared and posted to the expense analysis register for expended items of provisions and fuel received but not paid during the quarter, and which have been taken up by memorandum voucher as prescribed by paragraph 3097. Other unliquidated items, such as electric, gas, and water services, shall not be expended unless accurate calculation of the charge is practicable. 3105. Heat, Electric Current, Gas, and Water, Officers’ Quarters.— The value of heat, electric current, gas, and water, furnished officers residing in public quarters, when originally charged to hospital funds and accounts, shall be transferred to the supply officer in accordance with the instructions contained in article 1742, Bureau of Supplies and Accounts Manual and Memoranda. The value of such trans- ferred services shall be debited to Account IS—Navy as a whole and credited to Account 10—operating expense. Suitable adjustment in the expense analysis register shall be made, notation being made on the voucher indicating the expense analysis accounts credited. 3106. Part Compensation and Special Duty Services Allowances.— The value of quarters, household equipment, heat, electric current, gas, water, subsistence, and laundry services, furnished civil employees as part compensation or special duty compensation, in accordance with the instructions contained in the schedule of wages, is a proper charge to operating the hospital. The original cost is lodged in the appropriate hospital expense accounts from routine paid vouchers and transfer or adjustment for the value indicated in pay rolls is not necessary. 3107. Special Depositors, Civil Employees.—(a) The value of serv- ices, which is not part compensation or special-duty services allowances, is reimbursed to the Government. (References: Instructions, sched- 458 SEC. VII.—ACCOUNTING RECORDS, HOSPITALS 3108 ule of wages; Navy Department letter S. 0. N. Y. D. 7Gn, May 31, 1927; art. 2121-3, Bureau of Supplies and Accounts Manual.) (b) Where heat, electric current, gas, water, subsistence, or laundry services are furnished civil employees, which is not part compensation or special-duty services allowances, each employee shall be required to maintain a special (advance) deposit to cover the estimated value of the service to be furnished, in accordance with article 2121-3 (g) Bureau of Supplies and Accounts Manual. (c) The value of quarters and household equipment (rent) furnished special depositors does not result in reimbursement to the naval hospital fund (NHF). Such monies are deposited to miscella- neous receipts by the disbursing officer. (d) The value of heat, electric current, gas, water, subsistence, or laundry services furnished special depositors is to be credited to the NAVAL HOSPITAL FUND. (e) At the month end or at such times as may be necessary, the commanding officer shall request the disbursing officer by letter, to check the employees’ special (advance) deposit account, for the value of the services listed on the letter request. The request shall indicate the appropriation or fund to be credited as indicated by subparagraph (c) and (d) above. (f) The value of services furnished, credited to NHF, shall be trans- ferred by journal entry (adjustment voucher) from Account 10— operating expense to Account IS—Navy as a whole, and the expense analysis register accounts of each section adjusted appro- priately. (g) Copies of letters to the disbursing officer directing checkage against special (advance) deposits of the individuals, and credits to the appropriate fund shall be assigned adjustment voucher numbers, and forwarded with the hospital’s quarterly financial returns. Letters covering similar services may be grouped and assigned one transfer voucher issued number. 3108. Services Furnished Ship’s Service.—The value of heat, elec- tric current, gas, water, refrigeration supplies or ice furnished the ship’s service activities and a portion of the cost of building main- tenance, appropriate to the space occupied, is chargeable to the ship’s service (art. 602, Regulations for ship’s service departments (ashore), issued by the Bureau of Navigation dated March 15, 1930). The estimated cost of services furnished and the appropriate amount of building maintenance shall be collected from the ship’s service on the first day of each month, or of each quarter, and transmitted to the disbursing officer as a special deposit. At the end of each month, or quarter, the value of services furnished shall be checked against the 459 3109-3110 CH. 20.—FINANCE AND PROPERTY special deposit and credited to the naval hospital fund in the same manner as other special deposits. The value of services furnished the ships’ service activities shall be transferred by journal entry (adjust- ment voucher (from Account 10—operating expense to Account IS— Navy as a whole, and the expense analysis register accounts adjusted accordingly. A copy of the letter directing checkage against the advance deposit shall be forwarded to the Bureau with the hospital’s quarterly financial returns. 3109. Subsistence Checkages.—Subsistence or occasional meals furnished officers, officers’ guests, nurses’ guests, and enlisted person- nel credited with the commuted value of the ration, shall be checked against the pay accounts of the individual furnished such subsistence, at the rate of $0.25 per meal. Checkage shall be made monthly or immediately prior to detachment or transfer of the individual con- cerned. An adjustment voucher, covering the total amount checked during the quarter against the pay accounts of naval personnel, shall be prepared and posted by journal entry debiting Account IS—Navy as a whole and crediting Account 10—operating expense. The amount of all subsistence furnished personnel not entitled thereto as indicated on adjustment vouchers shall be distributed in the expense analysis register account commissary as follows: Excess of checkage above average cost of ration, credit expenditure classification column headed Federal Standard Stock Catalog material and for the average cost of ration, credit expenditure classification column headed provisions. The identical columns shall be charged in the expense analysis register account other nonhospital expense. When sub- sistence charges for Red Cross representatives are checked against the pay account of an officer, the foregoing instructions shall apply. A copy of letters directing checkages against pay accounts of personnel for meals furnished, or transmitting cash for deposit to the credit of the naval hospital fund, shall be forwarded with the hospital’s quarterly financial return. 3110. Services Furnished Other Medical Department Activities.— Laundry and other services regularly furnished the medical depart- ment of other activities shall be invoiced at the end of each quarter or on termination of such services. The value of such services shall be calculated on a prorated cost basis except when otherwise specifically authorized by the Bureau. Transfer vouchers, indicating the data on which the prorated charges are calculated, shall be prepared and posted by journal entry as a debit to Account IS—Navy as a whole, and as a credit to Account 10—operating expense, with suitable adjustment of expense analysis accounts. 460 SEC. VII.—ACCOUNTING RECORDS, HOSPITALS 3111-3113 3111. Material and Services Furnished Other Government Agen- cies.—The value of material or services, except hospitalization, furnished other Government agencies by authority of the Bureau or other competent naval authority, shall be invoiced at cost for ma- terials, or calculated on a prorated cost basis for services. Transfer vouchers, indicating the data on which prorated charges are calcu- lated, shall be prepared and posted by journal entry debiting Account 8—transfer vouchers issued, and crediting the appropriate prop- erty account, in the case of material, or Account 10-—operating expense, in the case of services, with suitable adjustment of expense analysis accounts. 3112. Closing Receipt, Expenditure, and Adjustment Account.— At the end of the fiscal year, after all adjustments have been made, the general ledger receipt, expenditure, and adjustment account shall be closed by transfer to capital account. The following procedure shall be followed: (1) Determine the net debit or credit balance of all accounts by totaling, separately, the debits and credits posted during the year; subtract the lesser sum from the greater sum, the difference repre- senting the net debit or credit balance. (2) Prepare a trial balance, listing the account numbers and names, the net debits in one column and the net credits in another column. The total of the debit column must equal the total of the credit column. (3) Transfer the net credit balances of the receipt accounts to capital by journal entry, as follows: Medical supply depot $ Other naval supplies Vouchers payable Transfer vouchers received Inventory adjustments (if net credit balance) _ Capital - $ (4) Transfer the net debit balance of the expenditure accounts to capital by journal entry as follows: Capital $ Transfer vouchers issued $ Inventory adjustments (if net debit balance) Navy as a whole Pay and allowances, military staff Operating expense 3113. Balance Sheet.—A balance sheet shall be prepared at the end of the fiscal year, after transfer of receipt, expenditure, and adjustment 461 3114-3117 CH. 20.—FINANCE AND PROPERTY accounts, and forwarded to the Bureau with Register No. 3. The balance sheet shall be prepared in the following form: United States Naval Hospital, Balance Sheet as at June 30 19— ASSETS Land and buildings $ Equipment Supplies $ Provisions Stores Total assets $ CAPITAL Capital $ 3114. Inventory, Land and Buildings.—An inventory of items car- ried in Account 2, land and buildings, shall be prepared at the close of the fiscal year and forwarded to the Bureau with Register No. 3. The inventory shall be prepared in letter form on standard 8 by 10% inches typewriter paper, written lengthwise, and shall contain the following data: Item symbol and name; value of subsidiary items; group totals; subdivision totals and division totals, in the order listed in the land and buildings ledger. 3115. Inventory, Equipment.—An annual inventory of items carried in Account 8, equipment, shall be prepared at the close of the fiscal year and forwarded to the Bureau with Register No. 3. The items shall be listed in the order prescribed for the equipment ledger. 3116. Register No. 3—Recapitulation of ledger Accounts.—A re- capitulation of ledger accounts, Register No. 3, shall be prepared, quarterly, and when decommissioned, and forwarded to the Bureau, accompanied by the quarterly ration return, allotment reports, and other required financial data, not later than the fifteenth day after the close of the quarter. Instructions relative to the preparation of Register No. 3 are contained in paragraph 3498. 3117. Quarterly Ration Return.—The quarterly ration return, NMS—Form 36, shall be prepared quarterly, and when decommis- sioned, and forwarded to the Bureau with Register No. 3, not later than the fifteenth day after the close of the quarter. Instructions relative to the preparation of NMS—Form 36 are contained in chapter 23. 462 SEC. VIII. MEDICAL STORES, SUPPLY DEPOTS 3142-3143 SECTION VIII. MEDICAL STORES, NAVAL MEDICAL SUPPLY DEPOTS Paragraph Functions of Depots 3142 Medical Stores Available for Issue 3143 Medical Stores Replenishment Schedule 3144 Medical Stores, Procurement 3145 Medical Stores, Maintenance 3146 Annual Inventory 3147 Table of Annual Issues 3148 Medical Stores, Accounting Procedures 3149 Statement of Receipts and Expenditures of Medical Stores 3150 Medical Stores, Issue 3151 Medical Stores, Transfer Between Depots 3152 Medical Stores, Transfer to Supply Department 3153 Medical Stores, Transfer to Reserve Activities 3154 Medical Stores, Transfer to Other Government Agencies 3155 3142. Functions of Depots.—The functions of the naval medical supply depots are: (1) To provide standard medical stores (1) for the fleet and outlying shore stations, and (2) for shore stations within the United States. (2) To maintain on hand, in accordance with approved naval policy, such medical stores as may be designated by the Bureau. (3) To provide facilities for salvage and for repair of medical equipment. (4) To provide laboratory facilities for examination and testing of medical stores. (5) To develop and revise material specifications for medical stores and to initiate recommendation for revision of Federal, Navy Department, and Bureau specifications when indicated. (6) To develop logistic data relative to medical stores. (7) To develop and revise commissioning outfit lists of material for ships and shore stations. (8) To recommend modifications in the supply and supplementary supply tables, annually, October 1. Note.—The term medical stores includes both supplies and equipment. 3143. Medical Stores, Available for Issue.—(a) Medical stores at medical supply depots shall be designated as: (1) Available stores.—Quantity available for issue on routine requisitions. (2) Reserve stores.—Quantity held for special purposes. This quantity, pre- scribed by the Bureau, shall be maintained on hand at all times. Issues from reserve stores shall be made only upon specific order of the Bureau or other com- petent naval authority. The designations available stores and reserve stores indicate only the category of the total stores; therefore, the reserve stores shall not be segregated from the available stores but shall form a part of the rotating stores from which routine issues are made. 463 3X44-3145 CH. 2 0.—FINANCE AND PROPERTY (b) Reserve stores are divided into four classes, as follows: (1) Reserve stores A.—Consists of commissioning outfits for vessels, except books and perishable items. (2) Reserve stores B.—Consists of outfits for expeditionary force units, except books and perishable items. (3) Reserve stores C.—Consists of quantities of standard items necessary to meet immediate demands incident to increasing personnel allowances of ships and stations to full complement, until such time as post-mobilization procurement plans are in operation. (4) Reserve stores D.—Consists of commercially nonstandard medical units, designed and manufactured to meet specific Navy requirements. Instructions relative to reserve stores A, B, C, and D, and changes therein, will be issued by Bureau Circular Letter F. 3144. Medical Stores Replenishment Schedule.—A replenishment month schedule shall be maintained by the Medical Supply Depot, Brooklyn, N. Y., and routine replenishments of each item of medical stores shall be planned for accomplishment in accordance with this schedule. A copy of the replenishment schedule, and any changes therein, shall be furnished the Bureau and each medical supply depot. The replenishment schedule shall be prepared in columnar form and include the following data: Column No. Data 1 Stock number. 2 Name of item and quantity in unit. 3 Package unit (number of units in package). 4 Quantity, in standard case. 5 Replenishment month (month in which delivery of annual purchase is planned). 6 Number of months normally required to obtain delivery after sub- mission of purchase requisition or order for delivery under annual contracts. 7 Scheduled “requisition or order month” (month in which requisition or order for delivery under annual contract is scheduled to be submitted). 8 Procurement method (annual requisition, specific requisition, expendi- ture invoice from supply department; depot assembly, etc.). 3145. Medical Stores, Procurement.—(a) The Naval Medical Sup- ply Depot, Brooklyn, N. Y., is the chief procurement agency. At other depots procurement is limited to perishables and certain other items. (b) The quantities of each supply-table item of medical stores, except perishables, to be purchased annually by the chief procurement agency, shall be calculated in accordance with the following formula: (1) Quantity required for issue by all depots between Mar. 31 of the preceding fiscal year and 12 months after the scheduled replenishment month in the ensuing fiscal year 464 SEC. VIII. MEDICAL STORES, SUPPLY DEPOTS 3146-3147 (2) Plus: Total quantity directed to be carried as reserve stores at all depots (3) Total: (1) plus (2) (4) Less: Total inventory on hand at all depots on Mar. 31 of the preceding fiscal year (5) Quantity to be purchased during the current fiscal year. _ (c) The quantity of each supply table item to be purchased during the current fiscal year, as determined by the foregoing formula, shall be adjusted to the nearest packing case unit, not to exceed a variation equal in quantity to more than 2 months’ average issues. If the quantity to be purchased is less than 2 months’ supply at the average rate of issue, purchase of the item shall be deferred until the ensuing fiscal year. (d) From the data obtained under paragraphs 3144 and 3145, a monthly procurement schedule shall be prepared and maintained by the Medical Supply Depot, Brooklyn, N. Y. 3146. Medical Stores, Maintenance.—(a) The Medical Supply Depot, Brooklyn, N. Y., shall maintain on hand at all times a minimum quantity of each supply-table item of medical stores, except perish- ables, equal to the average annual issues (par. 3148), plus such quan- tities of reserve stores as may be designated by the Bureau. (b) The Medical Supply Depots, Mare Island, Calif., and Canacao, P. I., shall: (1) Maintain on hand a minimum quantity of each supply-table item of medical stores, except perishables, equal to the average annual issues (par. 3148), plus such quantities of reserve stores as may be designated by the Bureau. (2) Establish a maximum quantity, of each supply-table item of medical stores, except perishables, equal to twice the average annual issues (par. 3148), plus such quantities of reserve stores as may as designated by the Bureau. (3) Establish a replenishment order point for each supply-table item of medical stores, except perishables; the replenishment order point is a quantity consisting of minimum quantity plus a quantity sufficient to meet average issues for the number of months normally required to obtain replenishments. (4) Submit normal replenishment requisitions four times annually (following the beginning of each quarter). This procedure should result in replenishment of approximately one-fourth of the items carried, to the maximum quantity, each quarter, and, except for fluctuations in current issues, the replenishment quantities requisitioned should approximate 1 year’s average issues. Replenishment quanti- ties shall be adjusted to the nearest case unit, except when such adjustment would exceed 2 months’ average issues. (5) Suitable modification of the foregoing procedure should be made in the case of stores subject to rapid deterioration. 3147. Annual Inventory.—(a) Each medical supply depot shall prepare and forward to the Bureau, annually, an itemized inventory of medical stores on hand as of March 31. The Medical Supply Depots, Mare Island, Calif., and Canacao, O. I., shall forward a copy 465 3148 CH. 20.—FINANCE AND PROPERTY of the inventory direct to the Medical Supply Depot, Brooklyn, N. Y. The annual inventory shall be prepared in columnar form and shall contain the following data: Column No. Data 1 Stock number. 2 Name of item and quantity in unit. 3 Package unit (number of units in package). 4 Total quantity on hand. 5 Quantity designated as reserve stores A. 6 Quantity designated as reserve stores B. 7 Quantity designated as reserve stores C. 8 Quantity designated as reserve stores D. 9 Total reserve stores (total of columns 5, 6, 7, and 8.) 10 Available stores (column 4 less column 9). (b) After all annual inventories have been received, a consolidated inventory of medical stores, including medical stores in transit between depots, will be prepared by the Medical Supply Depot, Brooklyn, N. Y. for use in determining replenishment quantities to be procured during the ensuing fiscal year. 3148. Table of Annual Issues.—(a) Each medical supply depot shall prepare and forward to the Bureau, annually, after the close of the fiscal year, a table showing the issues, during the 3 most recently completed fiscal years, of each item of medical stores listed in the supply table and the supplementary supply table (exclusive of transfers to other depots, and surveys). The Medical Supply Depots, Mare Island, Calif., and Canacao, P. I., shall forward a of the table direct to the Medical Supply Depot, Brooklyn, N. Y. The table shall be prepared in columnar form and shall contain the fol- lowing data: Column No. Data 1 Stock number. 2 Name of item and quantity in unit. 3 Package unit (number of units in package). 4 Issues, FY 19 (third latest completed year). 5 Issues, FY 19 (second latest completed year). 6 Issues, FY 19 (latest completed year). 7 Total issues during 3-year period (total of columns 4, 5, and 6). 8 Average annual issues (one-third of column 7). 9 Average monthly issues (one-twelfth of column 8). (b) After all tables of annual issues have been received, a con- solidated table of annual issues will be prepared by the Medical Supply Depot, Brooklyn, N. Y. for use in determining replenishment quan- tities to be procured during the ensuing fiscal year. 466 SEC. VIII.—MEDICAL STORES, SUPPLY DEPOTS 3149-3150 3149. Medical Stores, Accounting Procedures.—The following policies and procedures shall govern the accounting for medical stores at medical supply depots: (1) Separate stock ledger divisions shall be maintained for (a) items listed in the respective supply-table classes and (&) items listed in the supplementary supply-table classes. (2) Every item of stores in stock for issue or for use in manufacturing or assem- bling stores units, shall be entered in the stock ledger at cost. Items shall be entered at an appraised value if cost is not known or, if due to obsolescence or other reason, the item has been reappraised at a value other than known cost. (3) Upon receipt of new stock with a different unit price from that of the old stock, a revised unit price shall be calculated by dividing the total sum of the old and new stock by the total quantity on hand and adjusting the resulting unit price to the nearest even cent. Subsequent issues shall be valued at the new unit price. The increase or decrease in value, incident to the adjustment, shall be reported as gain (or loss) by unit price adjustment. (4) All surveyed or other stores returned from field activities (except stores replenishments invoiced from other medical supply depots) shall be taken up at invoice value in the account titled “Material returned to store." (5) All surveyed or other stores returned from field activities (except stores replenishments invoiced from other medical supply depots) shall be informally examined and any stores determined to be suitable for reissue shall be transferred from the “material returned to store" account to appropriate stock ledger sheets at the current unit price of similar stock. Any increase or decrease in the in- voiced value shall be adjusted as a gain (or loss) by unit price adjustment. (6) Returned stores, determined to be suitable for reissue after repair or addi- tion of component items, shall be transferred, after repair or completion of com- ponent items, from the “material returned to store” account to appropriate stock ledger sheets at the current unit price of similar stock. The cost of repairs shall be charged to the depot’s maintenance allotment. Incomplete units of returned stores shall be completed by transfer of component items required through the “manufacturing” account. Any increase or decrease in the invoice value shall be adjusted as a gain (or loss) by unit price adjustment. (7) Returned stores, determined to be unsuitable for reissue and not wrorth repair, shall be formally surveyed at least quarterly. Formal survey of items intended to be delivered to the supply officer for sale in conjunction with the purchase of similar items shall be deferred to permit submission of the survey report with the purchase requisition. (8) Stores in stock which become unfit for Issue shall be accounted for in a manner similar to that prescribed for returned stores. 3150. Statement of Receipts and Expenditures of Medical Stores.— A statement of receipts and expenditures of medical stores, NMS— Form V, shall be prepared quarterly and forwarded to the Bureau (see ch. 23). The Medical Supply Depots, Mare Island, Calif., and Canacao, P. I., shall forward one copy direct to the Medical Supply Depot, Brooklyn, N. Y. The statement for the quarter 467 3151-3152 CH. 20. FINANCE AND PROPERTY ending June 30, annually, shall include the following data under (10)—remarks: Value of reserve stores on hand June 30, 19 : Reserve stores A $ Reserve stores B Reserve stores C ' - Reserve stores D Total, reserve stores $ 3151. Medical Stores, Issue.—(a) Medical stores shall be issued by medical supply depots upon receipt of a medical stores requisition and invoice, NMS—Form 4 or other appropriate voucher approved by the Bureau or other competent naval authority, except as noted in the following subparagraphs: (b) Items of medical stores shall not be issued if the issue would reduce the quantity on hand below the designated total quantity of reserved stock to be maintained, except when issue of the reserved stock is specifically authorized by the Bureau or other competent naval authority. (c) The issue of medical stores on requisitions or dispatch requests submitted direct to a supply depot in emergency, or for items author- ized for issue without Bureau approval, shall be subject to the follow- ing restrictions: When it appears that quantities or items requested are in excess of normal requirements, or are of a type not routinely issued to similar activities, and the apparent variance is not justified by letter or notation in the request, the commanding officer of the medical supply depot shall modify the requisition by reduction in quantity, by elimination, or by substitution of items and shall inform the requiring activity of such modification. 3152. Medical Stores, Transfer of, Between Depots.—The following procedure shall be observed in effecting transfer of medical stores between medical supply depots: (a) The requiring depot shall submit to the Bureau in quintupli- cate, replenishment requisitions, NMS—Form 4. When medical stores are shipped, the transferring depot shall forward one priced copy of Form 4, which shall indicate shipment data, to the Bureau, and the usual copies to the requiring depot. When shipment is received, the transfer invoices shall be completed, receipted, and dis- posed of in the manner prescribed for this type of invoice. (b) Transfer of medical stores between depots shall be planned for shipment by Government carriers, whenever possible, to avoid the high cost of commerical shipments. 468 SEC. VIII. MEDICAL STOBES, SUPPLY DEPOTS 3153~3155 3153. Medical Stores, Transfer, to Supply Department.—(a) Med- ical stores may be transferred to the supply department upon request of a supply officer, provided credit is made to the appropriate current year appropriations by the supply officer for the value of stores transferred. The medical stores shall be invoiced by expenditure invoice, S. & A. Form 71, which shall indicate the appropriations or the fund to be debited and credited. (b) A statement of medical stores transferred to the supply depart- ment, listing the invoice number, date shipped, name of supply activity to which transferred, and total value of each invoice, shall be prepared at the end of each quarter and forwarded, accompanied by one copy of each invoice, to the Bureau. 3154. Medical Stores, Transfer, to Reserve Activities.—(a) Medical stores may be transferred to Naval Reserve or Marine Corps Reserve activities when approved by the Bureau or other competent naval authority. (b) Medical stores transferred to Reserve activities shall be invoiced on NMS—Form 4, S. & A. Form 71, or other suitable voucher form. The issuing depot shall price all copies of such invoices and shall forward one copy to the Bureau at the time stores are shipped. The Reserve activity to which the stores are shipped shall be requested, by stamped notation on the copies of the invoice, to receipt and mail two additional copies to the Bureau and one copy to the commandant of the naval district. (c) A separate statement of medical stores transferred to each of the following types of Reserve activities, listing the depot invoice number, date shipped, name of activity to which transferred, and total value of the respective invoices, shall be prepared at the end of each quarter and forwarded to the Bureau with the financial reports: Naval Reserve units, except aviation units. Naval and Marine Corps Reserve aviation units. Marine Corps Reserve units. 3155. Medical Stores, Transfer to Other Government Agencies.—(a) Medical stores may be transfered to other Government agencies when approved by the Bureau. (b) Medical stores transferred to other Government agencies shall be invoiced on NMS—Form 4, S. & A. Form 71, or other suitable voucher form. The issuing depot shall price all copies of such in- voices and shall forward one copy to the Bureau at the time stores are shipped. The Government agency to which the stores are shipped 469 3155 CH. 2 0.—FINANCE AND PROPERTY shall be requested, by stamped notation on the copies of the invoice, to receipt and mail two additional copies to the Bureau. (c) A separate statement of medical stores transferred to any other Government agency, listing the depot invoice numbers, date shipped, name of the agency to which transferred, and total value of the respective invoices, shall be prepared at the end of each quarter and forwarded to the Bureau with the financial reports. 470 CHAPTER 21 MEDICAL AND DENTAL ATTENDANCE Paragraphs Section I. MEDICAL ATTENDANCE 8161-3168 H. NAVAL AND MARINE CORPS RESERVE PERSONNEL.... 8169-3180 m. DENTAL TREATMENT 3190-3199 * Paragraph Officers and Enlisted Men on Detached Duty 3161 Report of Treatment Other Than Naval 3162 Services of Specialist 3163 Officers 3164 Government Hospitals Other Than Naval 3165 Enlisted Men 3166 Bills 3167 Retired Officers and Enlisted Men 3168 SECTION I. MEDICAL ATTENDANCE 3161. Officers and Enlisted Men on Detached Duty.—Officers and enlisted men of the Navy and Marine Corps, when on duty at a place where there is no naval hospital, may be sent to other hospitals upon the order of the commander in chief or the senior officer present (art. 1187, N. R.). When on duty where a superior officer is not present, and the services of a naval medical officer or naval hospital facilities are not available, officers and enlisted men should apply to other Government hospitals for treatment, if practicable, and in the absence of such hospitals, may apply to a civilian physician or a civil hospital for necessary emergency treatment. 3162. Report of Treatment Other Than Naval.—(a) Report on NMS—Form U shall be promptly forwarded in duplicate to the Bureau in each case of any sickness or injury of personnel of the Navy or Marine Corps where treatment is received from other than the Med* ical Department of the Navy. It is required in all cases where medical or hospital treatment is furnished by civilian physicians, civil hos- pitals, or Government hospitals other than naval to the personnel, active or inactive, on duty or on liberty or leave, under circumstances that eventually may be used as the basis of a claim against the Navy Department. This report should be prepared by a naval medical officer when practicable, and in the absence of such officer, by the senior officer present or by the individual concerned as soon as able. (b) Commanding officers are responsible for bringing this informa- tion to the attention of all officers and enlisted men about to go on 471 3162 CH. 21. MEDICAL AND DENTAL ATTENDANCE leave of absence and to the personnel under their charge when on detached duty. (c) Where printed forms are not available, a typewritten report may be made in duplicate giving the information required by the form, which is as follows, including the instructions on the back thereof: Name and rank or rating; date and place of birth; station to which attached; diagnosis; prognosis; status (duty or not). If on liberty, state exact period for which granted and the hours and dates from and to; circumstances; disposition; give dates on or between which services were rendered; by whom were the services rendered? Were the services necessary and authorized, and by whose authority? Where authority is given in writing a certified copy of same should be attached to this form. Where authority is given verbally a certificate of the officer granting same should be attached and should show when and how the services were authorized. Were the services of a naval medical (or dental) officer or a naval hospital available? In the case of an officer, the date of his orders and the name of the Supply Corps officer carrying his accounts shall be stated. When an officer is admitted to a hospital for treatment, statement shall also be made as to whether or not hospital ration notices (S. & A. Form No. 35-M) have been issued. (1) Report on this form (NMS—Form U), shall be forwarded in duplicate to the Bureau, Navy Department, whenever medical, dental, or hospital treat- ment is furnished the personnel of the Navy and Marine Corps by other than the Medical Department of the Navy, including treatment in Government hospitals other than naval. It will be forwarded immediately, upon authoriza- tion of treatment, by the officer concerned or by the officer having cognizance of emergency cases where prior authority is not practicable. (2) Claims for dental expenses will be allowed only when such expenses have been incurred in emergencies by personnel of the Navy or Marine Corps to whom the services of a naval dental officer were not available!, and when the approval a naval medical officer, if available, has been secured. (3) The term in emergencies is intended to be applied to treatment rendered to alleviate suffering or to prevent suffering which will obviously occur before the approval of the Bureau can be obtained. Emergency treatment will not include the furnishing of prosthetic appliances or the use of precious metals. (4) Attention is invited to article 1189, Navy Regulations, in which are stated the conditions under which medical expenses may be allowed, and espe- cially to the requirement that payment of such expenses is contingent upon the prompt reporting of illness or injury to the Bureau. (5) When copies of this form are not available, a preliminary report should be made promptly to the Bureau by letter in which a request for a supply of this form may be included. (6) Upon completion of treatment, unless authorized in advance by an ap- proved requisition, itemized certified bills shall be submitted to the Bureau in duplicate, and shall show the cost of each item of expense and the dates on or between which the services were rendered; for dental treatment they shall also show in detail which teeth were treated, the nature of the treatment rendered, and the materials used. Bills of other Government hospitals will be submitted through their respective headquarters. (7) Receipt of the services by the party receiving treatment or by the officer authorizing same shall be acknowledged either on the face of the bills or by sepa- rate certificate. 472 SEC. I.—MEDICAL ATTENDANCE 3163-3164 (8) When requisitions for civilian medical, dental, nursing, and/or hospital treatment of service personnel are approved by the senior officer present in advance of the Bureau’s approval, this report shall be accompanied by a copy of the requisition and a copy of each public voucher covering payment. The ex- penditure shall be included in the report of expenditures, NMS Forms B and E. (9) This, report will be submitted by the naval medical officer having cognizance of the case, by the senior officer present where a naval medical officer is not op duty, or by the individual concerned when on detached duty where a superior officer is not present. 3163. Services of Specialist.—(a) Where the services of a naval medical officer are available, and when, in his own opinion, he is not sufficiently skilled to treat the affection properly, or lacks the proper equipment or facilities for the required treatment, the employment of a civilian physician or specialist may be permitted upon prior au- thority of the Bureau on recommendation of the medical officer in charge of the case (art. 1189 (4), N. R.). (b) Requests for the employment of a specialist may be made by letter or dispatch to the Bureau, according to the urgency of the case, stating the nature of the illness, the condition of the patient, and the necessity for the special treatment, together with an itemized estimate of the cost of such treatment. (c) The foregoing instructions also apply to the employment of specialists for treatment of the personnel of other Government de- partments or agencies who are patients in naval hospitals, the Comp- troller General having ruled that the prior authority of the Bureau is required for these as well as for Navy patients (15 Comp. Gen. 874). (d) Refraction of Eyes.—The provisions of article 1189 (4) Navy Regulations, are also applicable to the procurement of services for refraction of the eyes for adjustment of glasses where a naval medical officer qualified to perform this service is not available and when prior authority has been obtained in accordance with the fore- going instructions. The purchase of eye glasses at the expense of the Government will not be authorized except in cases of injuries received in acts of duty and for general courts-martial prisoners without funds. 3164. Officers.—(a) Not in duty status.—Expenses incurred by an officer for medicines and medical attendance shall not be allowed unless they were incurred when he was on duty and the medicines could not have been obtained from naval supplies or the attendance of a naval medical officer could not have been had (U. S. Code, title 34, sec. 921). (b) On detached duty; settlement of bills.—Personal settle- ment should be made of any bills contracted by an officer on detached duty for civilian medical, dental, or hospital treatment, and a claim for reimbursement submitted in duplicate to the Bureau, accompanied 473 3165-3166 CH. 21.—MEDICAL AND DENTAL ATTENDANCE by receipted bills in duplicate and any other papers pertaining thereto (par. 3167). As a basis of claim for such expenses, report of any sickness or injury shall be promptly forwarded to the Bureau (art. 1189 (2), N. R.). Whenever practicable this report shall be made on NMS—Form U, which form shall also be used in the submission of claims for reimbursement. (c) Absence by permission.—The Comptroller General has held (10 Comp. Gen. 40) that officers may be considered as constructively on duty entitling them to medical treatment in emergency cases, * * * if the permitted absence does not exceed 24 hours, and if during such absence from ship or station their whereabouts are known and it is fairly practicable to secure their return for the performance of duty should their presence be required. Where in such a case the officer’s whereabouts are unknown to his commanding officer, or he has gone beyond the limits of the city or post in which his ship or station may be, he is not in fact or constructively on duty. The Comptroller General has further held as essential that it be shown in such cases that the appropriate naval authority is fully in- formed of the matter at the earliest possible moment so that arrange- ments may be made to afford the officer the benefit of naval medical aid or Government hospital facilities. 3165. Government Hospitals Other Than Naval.—Where naval hospitals are not available, the Bureau may authorize treatment in Government hospitals other than naval of officers and enlisted per- sonnel, whether on duty or leave status. Authorization for treatment in such hospitals should be immediately requested by dispatch for personnel not in a duty status. 3166. Enlisted Men.—(a) Expenses not allowable when Navy facilities available.—Expenses for medicines and civilian medical and hospital attendance shall not be allowed in the case of enlisted men of the Navy and Marine Corps where naval medical supplies are available or where the services of a naval medical officer or naval or or other Government hospital facilities are available; nor shall they be allowed unless the sickness or injury has been promptly reported to the Bureau by the officer in command; or if on detached duty as at radio stations, subrecruiting stations, etc., by the enlisted man himself as soon as able. This report should be submitted in duplicate and in conformity with instructions contained in paragraph 3162, the printed form being used wherever practicable. (b) Expenses not allowed while on leave.—Under decisions of the Comptroller General an enlisted man on leave of absence is not in a duty status and is not, therefore, entitled to medical or hospital treatment at Government expense. When leave is canceled or ex- tended on account of sickness or any other cause, or absence in excess of leave is excused as unavoidable, the status of the man remains the 474 SEC. I. MEDICAL ATTENDANCE 3167 same; he is not on duty and not entitled to payment for medical attendance while so absent, and commanding officers are without au- thority to authorize treatment for them at Government expense (5 Comp. Dec. 364). Permission to be absent for over 24 hours is con- sidered as leave or furlough (1 Comp. Gen. 137). (c) Exceptions to the foregoing may be submitted for consideration as claims where it can be shown that the enlisted man was actually suffering from a contagious disease probably contracted while on duty; where the enlisted man actually reports to a naval station or post and relinquishes the balance of his leave; or where treatment in other Government hospitals is available. In all such cases, however, it must be shown that the enlisted man has actually come under the control and supervision of competent naval authority, and that due investigation of the circumstances has been made by the officer exercising such authority to justify the authorization of medical treatment at Government expense. (d) Liberty as distinguished from leave.—It has been held by the Comptroller than an enlisted man who has been granted liberty for a period of 24 hours or less is considered as in a duty status, and that there is authority of law to reimburse private institutions or physicians for hospital or medical attendance rendered necessary by the fact that no naval surgeon or Government hospital is available; provided, however, that during the period of liberty it would be fairly practicable to secure his return for the performance of duty should his presence be required; the distance he has gone and the commanding officer’s means of securing his return being important elements in determining whether or not he was in a constructive duty status. Facts necessary to bring the case within the limitations prescribed must be shown. It is essential that it be also shown that the appropriate naval authority in the particular circumstances of the case was fully informed of the matter at the earliest possible moment so that arrangements could be made to afford naval medical and hospital treatment as soon as practicable. 3167. Bills.—Bills incurred for civilian medical treatment of naval personnel, while in a duty status, should be forwarded to the Bureau for settlement. Bills should be prepared in duplicate, itemized to show the dates on or between which services were rendered or supplies furnished; the original certified as “correct and just, payment not received”, and bear the autographic signature of the payee or, in the case of a company or firm, of a responsible official thereof, whose title or connection therewith should be indicated. Receipt of the services or supplies should be acknowledged on the face of the bill, or by separate certificate, by the person receiving treatment, or by 475 3168-3169 CH. 21. MEDICAL AND DENTAL ATTENDANCE an officer having cognizance of the case. The dates, charges, etc., should be carefully scrutinized and verified when practicable. Sep- arate certified bills should be submitted for services of special nurses, anaesthetists, or other persons on fee basis, unless the bill including such services is accompanied with receipts to show that the expenses have been defrayed by the hospital or physician submitting the bill. Bills for treatment in Government hospitals other than naval are submitted to the Bureau for payment through the respective heads of the activities concerned. 3168. Retired Officers and Enlisted Men.—Retired officers and enlisted men, inactive, are not entitled to civilian medical and hospital treatment at Government expense. They are entitled to treatment in naval hospitals and by naval medical officers when available upon application, but no expenses for travel in connection with such treat- ment may be allowed. Retired personnel and members of the Fleet Reserves transferred thereto after 16 or more years service, may be admitted to Army hospitals upon their own application, and with the consent of the commanding officer of the hospital, upon the payment of the subsistence charge, which is comparable to the cost of a Navy ration (art. 1204, N. R.); also, they may be admitted to Government hospitals other than naval, when appropriate naval hospital facilities are not available, upon prior approval of the Bureau and with the consent of the commanding officer of the hospital concerned (par. 2166). SECTION II. NAVAL AND MARINE CORPS RESERVE PERSONNEL Paragraph On Active Duty; Entitled to Medical Treatment 3169 Inactive; Not Entitled to Treatment — 3170 Transferred After 16 or More Years Service _ 3171 Treatment Other Than Naval, or Beyond Active Duty Period 3172 Reports of Civilian Treatment - 3173 Care by Employees’ Compensation Commission 3174 Reserve Classes Not Under Compensation Act. 3176 Treatment in General and Forms Required. 3176 Injuries Occurring at Sea 3177 Injuries Occurring at Shore Stations 3178 Expenses Chargeable to Employees’ Compensation Commission 3179 Care of the Dead 3180 3169. On Active Duty; Entitled to Medical Treatment.—(a) Members of the Naval Reserve and Marine Corps Reserve when on active duty being subject to the laws, regulations, and orders for the government of the regular Navy and being entitled to the same pay and allowances, are subject to the 20-cent deduction authorized by section 4808 R. S. (hospital tax), and are entitled to 476 SEC. H. RESERVE PERSONNEL 3170-3172 medical treatment under the same conditions as members of the regular Navy (3 Comp. Gen. 301; 4 Comp. Gen. 783; 4 Comp. Gen. 1005). (b) Aviation cadets.—Aviation cadets (U. S. Naval Reserve) while on active duty or active duty undergoing training are entitled to medical treatment under the same conditions as other members of the Naval Reserve and Marine Corps Reserve except that when suffering from sickness or injury incurred in line of duty while per- forming active duty, they may, in the discretion of the Secretary of the Navy, be retained on such active duty status beyond the specified date of termination thereof (49 Stat. 156). 3170. Inactive; Not Entitled to Treatment.—While in an inactive status, members of the Naval Reserve and Marine Corps Reserve (with the exception next noted) are not entitled to medical or hospital treatment (4 Comp. Gen. 934). 3171. Transferred After 16 or More Years’ Service.—Enlisted men transferred to the Fleet Reserves after 16 or more years of service, on inactive duty, are entitled to naval hospital treatment and to naval medical treatment upon applying for same where such facilities or services are available. Treatment will be given under the same local rules as govern treatment of enlisted personnel of the Navy. They are not entitled to treatment by other than naval medical officers or in other than naval hospitals, except as provided by the act of January 19, 1929 (par. 2166) (also see par. 3168). 3172. Treatment Other Than Naval, or Beyond Active-duty Period.— When medical officers and medical facilities of the Navy are not avail- able, treatment may be procured for the personnel on active or training duty from sources outside of the Navy under the following conditions: For injuries received in the line of duty, necessary treatment will be furnished at the expense of the Navy only during the period of active or training duty, upon the expiration of which they come under the jurisdiction of the Employees’ Compensation Commission (except as noted in par. 3175); those who become ill or contract diseases in the line of duty during the period of active or training duty, with or with- out pay, are entitled to necessary medical, hospital or other treatment during the period of recovery. Treatment in such cases shall not be continued for more than ten weeks following discharge from active or training duty, except on the approved recommendation of a board of medical survey or on authorization of the Surgeon General of the 477 3173-3176 CH. 21.—MEDICAL AND DENTAL ATTENDANCE Navy. (Naval Reserve Act of 1938). When the disability of a reservist, incurred while on active or training duty, necessitates his retention in a hospital other than naval or medical treatment from other than a navy medical officer beyond the period of active duty, telegraphic instructions shall be requested from the Bureau, giving diagnosis, prognosis and present condition, with information as to the practicability of removal to a naval or other government hospital in appropriate cases. 3173. Reports of Civilian Treatment.—WTien given treatment by other than Navy facilities during the period of active duty, the report required by paragraph 3162 shall be submitted to the Bureau. 3174. Care by the Employees’ Compensation Commission.—The Naval Reserve Act of 1938 provides: If in time of peace any member of the Naval Reserve is physically injured in the line of duty while performing active military or naval service, or dies as the result of such physical injury, he or his beneficiaries shall be entitled to all the benefits prescribed by law for civil employees of the United States who are physically injured in the line of duty or who die as a result thereof, and the United States Employees’ Compensation Commission shall have jurisdiction in such cases and shall perform the same duties with reference thereto as in the cases of civil employees of the United States so disabled: * * * And provided further, That in no case shall sickness or disease be regarded as an injury within the mean- ing of this section relating to the Naval Reserve. 3175. Reserve Classes Not Under Compensation Act.—As enlisted men transferred to the Fleet Reserve and Fleet Marine Corps Reserve after 16 or more years of service and retired personnel of the Navy and Marine Corps are at all times governed by the laws and regulations for the government of the Navy, these members of the Naval Reserve do not come within the provisions of the act quoted in par. 3174, and the U. S. Employees’ Compensation Commission does not have juris- diction in injury cases of such personnel (Comp. Gen. August 5, 1926, No. A-14470). 3176. Treatment in General and Forms Required.—Naval Reservists on active or training duty (with or without pay) shall initially be given the same medical care and treatment as would be accorded personnel of the Navy. When so treated, admitted to the sick list, or hospitalized, for sickness or disease, no action shall be taken or reports submitted other than as required for Navy purposes. When physically in- jured in the line of duty the case must be considered from the aspect of the Employees’ Compensation Commission, and to protect the individual, the various forms of the Commission must be executed and submitted except as noted in paragraph 3175. Special attention should be given to the prompt submission of the official superior’s report of injury, which shall include a complete statement of witnesses 478 SEO. II.—RESERVE PERSONNEL 3177-3190 and preliminary medical statement. A hernia form should also be immediately submitted, when necessary (ch. 9, sec. III). 3177. Injuries Occurring at Sea.—Cases of injury occurring at sea or away from United States ports shall be cared for aboard ship or by the regular medical department facilities until the vessel returns to a port where cases requiring hospitalization shall be transferred to a naval hospital. It then becomes the duty of the naval hospital to arrange for continuation in naval hospital or retransfer to a marine or other hospital as may be directed by the Employees’ Compen- sation Commission. The cases of injury which do not require further treatment, upon the return of the vessel to port, shall be closed out as required by commission forms. 3178. Injuries Occurring at Shore Stations.—Cases of injury oc- curring at stations within the United States or aboard ship in home waters will initially be cared for the same as Navy personnel, but if requiring treatment or hospitalization beyond the period assigned to active duty or on authorized training duty, such cases thereafter shall be provided with medical facilities in accordance with instructions and list issued by the Employees’ Compensation Commission. 3179. Expenses Chargeable to Employees’ Compensation Com- mission.—No charges will be made against the Employees’ Compen- sation Commission for care of cases of physical injury in the line of duty during the period of active duty, but when an injured Reservist is retained in naval hospital after expiration of the period for which ordered to active duty, report will be made to the Bureau in the same manner as for other Employees’ Compensation Commission patients. 3180. Care of the Dead.—For instructions regarding disposition of the remains of deceased Naval Reserve personnel, see chapter 19. Dental Treatment 3190 Treatment Other Than Naval Allowed in Emergency 3191 Definition of Term “Emergency” 3192 Requests for Dental Treatment 3193 Prosthetic Dental Treatment; Limitation of 3194 Requests for Prosthetic Dental Treatment 3195 Pyorrheal and Prophylactic Treatments 3196 Report of Dental Treatment Other Than Naval 3197 Treatment of Naval Reserve Personnel 3198 Claims 3199 SECTION III. DENTAL TREATMENT Paragraph 3190. Dental Treatment.—Dental treatment will be furnished to personnel of the Navy and Marine Corps insofar as may be practicable with the facilities available and under the provisions and conditions and in the manner prescribed in chapter 3. 479 3191-3196 OH. 21. MEDICAL AND DENTAL ATTENDANCE 3191. Treatment Other Than Naval Allowed in Emergency.—(a) Officers and enlisted men on duty where the services of a naval dental officer are not available should consult the naval medical officer, and secure his approval prior to the procurement of dental treatment as an expense against the Government. Approval shall be limited to cases of emergency, and shall not include restorations by means of gold, inlays, or prosthetic appliances. (b) In cases of personnel on detached duty where neither a naval dental officer nor a naval medical officer is available, dental expenses without prior approval will be allowed only when treatment is immedi- ately required to relieve pain and suffering. 3192. Definition of Term “Emergency.”—The term emergency is held to apply only to treatment rendered to relieve suffering, and shall include only such measures as are deemed necessary to provide a reasonable degree of comfort until the services of a naval dental officer can be obtained, or until a report can be forwarded to the Bureau and appropriate instructions issued. Emergency dental treat- ment shall involve the minimum expense necessary to secure satisfactory professional service. 3193. Requests for Dental Treatment.—(a) Where time will per- mit, requests for dental treatment where the services of a naval dental officer are not available shall be forwarded to the Bureau by the medi- cal officer with his recommendation, or, if no medical officer be avail- able, by the senior officer present. Every request shall contain a detailed statement of the disease or injury from which the necessity for treatment has arisen, together with a detailed estimate of the cost of the treatment considered to be necessary. On detached duty, such as at recruiting stations, radio stations, etc., the request shall show the date on which the person for whom treatment is requested was assigned to that duty, and the probable date of transfer to other duty. (b) Whenever dental treatment is obtained from sources other than those under the cognizance of the Bureau, a note, stating the facts in detail, shall be inserted on the medical history sheet of the health record of the person who has received the treatment. 3194. Prosthetic Dental Treatment, Limitation of.—Prosthetic dental treatment at the expense of the Government will be allowed only when authorized in advance by the Bureau (art. 1189, N. R.). 3195. Requests for Prosthetic Dental Treatment.—Every request for authority to obtain prosthetic dental treatment shall contain a statement of the oral condition and of the necessity for the treatment; also a history of the case and a copy of the dental abstract. 3196. Pyorrheal and Prophylactic Treatments.—Pyorrheal treat- ments and dental prophylaxis are not regarded as emergencies. 480 SEC. III.—DENTAL TREATMENT 3197-3199 3197. Report of Dental Treatment Other Than Naval.—A report in duplicate, as outlined in paragraph 3162, shall be submitted to the Bureau for dental treatment other than naval. 3198. Treatment of Naval Reserve Personnel.—Members of the Naval Reserve, while on active duty, are entitled to necessary dental treatment. It is not expected, however, that members of the Naval Reserve on active duty for training or on week-end cruises will be recommended for other than emergency dental treatment. 3199. Claims.—Claims for dental service will be considered in like manner to claims for medical treatment other than naval and only when such expenses were incurred in an emergency, when in a duty status, where the services of a naval dental officer could not have been had, and when a naval medical officer, if available, has been consulted in advance. 481 CHAPTER 22 THE NAVAL MEDICAL CENTER Paragraph Organization and Function 3301 Communications 3303 Consultation Service _ 3305 Staff 3311 Instruction 3313 Assignment to Instruction 3315 Instruction Considered Duty Status 3317 Special Courses 3319 Research Work 3321 Clinical Service 3323 Laboratory Service 3331 Laboratory Supplies 3333 Library Service 3341 3301. Organization and Function.—The Naval Medical Center, Washington, D. C., was established by General Order No. 70, dated June 20, 1935. This order created a unitary organization which functions as a medical, diagnostic, and educational center directly under the control of the Bureau, and with an officer of the Medical Corps of the United States Navy in command (art. 170, N. R.). When established, the Medical Center consisted of two subordinate administrative units, namely, the United States Naval Hospital and the United States Naval Medical School. On April 1, 1936, the Naval Dental School was formed as a distinct unit and attached to the Naval Medical Center by authority of the Secretary ,of the Navy. Each of these units is a subordinate command of the Naval Medical Center and the commanding officer of each assumes the prerogatives and is charged with the responsibilities of command. In character, the reciprocal relationship obtaining between the center and its constituent commands is that in force between a commandant and the adminis- trative units within his command. 3303. Communications.—Communications involving policy, person- nel, and all matters of official interest or requiring administrative action shall be routed via the commanding officer, Naval Medical Center. Communications involving only routine services should be addressed directly to the unit concerned. 3305. Consultation Service.—The Naval Medical Center maintains liaison with other institutions to facilitate promotion of common 483 3311-3319 CH. 2 2.—NAVAL MEDICAL CENTER professional interests. It is prepared to furnish the service at large with certain consultation and diagnostic facilities. Requests for professional assistance should be addressed directly to the unit con- cerned. The detailed current service available is incorporated in Circular Letter X of appendix D of this manual. 3311. Staff.—Each school has a staff which consists of personnel ordered to the school as instructors, or so serving. The commanding officer of each school shall preside over and conduct all faculty meet- ings, and the junior member of the faculty shall keep a record of all proceedings. Faculty meetings will be held from time to time as may be considered advisable by the commanding officer, and repre- sentations made to his immediate superior in command concerning changes regarded as desirable to improve the efficiency of the school as a whole or in any individual branch. At such meetings deficiencies of individual students will also be given careful consideration. 3313. Instruction —These schools shall afford such courses of instruction as may from time to time be determined by the Bureau to accord with current needs of the service. The commanding officer of each shall exercise supervision over the courses of instruction and examinations and he shall on occasion inform the Bureau of each student’s special aptitudes or deficiencies. Reference should be made to the Bureau’s current Circular Letter M, appendix D, on instruction of Medical Department personnel. 3315. Assignment to Instruction.—Medical Department personnel are assigned to these schools for instruction by official orders as recom- mended by the Bureau. Personnel desiring instruction should make official request to this Bureau. The Bureau’s current policy on in- struction of personnel is incorporated in current circular letters. 3317. Instruction Considered Duty Status.—Students shall be required to be present at all the exercises of the school unless excused by the commanding officer or other competent authority. They shall be considered on duty dining the course of instruction at the school and shall be required to conform in all respects to the Navy Regulations and such orders as may be issued from time to time for their guidance and the maintenance of discipline. 3319. Special Courses.—(a) Medical Department personnel who desire special courses of instruction elsewhere at Government expense should make official request to the Bureau. This request should contain sufficient information to permit the Bureau to properly evalu- ate the situation. (a) When taking special instruction elsewhere, students shall submit to the commanding officer of the Naval Medical Center such periodical reports as he may require, in order that he may keep 484 3321-3341 CH. 22.—NAVAL MEDICAL CENTER informed concerning the student officers’ progress and the character of the instruction afforded by the several teaching institutions. 3321. Research Work.—The Naval Medical Center laboratories are available, on approval by the Bureau, to Medical Department personnel who are detailed elsewhere and who desire to undertake research work. 3323. Clinical Service.—The Naval Medical School provides certain clinical diagnostic facilities for the Medical Center and the service at large on consultation request (par. 3305). 3331. laboratory Service.—The Naval Medical School provides routine clinical laboratory service to the Medical Center. In addition the laboratories serve for instruction of Medical Department person- nel. Limited use of these facilities is also extended to the service at large. Shipments of material shall comply with safety regulations which should be obtained from the local shipping agency. Letter of transmittal should include all pertinent clinical data, tentative diagnosis, and laboratory findings (par. 3306). 3333. laboratory Supplies.—Certain laboratory supplies such as diagnostic and illustrative material are, on request, available from the Naval Medical School (par. 3305 and supplementary supply table). 3341. library Service.—Applications from medical department personnel of ships and stations for the temporary loan of books and duplicate copies of current periodicals in the Medical School library, or obtainable from other sources, should be addressed to the com- manding officer of the school. It is the intent to have the library of the school utilized generally, but danger of loss in transit prevents issue of unbound periodicals, and there are certain books which are so valuable or in such current demand that they may not be loaned. When it is not practicable to furnish originals, it may be possible to supply photostatic copies of particular articles. See Circular Letter X, appendix D, for services currently available. 485 CHAPTER 23 REPORTS AND RETURNS Paragraphs Section I. GENERAL INSTRUCTIONS 3401-3406 H. LETTERED FORMS. 3411-3438 m. NUMBERED FORMS 3442 IV. HOSPITAL FORMS 3451-3498 V. MISCELLANEOUS 3501-3520 VI. TABULATION 3551-3555 SECTION I. GENERAL INSTRUCTIONS Paragraph Manner of Making Returns 3401 How Forwarded 3402 Copies 3403 Elimination, Etc., of Forms 3404 Recommendations 3405 Blank Forms 3406 3401. Manner of Making Returns.—The reports and returns enu- merated in this chapter shall be made in the manner indicated, but nothing herein shall be construed as warranting the omission of any other reports and returns required by the Navy Regulations or by order from competent authority. Careful compliance with in- structions printed on forms or issued concerning special reports and returns is required. 3402. How Forwarded.—Reports and returns and other official com- munication shall be forwarded in accordance with articles 2032, 2033, 2034, and 2044, Navy Regulations, except when otherwise specifically directed. 3403. Copies.—(a) Copies of all official reports, letters, and in- dorsements shall be kept in suitable files (art. 2047, N. R.). (b) When two or more copies of the same report are forwarded separately to different offices or officers a rotation shall be made on each copy that it is a copy and of the disposition of the others for the information of such office or officer. 3404, Elimination, etc., of Forms.—Reduction in number and con- tent of periodical reports and returns, to the actual requirements of the service, is desired. Suggestions and recommendations to elimi- nate, consolidate, or simplify medical department forms, are requested. 3405. Recommendations.—Recommendations and suggestions on various subjects should preferably not be incorporated in an annual or other periodical report. They should be made the subject of a separate report. 487 3406-3417 CH. 23.—REPORTS AND RETURNS 3406. Blank Forms.—Officers required to make reports and returns must keep themselves supplied with the necessary blank forms by application to the proper bureau or office. Letters shall be used where printed forms are not provided and they shall be prepared in accordance with the chapter on official correspondence in the Navy Regulations. Paragraphs Forms A to Z (with some omissions) 3411-3438 3411. Form A—Report of Cases of Syphilis and Arsenical Treat- ments.—This report shall be prepared and submitted as follows: Monthly.—The monthly report of arsenical compounds administered and reactions (front side of Form A) shall be prepared in accordance with instructions printed on the form. Annually.—The annual report of cases and number treated shall be made on the reverse side of the Form A submitted for the month of December. SECTION II. LETTERED FORMS 3412. Form B—Report of Allotment Expenditures.—This form shall be prepared and forwarded to the Bureau in accordance with the instructions contained in Circular Letter F, appendix D. 3413. Forms D and Da—Inventory of Material.—These forms shall be prepared and forwarded to the Bureau in accordance with the instructions contained in Circular Letter F, appendix D. 3414. Form E—Statement of Receipts and Expenditures of Medical Department Property.—This form shall be prepared and forwarded to the Bureau in accordance with the instructions contained in Circular Letter F, appendix D. 3415. Form F Card.—This card shall be prepared and forwarded in accordance with instructions contained in paragraphs 2405 and 2407, chapter 15, of this manual. 3416. Form F—Abstract of Patients.—This form shall be prepared and forwarded in accordance with instructions contained in para- graphs 2400 and 2407, chapter 15, of this manual. 3417. Form G—Hospital Ticket.—(a) A copy of this form, with all the required data entered thereon, shall accompany each patient transferred from a ship or station to a hospital or hospital ship, either directly or by transportation on a ship or other means of con- veyance. (b) In cases of emergency, patients may be admitted to a naval hospital or hospital ship without this form, but the medical officer transferring such patients shall prepare and forward a Form G for each as soon as time will permit. (c) The hospital ticket shall be examined upon arrival at the naval hospital or hospital ship and the patient’s clothing and effects 488 SEC. II.—LETTERED FORMS 3418-3423 checked with the list on the reverse side and verified or corrections noted. (d) When the patient is detached, he shall receipt on the back of the hospital ticket for the clothing and effects returned to him and the receipted ticket shall be placed in the files. 3418. Form H—Health Record.—(See ch. 14.) 3419. Form I—Weekly Report of Patients in Naval Hospitals, Bed Capacity, Distribution, and Certain Classifications.—This report shall be forwarded to the Bureau direct, not later than Friday of each week, for the week ending Wednesday at midnight, from each naval hospital and hospital ship. It shall be forwarded even though there have been no admissions, discharges, or changes in diagnosis during the week, in order that the Bureau may be assured that the report has not been overlooked or lost in transit. An additional report is required as of midnight, December 31. This shall differ in that the names of all regular officers on the sick list at that time shall be given in column 1. Instructions for the preparation of Form I are incorporated in Circular Letter I, appendix D. 3420. Form K—Dental.—This form shall be forwarded in accordance with instructions printed on the form. 3421. Form L—Dental.—Request for dental prosthetic treatment. (a) This form shall be used in every instance where prosthetic dental treatment is requested. (b) It shall be prepared in accordance with instructions contained in paragraph 240 (c) of this manual. The reverse side of the form shall be utilized to supply the additional information required by paragraph 240 (h) of this manual. 3423. Form M—Report of Medical Survey.—(a) When the medical officer of a ship or station considers it necessary to hold a medical survey on personnel a letter requesting the medical survey shall be prepared, which may embrace any number of cases. (b) After approval by the commanding officer, the request shall be forwarded from a ship to the commander in chief, division commander, or senior officer present, and from a shore station to the commandant. For composition of the board and other information see articles 1197— 1199 N. R. (c) Request for medical survey, either ashore or afloat, shall be made when it is desirable to establish the origin of a disability, to obtain an opinion as to the nature of a case, or to determine fitness for duty. (d) Requests for medical surveys ashore. (1) Medical officers, particularly those in command of naval hos- pitals, will request without delay, medical survey of all officers or 489 3423 CH. 2 3.—REPORTS AND RETURNS enlisted men who are considered physically unfit for further service, with a view to final action in such cases, so that their places in the service may be filled. (2) A medical survey of each person in the naval service who has been on the sick list continuously for 3 months shall be requested, regardless of any change of station which may have occurred. A survey shall also be requested at the expiration of each period of 3 months thereafter in order that further treatment or other disposition may be authorized, and that the Bureau may be fully cognizant of the progress of the case. (3) When the transfer of a patient from one hospital to another for further treatment is considered advisable, a medical survey shall be requested. (4) No person shall be discharged from the service for physical disability, except upon the recommendation of a board of medical survey. (5) When an officer is undergoing treatment at a naval hospital for a severe or possibly incapacitating condition, he shall be ordered before a board of medical survey before being recommended for return to duty. Full details and circumstances relative to the case should be reported in order that the Bureau of Navigation will have the necessary infor- mation on which to assign the officer to his next duty. This is par- ticularly important in the case of officers who were admitted from sea duty or officers who are due for assignment to sea duty in the near future. Officers who have had a major operation or who have suffered from mental or nervous disturbances, severe constitutional conditions, defects of vision and hearing, or other severe conditions or diseases, and especially those suffering from injury, are to be considered in this connection. (e) Requests for medical surveys afloat shall be made: (1) When, in the case of an officer, transfer to a hospital and de- tachment from the ship are believed advisable. (2) When transfer to a distant station or hospitai is involved. (f) A medical survey is not required for transfer to a near-by naval hospital and should not as a rule be requested afloat for the purpose of invaliding from the service. (g) When a hospital ship is available, it is preferable that patients requiring hospital treatment or sick leave should be transferred to the hospital ship for treatment and further disposition. Medical officers on ships away from a hospital ship or naval hospital shall hold their patients for transfer to such hospital ship or hospital, except in those cases which admit of no delay. 490 SEC. II.—LETTERED FORMS 3423 (h) Officers shall be granted sick leave only upon approved recom- mendation of a board of medical survey and shall be brought before a board of medical survey to determine their fitness for duty upon the expiration of sick leave (art. 1728 N. R.). (i) Reports of medical survey upon officers, nurses, and enlisted men of the Navy and Marine Corps shall be made out in triplicate and directed to the officer ordering the survey. (j) Reports of medical survey upon officers, nurses, and enlisted men of the Navy and Marine Corps shall be forwarded through the commanding officer under whom the person surveyed is serving, to the officer ordering the survey, by whom they shall be endorsed in tripli- cate, and transmitted, direct, to the Bureau for recommendation by the Surgeon General. All medical surveys during the first 6 months of the first enlistment shall be forwarded to the Bureau via the recruiting station where the man was enlisted for appropriate comment before final action is taken by the Bureau. These surveys shall be given prompt attention in order that they may be disposed of as soon as possible. (k) One copy of the medical survey is then forwarded to the Bureau of Navigation or to the Major General Commandant, United States Marine Corps, and two copies are retained in the files of the Bureau. (l) The copy sent to the Bureau of Navigation or the Major General Commandant, as the case may be, is forwarded to the officer con- vening the board for compliance with the Department’s action, and when completed, it is returned to the Bureau of Navigation or the Major General Commandant for permanent fifing. (m) The present history of the case should be recorded as follows: (1) Diagnosis.—The diagnosis shall be selected from the Navy nomenclature and correspond with that under which the man is carried on the sick list. The diagnosis number and key letter, in case of injury, shall also be recorded. Injuries and poisonings shall be classified in accordance with the instructions in paragraph 2416 (4). (2) Misconduct status.—The board shall state whether, in its opinion, the disease or injury is or is not due to the patient’s own misconduct. (3) Line of duty status.—The line of duty status shall be determined and stated in all cases brought before a board of medical survey with a view to discharge from the service. In cases where the disease or injury is held to have been incurred not in the line of duty, a signed statement from the patient regarding the origin of the disability shall be attached to each copy of the report of medical survey. This statement is required in order that the Government may be in a position to rebut the pos- sibility of a denial on the part of the patient as to the origin of the disability in claims for benefits under existing and future laws. A statement that the condi- tion has or has not been aggravated by service shall be made in all cases held not in the line of duty having existed prior to enlistment. 491 3423 CH. 23.—REPORTS AND RETURNS (4) Facts.—All facta relative to the present history of the case, especially all facts and circumstances connecting the disease or injury with the performance of duty or exposure incident thereto, and a description of the existing disability shall be given. When the origin is due to misconduct, the board shall state clearly the reasons for its opinion. The Navy Department has held that the burden of proof lies with those who would show that an individual was suffering from a disease prior to his entry into the naval service. Facts which are not a matter of record nor of personal knowledge to a member of the board, but which are based on the man’s own statement should be recorded as “according to the man’s own statement.” The statement of the patient in connection with the origin of the disease or disability must be weighed by rules governing evidence in general and shall be noted as accepted or rejected. The Navy Department has held gen- erally in the absence of evidence rebutting the presumption, that an enlisted man was in sound condition at the beginning of his active service except as to defects officially recorded at that time, and that any disability discovered during this service was incurred in the line of duty unless due to his own wilful misconduct or was caused by something done by him in pursuing a private avocation or business, or otherwise grew out of relations unconnected with the naval service. (5) Present condition.—“Unfit for duty” means temporary unfitness; “Unfit for service” means permanent unfitness. If the patient is found fit for duty, the report shall be concluded at this point. (6) Probable future duration.—When unfitness is found and is regarded as tem- porary, the phrase “temporary” shall be used. When the unfitness is permanent, the expression “permanent” shall be employed. When the probable future dura- tion of the unfitness for duty is very uncertain, the word “indefinite” may be used. (7) Recommendation.—1. In the case of an officer, the board may recommend his detachment and transfer to hospital or sick leave; or if the unfitness be of a more temporary character, the board may recommend that treatment be con- tinued or that he be transferred to a naval hospital for treatment, with a view to his return to the ship or station. If the disability be considered permanent, the board shall recommend that he be ordered to a naval hospital or before a retiring board. 2. In the case of an enlisted man, the board may recommend that treatment be continued, that he be sent to hospital for treatment or observation, or that he be discharged from the United States naval service or from the United States Marine Corps (in the case of a marine). S. The recommendation that an officer be ordered before a retiring board, or that an enlisted man be invalided from the service, should not ordinarily be made until the case has been sufficiently long under observation to render the exact nature and degree of the disability and its probable permanency evident, and as a rule such recommendation shall not be made until the case has been under a period of observation and thorough treatment in a naval hospital. Before recommending the invaliding from the service of a continuous-service man, the board should carefully consider the probability of his recovery under extended treatment, especially when the disability is in the line of duty. In cases of recruits, retention for prolonged treatment when a restoration to duty is unlikely is unde- sirable. 4- In any case where the recommendation involves invaliding from the service for a mental infirmity, the board shall state that such a disposition will not consti- tute a menace to the individual surveyed or to the public safety, and that the individual is not likely to become a public charge. The next of kin shall be imme- 492 SEO. II.—LETTEBED FORMS 3423 diately advised of this recommendation. When a man with an infectious disease of disabling nature is recommended for discharge from service, a statement should also be made that he is unlikely to constitute an unusual menace to the public health or to become a public charge. (n) It shall be the duty of the senior member of a board which makes an adverse record relative to any disease or injury to inform the individual concerned of such record. In the case of a board of medical survey, any statement made in rebuttal should not be incor- porated in the body of the survey but should be forwarded as a separate paper attached to the report of survey. In the event that the condition of the patient be such as to render it impracticable or inadvisable to inform him of such adverse entry, this fact shall be noted on the report (art. 1196, N. R.). (o) In all cases of medical survey the medical officer requesting the survey shall have the report and recommendation of the board entered in the patient’s health record. No person shall be surveyed until he has been admitted to the sick list. (p) Where enlisted men are under treatment at naval hospitals for injury or disease received in line of duty, and their condition is such that there is no possibility that they may be reenlisted, if the expira- tion of their enlistment occurs while still under treatment, they shall be surveyed by a board of medical survey with a view to discharge for ‘‘physical disability” instead of being discharged “on account of expiration of enlistment.” This procedure is necessary in order to give men injured or diseased in the line of duty the benefits of the statute providing preference in civil-service appointments. (q) Enlisted men surveyed on foreign stations who are recom- mended for discharge from the seryice will be sent to a receiving ship and not to a naval hospital for final action, unless requiring hospital treatment, and such disposition shall be specifically recom- mended by the board. (r) An act of August 23, 1935, provides that the Veterans’ Ad- ministration may furnish domiciliary care to men discharged from the Navy and Marine Corps for disabilities incurred in the line of duty, or to those in receipt of pension for service-connected disability, when they are suffering with permanent disabilities, tuberculosis, or neuropsychiatric ailments, and medical and hospital treatment for diseases or injuries. The facilities of the Veterans’ Administration with respect to continued treatment shall be considered by boards of medical survey in cases found disabled for further service (par. 2122 (c)). (s) All officers admitted to a naval hospital, or hospital ship, be- cause of disabilities which may militate against their chances of 493 3424-3426 CH. 23.—REPORTS AND RETURNS selection for promotion shall be brought before a board of medical survey prior to discharge to duty. The report of the board shall contain the specific statement that the officer is, or is not, physically qualified to perform all the duties of his rank at sea or in the field as the case may be. (See subparagraph (d) (5).) 3424. Form N—Report of Death.—This form shall be accomplished and forwarded in accordance with the instructions printed on the form. 3426. Form P—Report of Surgical Operations and Diagnostic Exami- nations.—(a) This report shall consist of two parts: One part shall include all operations performed on personnel of the active list of the Navy and Marine Corps; the other part shall be a summaiy of the operations performed on supernumeraries other than members of families of officers and enlisted men. It shall be prepared quarterly for the periods ended March 31, June 30, September 30, and Decem- ber 31, and when a ship, station, or hospital is placed out of commission. It shall be forwarded to the Bureau within 10 days after the end of the period covered by the report. A duplicate copy shall be retained for the files of the transmitting office. The form shall be kept posted to date, the data required for each column shall be stated in brief, and each case separated from the preceding one by a line, except such operations as are referred to in subparagraph (b). (b) Operations shall be listed under the titles given in appendix A, section III (par. 2413). When several operations have been per- formed for distinct conditions, each operation must be recorded sep- arately—e. g., inguinal hernia, varicocele, and varix, even if performed under one general anesthetic, should appear on Form P as three distinct operations, giving the information required for each column. (c) Instructions for numbered columns. Column 1.—Give initials and grade or rate of patient and date of operation, as follows: F. H. R. (initial of surname last). Y. lc. 7-10. Column 2.—The diagnostic title entered in this column shall be that of the condition for which the operation was performed. Use titles of the nomencla- ture and state location when not covered by the title. Column S.—Enter the name of the operation, using one of the titles listed in appendix A, section III (par. 2418). Column 4.—Use abbreviations as follows: C, cured; DD, died; I, improved; T, transferred; U, unimproved. (Use no other notations in this column.) Column 5.—Give the name of the anesthetic employed and method of use, whether inhalant or local (indicating if spinal, caudal, or regional). Column 6.—Enter such information as may be necessary to indicate the degree of surgical risk or relative gravity of the condition covered by the nomenclature 494 SEC. II.—LETTERED FORMS 3426 title recorded in column 2. For example, appendicitis—suppurative, perforative, gangrenous, etc., or appendicitis with local peritonitis, appendicitis with general peritonitis. In the case of hernia—complete or incomplete—strangulated, etc. In other words, use terms commonly employed in clinical practice to grade cases. When no explanatory remarks seem necessary, no entry will be made in this column. For example, such a statement as “uneventful recovery” will not be made. (d) Titles that may be grouped.—In general all operations must be accounted for separately, but the following, when not complicated, may be grouped to show the number of like operations performed on active duty personnel: Abscess, incision. Adenoidectomy. Bubo, inguinal, operation for. Cellulitis, incision of. Chalazion, operation for. Chancroidal, lymphadenitis, op- eration for. Circumcision. Cyst, incision of. Cyst, enucleation, excision of. Ingrowing nail, removal of. Paracentesis (state location). Pterygium, operation for. Submucous resection. Tonsillectomy. Turbinectomy. V aricocelectomy. Sufch grouped operations shall be arranged alphabetically and shown on the report next after operations reported separately, subdivided according to the anesthetic employed and the method used, inhalant or local (spinal, caudal, or regional). (e) Summary of anesthetics.—The anesthetics employed and the method used in their administration shall be summarized at the end of the report as shown in the following example: Summary of Anesthetics Total operations performed Inhalant: Ether. Local—Continued. Caudal: Ether and nitrous oxide Nitrous oxide. Procaine Cocaine. Ethyl chloride. Miscellaneous (specify): Regional: Procaine. Miscellaneous (specify): Cocaine- Local: Spinal: Procaine. None. Cocaine.. Total. (f) Operations performed on supernumerary patients.—Opera- tions performed on supernumerary patients shall not be listed as individual operations, but at the end of the report a list shall be given 495 3427-3428 CH. 23.—REPORTS AND RETURNS of these operations, divided into operations on Veterans’ Administra- tion patients and other supernumeraries, in the following form: Op rations Performed on Supernumerary Patients Veterans' Administration patients Appendectomy 12 Amputation, hand 1 Tonsillectomy 20 Total 33 Other supernumeraries Reduction of fracture, femur 1 Removal of toeDail 2 V aricocelectomy 4 Total 7 All operations on supernumerary patients 40 (g) Summary of instrumental examinations.—Instrumental examinations for diagnosis or treatment shall be shown at the end of the report as follows: Navy (ac- tive) All others Total Miscellaneous (specify): Instrumental examinations for diagnosis and treatment 3427. Form Q—Clinical Chart.—This form shall be kept in each case in which it is considered by the medical officer to be advisable. In naval hospitals and on hospital ships the completed forms shall be filed as parts of the individual case records. 3428. Form R—Issue Voucher.—This form is used in Medical Department activities, except ships where hospital corps men are on independent duty, when supplies (expendable property) are with- drawn from or returned to the medical storeroom. The original, and as many copies as required, shall be properly prepared, approved, and forwarded to the medical storeroom for accomplishment. Each item on the voucher shall be priced and total value indicated after issue 496 SEC. II.—LETTERED FORMS 3429-3435 of the supplies. Hospitals and the larger shore stations may omit pricing these vouchers by preparing a tabulation of total monthly issues, by items and by departments. The item summaries shall be extended to disclose the total costs for ledger posting. No issues of supplies from the medical storeroom shall be made except by authority of a duly approved Form R. Equipment shall not be issued on this form. 3429. Form S—Binnacle list.— 3430. Form T—Morning Report of Sick.— 3431. Form U—Report of Civilian Medical, Dental, and Hospital Treatment of the Personnel of the Navy and Marine Corps.—This form shall be submitted in accordance with the instructions printed on the form (par. 3162). 3432. Form V—Quarterly Return of Medical Stores.—Submitted to the Bureau by medical supply depots. The Naval Medical Supply Depots at Mare Island, Calif., and Cafiacao, P. I., shall forward a copy of the quarterly return to the Naval Medical Supply Depot, Brooklyn, N. Y. Instructions for the preparation of Form V are incorporated in Circular Letter F, appendix D. 3433. Form W—Stock and Equipment Ledger Sheet. 3434. Form Wa—Land, Real Estate, and Buildings Ledger Sheet. 3435. Form X—Recruiting Statistics (Abstract of Enlistments).— (a) This report shall be prepared in duplicate from Form X (rough) annually for the year ending December 31, or when a ship or station is placed out of commission, or a recruiting office closed. The original shall be forwarded promptly to the Bureau and the duplicate retained for the files of the transmitting office. (b) Central recruiting stations shall include in their report the sub- stations and traveling parties under their jurisdiction. Medical officers of ships, naval stations, or navy yards, making examinations for ships or stations to which no medical officer is assigned, shall include such examinations in their reports. (c) If there have been no applicants, the report shall be forwarded and this fact so stated. (d) The number of total applicants and total enlisted shall be obtained from the recruiting officer. (e) Rejected by the medical officer shall include only those actually rejected by the medical officer as physically disqualified. Applicants rejected by the recruiting officer because of lack of service requirements such as alien, illiterate, under age, etc., shall not be included. (f) The number of rejections by principal cause shall be entered on the form in the space provided. The terms of the Navy nomenclature 497 3436-3442 CH. 2 3.—REPORTS AND RETURNS shall be used. The total of rejections as specified by principal causes shall agree with the number reported as rejected by medical officer. 3436. Form X (Rough).—This form shall be prepared in accordance with instructions printed thereon, for each applicant examined for original or reenlistment, whether accepted or rejected, and shall be used for preparing Form X. It shall be retained for ship or station files and shall be filed alphabetically, by calendar years, according to the applicant’s surname, in order that the information may be furnished the Bureau upon request. 3437. Form Y—Report of Physical Examination.—(a) All reports of physical examinations except special physical examinations in con- nection with aviation shall be submitted on this form. (Form NMS—Aviation No. 1 shall be used for the annual physical examina- tion of aviators and for every other purpose concerning aviation per- sonnel where a general physical examination is undertaken, and sub- mitted in accordance with instructions contained thereon.) (b) In recording the examination of the teeth on these forms, medical and dental officers will use the markings indicated for record of first dental examinations as outlined in paragraph 2318 of this •manual. (c) In submitting report of annual physical examination on Form Y, only the original copy will be forwarded to the Bureau (pars. 1403 and 1520 (k)). 3438. Form Z—Dental Appointment Card. SECTION III. NUMBERED FORMS 3442. Form 4—Requisition and Invoice, Medical Supplies and Equipment.—This form shall be employed for requisitioning all items of the supply table and supplementary supply table, or such nonlisted items as the medical supply depots may be authorized to procure for issue. Individual supply depot requisitions are required for each of the following items: 1. Biologicals. 2. Precious metals. 3. Supply table items classified according to stock numbers. 4. Supplementary supply table items classified according to stock numbers 5. Nonlisted items approved for procurement. 6. X-ray apparatus. 7. Books. Requisitions shall be prepared in accordance with the following in- structions and submitted to the Bureau in quintuplicate: (a) The official designation of the requisitioning activity, the location and the date shall be indicated. (b) Account No.—The accounting numbers for the majority of ships and stations are given in Bureau of Supplies and Accounts accounting bulletin. The 498 SEC. III.—NUMBERED FORMS 3442 number may be obtained from the supply officer. The account number shall always be entered by the activity submitting the requisition. (c) Requisition No. SD.—Requisitions shall be numbered consecutively in an individual series for each fiscal year, preceded by the letters SD and followed by the fiscal year; thus, No. SD—1-1939. (d) Total allotment.—The amount to be entered following these words is the annual allocated credit for medical supply depot supplies and equipment. This amount remains constant except when increases are regularly authorized. (e) This requisition.—Following these words the total estimated cost of the items requested on the requisition should be entered. The estimated cost of each item carried in stock at naval medical supply depots will be found in the supply table and supplementary supply table of the Medical Department. (f) Balance.—The total allotment minus the actual cost of all supplies and equipment received from the medical supply depot to date during the current fiscal year and the estimated cost of items ordered, the actual cost of which is not known at the time the requisition is submitted, will give the amount to be entered as BALANCE. Note.—The amounts required by subparagraphs (d), (e), and (f) shall be entered at the activity submit, ting the requisition. These entries keep the Bureau advised regarding the balance available for the re mainder of the fiscal year. (g) Item No.—All items on a requisition should be numbered consecutively. A new series of numbers should not be started under each class. (h) Stock No.—When supply table or supplementary supply table items are requested they should be arranged in the same sequence on the requisition as they appear in the respective tables. Items not listed in either the supply table or supplementary supply table should be assigned appropriate class numbers, using the classification in these tables as a guide. (i) Items.—(1) Items on a requisition shall be separated by classes and tran- scribed as indicated in the supply table or supplementary supply table. Do not copy the formula, description, or information shown parenthetically after the item. Requisitions for apparatus to be operated on electric current should show the type of current (A. C. or D. C.) and voltage. If alternating current is indi- cated, give voltage, cycle, and phase. In requisitioning parts for electrical or x-ray equipment, supply all available data in regard to apparatus; i. e., type, number, manufacturer’s name, etc. Individual requisitions shall not include items from both the supply table and supplementary supply table. Individ- ual requisitions shall be used for items listed on either of these tables, as well as for items not listed. Similar restrictions are placed on precious metals, class 25a; blank forms, class 30; biologicals, class S4; and books, class S16; each of which requires an individual requisition. 2. When requesting blank forms (class 30 items—supply table), Form 4 shall be used and the copies of the requisition handled as requisitions covering other items. 3. Requisitions for nonlisted items (not listed in either the supply table or supplementary supply table) should describe such items, referring to name of manufacturer, catalogue number (attach cut, if deemed advisable), etc., to readily identify what is desired. Requisitions for proprietary items shall bear the state- ment required by article 1610, Navy Regulations and Bureau of Supplies and Accounts memoranda, article 901, section Q. The estimated cost of each nonlisted item requested shall be indicated without exception. (j) Unit.—The unit as shown in the supply table or supplementary supply table shall be noted in each instance. The description of the unit shall be copied viz: Yt lb. bot., 10 in box, etc. 499 3451 CH. 23.—REPORTS AND RETURNS (k) Minimum quantity.—The minimum quantity requirements for each item as defined in chapter 20 of the manual. (l) On hand.—This column shall be filled in for each item on a requisition. The amounts shown as “on hand” should be verified by actual inventory and only the unexpended quantities recorded on the requisition. (m) Remarks.—Enter serial numbers of property surveys when requesting replacements; give reasons for requesting unusually large quantities of supplies and additional equipment, especially the reason and necessity for nonsupply table items, and any other information that may be deemed necessary. (n) NMS Form 4 shall be prepared and forwarded, in quintuplicate, to the Bureau by all Navy and Marine Corps activities requiring medical stores. NMS Form 4 shall be prepared and forwarded, in sextuplicate, to the Bureau by Naval Reserve and Marine Corps Reserve activities. The original shall be marked in the lower left-hand corner “first”; the copies shall be marked “second,” “third,” “fourth,” “fifth,” “sixth,” and “seventh” as appropriate. The “sixth” or “sev- enth” copy shall be retained by the requisitioning activity. Immediately upon shipment of stores, the medical supply depot filling the requisition, except for Naval Reserve activities shall enter the packing box number opposite each item on the third copy of the requisition and forward that copy to the requisitioning activity as an advance invoice for checking the items. As soon as practicable after the shipment of the stores, the issuing medical supply depot shall forward the first copy, completely priced, together with the second copy, unpriced, to the requisitioning activity. The requisitioning activity shall enter on the second and third copies the price opposite each item and other cost data appearing on the priced copy. The original and all copies properly receipted with the actual date of receipt of stores are disposed of, as follows; Original to medical supply depot filling requisition. Second copy to Bureau direct. Third copy retained by requisitioning activity. For Naval Reserve and Marine Corps Reserve activities the medical supply depot shall enter prices, extensions, and other cost data on all copies of each requisition. Upon receipt of stores and invoice, in quadruplicate, by the Naval Reserve requisitioning activity, the original and all copies shall be properly receipted with the actual date of receipt of stores and forwarded via the commandant’s office for disposition, as follows: Original to medical supply depot filling requisition. Second and third copies to the Bureau. Fourth copy retained by the requisitioning activity. Additional copies may be required by local or other authority. (o) In case of errors in prices, price extensions, over-shipments, under-shipments or other discrepancies, the activity shall return the original copy of the requisi- tion, together with a statement showing the error or discrepancy, to the medical supply depot which furnished the materials. The receiving activity shall not make changes or alterations in a requisition prior to returning it to the medical supply depot. SECTION IV. HOSPITAL FORMS 3451. Form 1—Admission or Discharge of Officer.—This form is prepared in duplicate whenever an officer on the active list of the Navy or Marine Corps is admitted to or discharged from a naval hospital. One copy is forwarded, via the commandant, to the 500 SEC. IV.—HOSPITAL FORMS 3452-3472 Bureau of Navigation or the Major General Commandant, United States Marine Corps. The other is retained for the hospital files. 3452. Form 3—Transfer of Men.—This letter form is used when enlisted men are transferred from a naval hospital. 3453. Form 4—Order To Transfer Accounts. 3454. Form 5—Order for Transfer of Men. 3455. Form 7—Order for Transportation. 3456. Form 9—Ward Report. 3457. Form 10—Daily Personnel Report. 3458. Form 11—Request and Disposition Form. 3459. Form 17.—Clinical Notes. 3460. Form 18—Diet Sheet. 3461. Form 20—liberty List. 3462. Form 21—Laundry List. 3463. Form 22—Personal Effects Tag. 3464. Form 23—Order and Inspection Blank. 3464a. Form 24—Muster Card. 3465. Form 25—Baggage Card. 3466. Form 27—Laboratory Examination. 3467. Form 32—Pass Book. 3468. Form 33—Letter Heads. 3469. Form 35—Commissary Ledger (Extra Sheets and Cash Value Sheets) 3470. Form 36—Quarterly Ration Return.—(a) This form shall be prepared quarterly and forwarded to the Bureau with the financial reports not later than the fifteenth day of the month following the last day of the quarter. For detailed information and instructions relative to this form see Circular Letter F, appendix D. (c) The data to be recorded at the right side of this form are adequately indicated on the form. 3471. Form 36a—Daily Ration Memorandum.—(a) This form shall be prepared daily and copy furnished the commissary officer. This form provides a means for the daily collection of data necessary for the preparation of columns 1, 2, and 3 of Form 36 at the end of each quarter. (b) The detailed instructions for preparing Form 36 apply also to this form with respect to each line thereon. Three columns are pro- vided which indicate for today: the total number attached, number not subsisted and number subsisted. Another set of three columns are provided for recording the cumulative total for quarter to date. (c) This form shall be retained ixi the files for a period of not less than 2 years. 3472. Form 37—Commissary Ledger (Receipt and Expenditure Vouchers). 501 3473-3502 CH. 23. REPORTS AND RETURNS 3473. Form 38—Burial Record. 3474. Form 39—Register of Patients. 3475. Form 40—Special Diet Order Sheet. 3476. Form 42—Monthly Return of Nurses. 3477. Form 45—Nurse Corps, Information Slip. 3478. Form 49—Report of Nurses for Disbursing Officer. 3479. Form 53—Notice of Change in Diagnosis. 3480. Form 57—Special Examination and Request for Physio- therapy Treatment. 3481. Form 58—Operation Record. 3482. Form 59—Clinical Record. 3483. Form 59a—Clinical Record, Anatomical Chart. 3484. Form 60—Government Bills of Lading. 3485. Form 61—Information for Next of Kin. 3486. Form 62—Time and Pay Roll Record. 3487. Form 63—Request for Repairs. 3488. Form 64—Operations Scheduled. 3489. Form 66—Communication Routing Slip. 3490. Register No. 1—Charge Register. 3491. Register No. 2—Expense Analysis Register. 3492. Register No. 3—Register No. 3 shall be prepared in accord- ance with the instructions contained in Circular Letter F, appendix D, and forwarded to the Bureau with other financial reports. SECTION V. MISCELLANEOUS Paragraph Bureau of Navigation Forms 3501 Bureau of Supplies and Accounts Forms 3502-3506 Dispatch Report, Civilian Conservation Corps 3507 Letter Reports, Supernumerary Patients 3508 Hospital Corps Reports 3509-3510 Reports Concerning Aviation Personnel __ 3511 Miscellaneous Reports 3512-3518 3501. Bureau of Navigation Forms.—The commanding officers of naval hospitals, naval medical supply depots, and the Naval Medical Center are required to submit the same reports as other officers in com- mand on shore (ch. 54, sec. 1, N. R.). 3502. Bureau of Supplies and Accounts Form No. 35-M—Hospital Ration Notice.—The following instructions apply to the preparation and forwarding of this form: (a) The value of one ration per day shall be deducted from the accounts of every naval or marine officer admitted into a naval hospital during his continuance therein, which amount shall be 502 3503-3506 SEC. V.—MISCELLANEOUS credited to the naval hospital fund by the supply officer on whose books such persons are borne (sec. 4812 R. S.; art. 1827, N. R.). (b) Hospital ration notices, S. & A. Form 35-M, shall be prepared and fowarded in accordance with the following table within 48 hours after the admission or discharge (or when subsistence terminates) of every naval or marine officer admitted to a naval hospital. The information furnished on the form is considered sufficiently clear for its preparation. Hospital ration notices (discharge) executed in the case of deceased personnel shall bear the word deceased immediately following the rank or rating. (c) In case patients of any of the above classes, the expenses of whom are borne by the Navy, are admitted to a hospital other than a naval hospital, the hospital ration notice shall be forwarded by the Bureau and not by the local activity (24 U. S. C. 31). (d) Hospital ration notices are not required for enlisted men on active duty admitted to naval hospitals for treatment or for rations. (e) Hospital ration notices on inactive personnel residing in Asiatic countries shall be forwarded to the disbursing officer carrying the individual's accounts. Table showing proper officer to whom hospital ration notices should be forwarded Class of patient To whom forwarded References Officer, Navy or Marine Corps, mid- shipmen and aviation cadets—active. Officer, Naval Reserve or Marine Corps Reserve on active duty. Officer, Navy retired not admitted as Veterans’ Administration patient. Officer, Marine Corps retired, not ad- mitted as Veterans’ Administration patient. Nurse, retired, not admitted as Veterans’ Administration patient. Disbursing officer carrying officer’s pay accounts. do Art. 1827 N. R.; art. 1320-11, S. & A. M.; 24 U. S. Code 16. Art. 1320-11, S. & A. M.; art. 1827 N. R.; 24 U. S. Code 16. Art. 2150-1 (2) S. & A. M.; 24 U. S. Code 16. Art. 1827, N. R.; 24 U. S. Code 16. Art. 1320-11, S. & A. M.; art. 2147-2b, S. & A. M.; 24 U. S. Code 16. do The Paymaster, U. S. Marine Corps, Navy Department, Washington, D. C. The Chief of the Bureau of Supplies and Accounts. 3503. Misconduct Reports (Admission and Discharge).—S. & A. Form 35-L in accordance with article 1196, Navy Regulations. 3504. Bureau of Supplies and Accounts Forms 44 and 44a—Pur- chase Requisitions (Afloat).—These forms will be obtained from the supply officer and shall be prepared in accordance with instructions in Bureau of Supplies and Accounts Manual. 3505. Bureau of Supplies and Accounts Forms 76 and 76a—Pur- chase Requisitions (Ashore).—These forms will be obtained from the supply officer and shall be prepared in accordance with instructions in Bureau of Supplies and Accounts Manual. 3506. Bureau of Supplies and Accounts Form 154—Survey of Medical Department Property.—These forms will be obtained from 503 3507-3517 CH. 23.—EXPORTS AND RETURNS supply officer and shall be prepared in accordance with instructions in section V, chapter 20, of this manual. 3507. Report of Hospitalization of Members, Civilian Conservation Corps.—This report shall be made in accordance with instructions in Circular Letter F, appendix D. 3508. letter Reports of Supernumerary Patients Hospitalized.— A summary report of hospitalization of supernumerary patients shall be prepared and forwarded to the Bureau not later than 1 week after the close of the quarter. This report shall be submitted in triplicate, even though no patients in any of the classes listed have been hos- pitalized during the quarter. See Circular Letter F, appendix D, of this manual for instructions and form letter. 3509. Form NMS—HC—3—Hospital Corps Transfer and Disposition Form.—This card is prepared and forwarded in accordance with instructions contained in Circular Letter M-6 of January 1, 1941. 3510. Form NMS—HC—4:—Roster Report of Hospital Corps.— This form is prepared and forwarded in accordance with instructions contained in Circular Letter M-7, dated January 1, 1941.* 3511. Form NMS—Aviation No. 1—Report of Physical Examina- tion for Flying.—This form shall be prepared and forwarded in accordance with instructions printed on form (pars. 1542-1544). 3512. Application for Headstones.—Use War Department O. Q. M. G. Form No. 623. Prepare and forward in accordance with instructions on form. (These forms may be obtained from Quarter- master General, Munitions Building, Washington, D. C.) 3513. Annual Sanitary Report.—For instructions concerning this report see section III, chapter 17, of this manual. 3514. Monthly Sanitary Reports, Shore Stations.—For instructions concerning this report, see section III, chapter 17, of this manual. 3515. Monthly Sanitary Report, Ships.—For instructions concerning this report, see fleet orders. 3516. Special Epidemiological Report.—For instructions concerning this report, see section III, chapter 17, of this manual. 3517. Report of Communicable Diseases.—(a) A report of communi- cable diseases is required monthly from each ship and station (in- cluding receiving ships and stations). Report all cases of communi- cable disease which occurred during the month and were taken up on the sick list under titles of the United States Navy Nomenclature of Diseases and Injuries, in classes VIII (A), VIII (B), IX, X, XI, XII, and XIII, listed separately under each of these classes. Only new admissions, A and ACD, should be reported. In all cases account for ACD admissions separately. 504 SEC. VI.—TABULATION 3518-3552 (b) This report is made in letter form, addressed to the Bureau. It shall be forwarded on the first day of each month and shall contain the following information for the preceding month: Average complement for the month Total admission (A and*ACD but not RA) during the month for all diseases and conditions exclusive of injuries and poisonings Injuries Poisonings . Total, all causes 3518. Report of Casualties.—This report, in letter form, shall be submitted after any casualty where there is serious injury to per- sonnel or loss of life. The original shall be forwarded immediately to the Bureau and a copy sent to the commander in chief or senior officer present. It shall state the date, place, nature and cause of the accident; and list the names in full (surname first); rank or rating, the diagnosis as required by the Navy Nomenclature of Diseases and Injuries; the prognosis (fatal, probably fatal, serious, favorable); and disposition (died, retained on board, transferred). If transferred as a patient, the place to which transferred shall be stated. Each case shall be separated from the preceding case by a line (par. 888). Reports From the Fleet Medical Officer .. Paragraph 3551 Reports From the Medical Department of a Ship. _ 3552 Reports From the Medical Department of a Hospital Ship 3553 Reports From the Medical Department of a Yard or Station 3554 Reports From the Commanding Officer of a Naval Hospital 3555 SECTION VI. TABULATION 3551. Reports From the Fleet Medical Officer.— Form Subject To— When Letter... Do General sanitary report Bu. M. and S. (via C in C). CinC Annually, Jan. 1. When directed. When necessary. Do. Do. Do Report of casualties Special report of unusual occur- rences. Bu. M. and S. (via C in C). C in C 3552. Reports From the Medical Department of a Ship.— Form Subject To— When nms-s Commanding officer Daily. NMS-T do Do. NMS-A Report of cases of syphilis and arsenical treatments. Bu. M. and S._ Monthly. NMS-F do - Do. NMS-K-Dental Dental operations and treat- ments. do Do. NMS-HC-4 Roster report, Hospital Corps... do Do. do... Do. Do Sanitary report C in C Do. 3553-3554 CH. 2 3.—REPORTS AND RETURNS Form Subject To— When NMS-B Bu. M. and S Quarterly. Do. NMS-E do NMS-P Report of operations and diag- nostic examinations Medical history sheets (officers and nurses) do Do. NMS-H do Annually, Jan. 1. Do. NMS-X do Sanitary report Bu. M. and S. (via C in Do. NMS-D-Da C). Bu. M. and S . Annually .June 30. When necessary. Do. NMS-D Transfer of property _ Bu. M. and S. (copies for NMS-F-card officers concerned). Bu. M. and S NMS-O Naval hospital. - Do. NMS-H Health record (when closed) B. M. and S Do. NMS-L-Dental do. Do. Request for medical survey S. 0. P Do. NMS-M Report of medical survey. Bu. M. and S. (via S. 0. Do. NMS-N . Report of death. P.) Bu. M. and S Do. NMS-U Civilian medical, dental, and hospital treatment. Report of physical examination . Report of physical examination for flying. do Do. NMS-Y do. Do. NMS-Aviat-1 do Do. NMS-Aviat-3 do_ Do. NMS-HC-3 Transfer and disposition card. . do Do. NMS-4 Requisition for supplies from medical supply depot. do. Do. S. & A. 35-L Commanding officer . Do. S. & A. 44-44a ... Purchase requisition (afloat) Bu. M. and S Do. S. & A. 154 .. do Do. do. Do. 3553. Reports from the Medical Department of a Hospital Ship.— (In addition to those listed in par. 3552.) Form Subject To— When NMS-HF-10 N M S-H F-36-A NMS-I Daily personnel report Daily ration memoranda Commanding officer. do Bu. M. and S._ Daily. Do. Weekly. Monthly. Do. Quarterly. Annually by Mar.l. Annually, by Apr. 1. When necessary. (See par. 474.) When necessary. Do. Do. NMS-H F-42 Return of nurses _ ..... do _ NMS-HF-49 NMS-HF-36 Special Do Report of nurses Quarterly ration return. Estimate of expenditures Estimate of expenditures, ad- vance fiscal years. Disbursing officer Bu. M. and S.. do do. NMS-HF-44 . do. - NMS-HF-45 NMS-HF-1 S. & A. 35-M Information slip, Nurse Corps... Amdission or discharge, oflicer patient. Ration notice do. Bu. Nav. or Comdt., Ma- rine Corps. Disbursing officer carry- ing accounts. 3554. Reports From the Medical Department of a Yard or Station.— (In addition to those listed in par. 3552.) Form Subject To— When NMS-HC-4 Roster report, Hospital Corps... Sanitary report. . Bu. M. and S Weekly from receiv- ing and training stations, H. C. schools. Monthly. Annually, by Mar.l. Annually, by Apr. 1. Letter do Special, . __ Estimate of expenditures . do Do, Estimate of expenditures, ad- vance fiscal years. do Note.—Stations to which members of the Navy Nurse Corps are attached shall submit those Nurse Corps reports required from naval hospitals. SEC. VI.—TABULATION 3555 3555. Reports From the Commanding Officer of a Naval Hospital.— (In addition to those required from all officers in command on shore.) Form Subject To— When NMS-HF-10 NMS-HF-36-A Daily personnel report Commanding officer do.. Daily. Do. NMS-I Bu. M. and S Weekly. Do. NMS-HC-4 Roster report, Hospital Corps... Pay roll of persons employed ... _do Standard No. 1073.. Disbursing officer. (Copy Semi-monthly S. & A. 184 Labor roll summary. to Bu. M. and S.) Disbursing officer. (Copies to Bu. M. and S. and Bu. S. and A.). Bu. M. and S Do. NMS-A-. Report of cases of syphilis and arsenical treatments. Reportof allotment expenditures. Monthly. Monthly. Do. NMS-B NMS-F Bu M. and S NMS-K-Dental Dental operations and treat- do Do. NSO-No. 69 ments. Report of employees (group IVb). Hospitalization, members of Civilian Conservation Corps. Sec. Nav Bu. M. and S Do. Do. NMS-HF-42 do Do. NMS-HF-49 Disbursing officer Do. S. & A. 280 Report of expenditures by ap- Bu. S. and A. (Copies to Do. NMS-P — NMS-HF-36 propriations and titles. Report of operations and diag- nostic examinations. Bu. M. and S. and bu- reau concerned) Bu. M. and S do Quarterly. Do. NMS-H F-69 Report of hospital treatment days. Do do Do. Do. Do Summary report, supernumer- aries. Report of motor vehicles do Do Y. & D. No. 124 Bu. Y. and D. (Copy to Semiannually, Mar. NMS-H Medical history sheets, officers and nurses. Bu. M. and S.). 31,-Sept 30. Annually, Jan. 1. Do. NMS-X do Do. Annually, by Mar. 1. Annually, by Apr. 1. Annually, June 30. Do. Do Estimate of. expenditures, ad- vance fiscal years. NMS-D-Da When necessary. Do. NMS-H NM S-L-Dental Do. Do. NMS-M NMS-N Report of medical survey.I Bu. M.and S. (viaComdt.). Bu. M. and S Do. Do. NMS-U Civilian medical, dental, and hospital treatment. Report of physical examination. Report of physical examination for flying. do Do. NMS-Y Do. NMS-Aviat-1 Do. NMS-HC-2 do Do. NMS-HC-3 do Do. NMS-4 Requisition for supplies from medical supply depot. Admission or discharge, officer Do. NMS-H F-l Bu. Nav. or Comdt., Ma- Do. NMS-HF-44 patient. rine Corps. Bu. M. and S When necessary. (See par. 474.) When necessary. Do. Special epidemiological report... do 8. & A. 36-L Commanding officer S. & A. 35-M Disbursing officer carry- ing accounts. Do. S & A. 76-76a Purchase requisition (ashore) Do. S & A. 154 Do. War Department, Application for headstones Quartermaster General, Do. O. Q. M. Q. form no. 623. War Department. 507 Changes in Manual of the Medical Department [Enter number and dates of changes as indicated] No. Dated Effective Date made 509 Changes in Manual of the Medical Department [Enter number and dates of changes Indicated] No. Dated Effective Date made 510 INDEX1 A, meaning of, 2403. Abandon ship drill, 862, 873. Abbreviation for: quarterly ration return, 3470. ranks and rates, 2252. sick list, 2403. Abdomen, 1493-1495. (See Physical examination.) (See Physical standards.) Abnormalitjr, physical, slight, officer, 1520. Abscess: ischiorectal, 1499. lungs, 1477. spine, 1468. Absence from duty: Chief of Bureau, relief, 3, 4- junior medical officer, 762. nurse, 1672. ship’s medical officer, 821. Abstract of enlistments, reporting, 3435. Abstract of patients (Form F, monthly), 2406, 2407, 3416. Academy, Naval. (See Naval Acad- emy.) Accelerated reaction, 2605. Accident, report of: aviation, 3513. diving, 1280. submarine, 1280. Accommodation of vision, 1556. Accounting officer, naval hospital, 1633. Accounting procedure. (See Property, accounting.) ACD, meaning of, 2403. Acne, 1450. ACR, meaning of, 3472. Acromegaly, 1516. Acting assistant surgeon: appointment, 111-121. physical examination, 117. professional examination, 118. qualifications, 112, 113. termination, 113. Actinomycosis, 1445, 1450, 1477. Action, clear ship for, 862, 863. Action, readiness for, 864, 865, 866. Active duty, Naval Reservist: death from injury, 2911. Active duty, return to: medical reserve, 171. misconduct case, 2506. retired chief nurse, 336. retired medical officer, 151. Active duty passenger of ship: method of reporting, 2405. Active-duty patients: quarterly ration return, 3470. Active-duty personnel. (See Personnel.) Active-duty training, Reserves, 171. Activities, special, 1201- 1283. Adenoids, 1455. Adherent or web fingers, 1511. Adhesion, peritoneal, 1495. Adjustment account, 3112. Adjustment voucher, 3103. Adjustment. (See Property, account- ing.) Administration officers, naval hospital, 1631. Administrative adjuncts, naval hospital, 1631-1653. Administrative assistants, naval hos- pital, 1631-1653. Admission to hospital: officer, report, 3451. report, 1672. Admitted contributory disability: abbreviation, 2403. intrepretation, 2404- poisoning, therapeutic, 2413. report on Form F card, 2405. venereal disease, 2408. Admitted to sick list: abbreviation, 2403. for disability incurred in— diving or submarine duty, 1280. interpretation, 2404- 1 Numerals refer to paragraphs. Those in roman type indicate the paragraph is limited to the subject indexed. Those in italics indicate that the paragraph includes subject indexed. 1 A INDEX Advance years, estimates of expendi- ture, 3016. Advanced-hospital station, 1232. Advancement to warrant rank: Hospital Corps, 607, 621. Advice to next of kin. (See Information.) Aeronautic duty. (See Aviation duty.) Aeronautical adaptability, 1565. Age, standards. (See Physical stand- ards, age.) Agent, immunizing. (See Immunizing agents.) Aid, company, 1232. Air force, medical assistance, 1261. Aircraft. (See Airplanes.) Aircraft gunnery observer, standards, 1539. Aircraft pilot. (See Aviation.) Airplane: drills, 862, 869. Mosquito control, 2882. quarantine, 2808, 2834- Alaska duty: civilian service, requisition, 3034. physical examination for, 1532. Albinism, 1439, 1516. Albuminuria, 1503, 1508, 1520. Alcohol: custody: on board ship, 738. by dental officer, 241. at hospital, 1621, 1640, 1672. procurement, 3049. specification, 3049. Alcoholism, 743, 1516, 1517. Alkaloidal poisons, 738. Allotment: estimates, 3012-3015. expenditures, 3023, 3024, 3412. Allotments, 3022-3024. Allowance for rental. (See Rental al- lowance.) Allowance for travel. (See Transporta- tion.) Allowance for uniforms, reserve officer, 171. Alterations and repairs, 3024- Ambulance: boat, 1216. company, 1232. service report, 2701. American consul, transfer of records to, 2407. American National Red Cross: medical officer, 101. at naval hospital, 1650; Appendix C. nursing service, 352. subsistence checkage, 3109. Amphibious operation, 1201-1217: composition of force, 1202. debarkation for land operation, 1216. duties of: fleet medical officer, 1209. force surgeon with troops, 1214. medical officer, base force, 1210. medical officer, staff, attacking force, 1212. medical officer, transport, 1213. medical officer, staff, transport force, 1211. embarkation, base port, 1215. evacuation of casualties, 1217. medical function: essentials for success, 1206. phases, typical operation, 1205. plans, 1208. responsibility, 1207. military phases, typical operation, 1204. purpose of landing troops, 1203. references, 1201. Amputation, 1510, 1511. Anal fistula, 1495, 1499. Anaphylaxis, 2413. Anatomical chart (Form 59a), 3483. Anemia, 1445, 1449, 1494- Anesthetics, summary, report, 3426. Aneurysm, 1481, 1490. Angina pectoris, 1490. Angle of convergence, 1557. Animals, meat, inspection, 2609. Ankylosis, 1510, 1511. Annual: estimates of expenditures. (See Prop- erty, accounting.) inventory. (See Property, inventory.) issue, medical stores, 3148. purchase requisition, 3033. requisitions, 3033, 3034. statistical rates, calculation, 2702. (See Physical examination.) (See Reports.) (See Sanitary reports.) 2 INDEX A Anthrax, 2820, 2827. Antidotes, 241. Antigen, procurement, 3052. Aorta, dilation, 1488. Aortic: injection, embalming, 2936. murmur, 1484- stenosis, 1481. APA. (See Property, accounting.) Aphonia, 1455. Apical areas of infection, teeth, 1462. Apical thrill, 1489. Appendicitis, 1495. Appliance, submarine escape: disability incurred, report, 2415. Appliance, orthopedic. (See Orthope- dic appliance.) Appliance, prosthetic. (See Prosthetic appliance.) Applicant for pension, aid to, 751. Applicant for service, record of physi- cal defect, 1414, 1415. Application form for: admission to: Army and Navy General Hospital, 2107. examination for: Dental Corps, 203. Medical Corps, 114. Nurse Corps, 341. Appointment: Assistant to the Bureau, 3. Chief of the Bureau, 2. Dental Corps, 201-208. health record, officer, at time of, 2202. Medical Corps, 111-121. Naval Reserve (Dental Corps), 281. Naval Reserve (Medical Corps), 171. Nurse Corps, 311, 321, 331-336. (See Physical examination, com- mission.) (See Physical standards, commis- sion.) warrant rank, 1507. Appraised value, property survey, 3076, 3077. Appropriational expenditures. (See Property, accounting.) Appropriations, annual. (See Property, appropriations.) Arcus senilus, 1481. Argyll-Robertson pupil, 1516. Arlington Cemetery, burial at, £960. Arms for medical personnel, 12£9. Army hospital, 2171. Army personnel in naval hospital: health records, 2207. Army and Navy General Hospital. (See Hospitals, other than naval.) Arrhythmia, 1635, 1636. cardiac, 1490. Arsenical treatment, report, 2703, 3411. Arsine in submarines, 1278, 12S2. Arterial injection, embalming, 2934, 2936. Arteriosclerosis, 1490, 1536, 2109. Arthritis, 1445. Article on professional subject by: dental officer, 242. medical officer, 739. Artificer branch, rates, 2262. Artificial eye and limb, procurement, 3056. Asiatic duty, ration notice, 3502. Assignment of: dental officer, 231. hospital personnel, 1612. Naval Medical Center personnel, 3315. nurse, 361, 362, 1671. Assistant dental surgeon: appointment, 201-208. qualifications, 202. physical examination, 206. professional examination, 207. (See also Dental Corps.) Assistant superintendent, Nurse Corps, 321, 322. Assistant surgeon: appointment, 111-121. authorization, 101. qualifications, 112. physical examination, 117. professional examination, 118. (See also Medical Corps.) Assistant surgeon, acting. (See Acting assistant surgeon.) Assistant to the Bureau, 3. Associated parallel movements, test of, 1554. Asthenopia, 1439. Asthma, 1477, 1536, 1565. Astigmatism, 1520. myopic, 1403, 1431, 1432. Aortic: 3 INDEX A Atabrin, 2615. Ataxia, 1516. Athletics: afloat, 702. regulations, 2603. at naval hospitals, 1648. Atrophy: facial, 1453. muscular, 1516, 1517. of optic nerve, 1429. of tongue, 1455. Attack force, staff medical officer, 1212. Attendance, dental. {See Personnel, treatment.) Attendance, medical. {See Personnel, treatment.) Attendant for insane during transfer, 2152. Auditory acuity, 1484, 1562. Auscultation: heart, 1481. lungs, 1475. Authorities, civilian, 1612, 2905. Authorized strength: Dental Corps, 201. Medical Corps, 101. Autopsy, deceased person, 2918. Available stores, supply depots, 3148. Average annual rate of use, medical supplies, 3069. Average complement, 2406. annual sanitary report: hospital, 2701. ship, 2699. station, 2700. statement of receipts and expendi- tures, 3414- Aviation: conditions, study of, 1263. disability, incurred, 2415. medical division, 1261-1266. medical examiner, 1544. personnel: cadet, 1416, 1431, 8169. physical examination: annual, 1543. applicant, 1548. re-examination, 1541. report, transfer, 1266. Reserve, 1542. vision, 1539. where made, 1543. Aviation—Continued, personnel—continued. {See also Physical examination, aviation.) rank and rate, 2252. specialty designation, 2417. quarantine, 2808. Babinski reflex, 1516. Bacterial culture, procurement, S052. Baggage, disinfection, 2854- Baggage card (Form 25), 3465. Bake shop, inspection, 2608. Bakers, supervision, 2608. Balance sheet, naval hospital, 3113. Barany chair, 1564- Barracks, sanitary standards, 2621. Basal metabolism room, 1680. Base force, staff medical officer, 1210. Base port, embarkation at, 1215. Base, sum, estimates of expenditure, 3015. Basic course, specialist, 1612. Bathing facilities: sanitary report: hospital, 2701. ship, 2699. station, 2700. sanitary standards: barracks, 2621. field service, 2672. hospital, 2622. Battalion-aid station, 1226, 1232. Battalion, medical, 1222. Battalion surgeon, 1226. Battle casualties. {See Casualties.) Battle-dressing station: dental officer, 231, 884. equipment, 877. first-aid box, 876. lighting arrangement, 879. location, 875. routes, 881. sterilizer, 880. water supply, 878. Battle dressings, afloat, 836. Battle plans, fleet surgeon, 807. Beach medical station, 1217. Beach party medical officer, 1217. Bearer, stretcher, 836. B INDEX Bed capacity, hospital, weekly report, 3419. Bedbugs, destruction, 2864, 2887. Bedding, inspection, 825, 2608. Beds, hospital, standards, 2622. Bell, diving, disability incurred, report, 2415. Benedict test, 1520. Beneficiary, Veterans’ Administration, treatment, 1678, 2104• Beneficiary slip, nurse, 476. Beriberi, 1445, 1517. Bichloride of mercury: disinfection by, 2855. tablets, 787. tinting of, 788, Bifid spine, 1468, 1516. Bifid tongue, 1455. Bill of health, chapter 18: data required for obtaining, 2840. expense, 2843. for fleet, 2842. for naval vessel: between United States port and Canal Zone, 2837. between United States port and United States possessions, 2837. calling at intermediate port, 2841. from foreign port to home port, 2839. from United States port to foreign port, 2838. penalty for failure to obtain, 2808. procurement, 2840. quarantine law, 2808. quarantine regulation, 2811. United States consular, 2839. where obtained, 2844. naval quarantine regulation, 2828- 2834. Bill of lading, Government, 3484. for shipment of-deceased, 2955, 2959. Bill for treatment: civilian dental, 8162. civilian hospital, 8167. civilian medical, 8162, 8167. Government hospital, 3167. Bills, quarter and station, 885, 862. watch, 885, 862. Bill, vendors. (See Property, account- ing.) Binaural hearing, 1436. Binnacle list, 826, 3429. Biologicals: procurement, 2607, S052. records, 3073. Birthmark, 1468. Bladder, tumor, 1608. Blank forms, 3406. Blepharitis, 1429, 1555. Blepharospasm, 1429. Blood, 1506, 1507. diseases, nomenclature, appendix A, section II, class I. in urine, 1508. Blood donor: allotment for, 8024. payment, 3050. Blood pressure, 1408, 1608, 1628, 1565. in physical examinations, 1483. annual, of officers, 1620. aviation duty, 1565. systolic, 1586. Blood-sugar, 1505. Blood vessels. (See Heart and blood vessels.) Board: medical examiners, 1415, 1480, 1524. permanent, Naval Academy, 1408. special for officer, 1523. medical survey, 1480, 2105, 2122, 2151, 2152, 2160, 8423. naval retiring, 1420. property survey, 8076. Board, bulletin, 1621. Boat: ambulance, 1216. troop, 1216. Boiling, disinfection by, 2853. Bone, diseases of, 1510, 1511. Book: organization, 780. standing order, 780. Books: disinfection, 2854- medical, procurement, 8051. at naval hospital, 1612. at Naval Medical Center, 8841• Bowlegs, 1511. Brace: for civilian personnel, 1658. procurement, 3056. Brain tumor, 1517. Branchial cleft, 1516. 5 INDEX B Brachial - femoral - carotid injection, 2934. Breaking camp, 2676. Breast, tumor of, 1472. Breath, offensive, 1535. Breath holding, 1536. Brig and locked patients space, 1621. Bromidrosis, 1510, 1511. Bronchiectasis, 1477. Bronchitis, 1477. Buboe, 1508. Budget. (See Property, accounting.) Bugler, standards, 1458. Buildings. (See Property, land and buildings.) Bulletin board, 1621. Bumboat, inspection, 2603. Bunion, 1510, 1511. Bunks, disinfection, 2887. Bu. C. & R. materials and services to Bu. M. & S., 3048. Bu. M. & S., 1-13. assistant to Bureau, 3. authority, 1. Chief Clerk, 4. Chief of Bureau, 2, 3. divisions, 5. duties, 6. duties relative to: accounts, 3005, 3011. buildings, 11. civil personnel, 11. dental officers, 10. hospitals, 11. information, restriction of, 12. laboratories, 11. material, apparatus, etc., 8. Medical Department, 5. medical supply depots, 11. Naval Dispensary, 5. Naval Medical Center, 5,11. public property, 8, 11. public works, 11. technical schools, 11. establishment, 1. finances of, 9. orders, 7. organization, 5. publications, 13. reports and returns: hospital forms, 3451-3492. lettered forms, 3411-3438. numbered forms, 3445. Bu. Nav. materials and services to Bu. M. & S., 3048. reports and returns, 3501. Bu. S. & A. materials and services to Bu. M. & S., 3048. reports and returns, 3502-3506. Burial. (See Personnel, deceased.) Burning, disinfection by, 2852. Butcher shop, inspection, 2608. Butchers, supervision, 2608. C, meaning of, 2403. Cadet, aviation. (See Aviation.) Caisson disease, 1536. Calculi: renal, 1508, 1532. salivary, 1462. vesical, 1508. Camp site: intelligence report, 2711-2713. sanitary regulation, 2664. Cancer: of neck, 7404- treatment, 2176-2178. Candidate for: commission. (See Commission.) Enlistment. (See Enlistment.) Naval Academy. (See Naval Acad- emy.) Canteen, sterilization, 2677. Capital account, 3098. Cap, disinfection, 2854• Carboxide gas, disinfection by, 2862. Carbuncle, 1450. Cardiac arrhythmia, 1490 Cardiorenal disease, treatment, 2109. Cardiovascular system: disease, 1503. physical examination, 1535-1537, 1565 standards. (See Physical standards.) Care of the dead. (See Property, ac- counting.) Care of the sick. (See Personnel, treatment.) Carfare, injured civil personnel, 1653. Caries: dental, 1462. facial, 1453. vertebral, 1468. Cartilage, floating, 1511. Case records, 1612. Casket, 2941. 6 c INDEX Casts, urine, 1503, 1520. Casualties: evacuation, 1217. medical treatment: afloat, 836. in field, 1231. reports, 3520. sorting, 1217. Catalog, Federal Standard Stock, 3037, 3100, 3103, 3109. Cause, nature and, of violence: nomenclature, 2419, appendix A, section IV. Cavity injection, embalming, 2935. Cell, inspection, 825. Cellulitis, 1445. Cerebrospinal: fever, 2616. fluid, 1507. syphilis, 1516, 1517. Ceremony, funeral, 2998. Certificate: of continuous service, 639. of death. (See Death certificate.) required for appointment to: Dental Corps, 204. Medical Corps, 115. Naval Reserve, Dental, 281. Naval Reserve, Medical, 171. unofficial, of ill health, 740. Cervical adenitis, 1463, 1464• Cervical fistula, 1464• Chalazion, 1555. Chamber, recompression, disability in- curred, report, 2415. Change of diagnosis. (See Diagnosis, changed.) Change of rate, hospital corpsman, 607. Chaplain, emergency duties, 883. Charge register, 3094, 3096, 3490. Charge, prohibited for service, 243, 752. Chart: (See Clinical chart.) organization, naval hospital, 1605. Snellen test, 1549. Stilling’s color test, 1558. Checkage of pay. (See Property, ac- counts.) Chemical warfare drill, 862, 868. Chest: abnormality, 1471, 1472, 1481. disease, 1471, 1472. Chest—Continued, measurement, 1441. physical examination, 1471, 1472. (,See Physical standards.) rejection, cause for, 14-72. Chief Clerk, 4. Chief nurse, 331-337. appointment, 331. recommendation, 332. revocation, SSI, S36. assignment, 334. duty, naval hospital, 1671. promotion, 333. reappointment, 336. Chief of Bureau, 2. assistant to, 3. relief, 3, 4- Chief pharmicist, qualifications, 621. Chief pharmacist’s mate: qualifications, 607. training, 613. Chief pharmacist’s mate-of-the-day 1625. Chlorinated lime, 2860. Chlorination of water, 2860. afloat, 2610. for field service, 2667. Choice of diagnostic title, 2402. Cholera, 2821. incubation period, 2820, 2821. quarantine regulations, 2821. report, 2694. Chorea, 1451, 1517. Choroiditis, 1429. .Cicatrix of: abdominal wall, 1495. face, 1453. head, 1452. skin, 1450. Circular letters, 13. Circulatory system: diseases, nomenclature, appendix A, section II, class II. efficiency test, 1565. Circumstance of occurrence: injury and poisoning, 2416. Citronella, 2615. Civil: authority: cooperation with, 1612. death certificate, 2905. death certificate, 2908. INDEX c Civil—Continued, pay roll account, 8096. personnel: accounting records: (See Property, accounting, for accounting.) (See Property, procurement for labor.) of naval hospital, 1653. physical examination, 1127, 1594- 1597. treatment, 751, 1128, 1653. Civilian: Conservation Corps: hospital treatment: letter report, 3508. monthly dispatch report, 3507. weekly report, 8419. hospital. (See Hospitals, civilian.) librarian, 1647. treatment, service personnel: (See Personnel, treatment, for provisions.) (See Property, accounting, for accounting.) Civilian, treatment of, 751-753. Class, preparatory, Naval Academy. (See Naval Academy.) Class number, meaning of, 2401. Clavicle, 1472. Clavus, 1510, 1511. Cleaning supplies, procurement, 8048. Cleanliness, regulations, 2603. Clear ship for action drill, 862, 863. Cleft, branchial, 1516. Cleft palate, 1516. Clergyman’s fee, 2984. Clinical: chart, 1612, 1672, 3427. chief of service, 1663. facilities, hospital, 1661-1680. head of department, 1664. notes, 1672, 3459. operating room, 1680. organization, 1661. records, 1612, 3482, 3483. regulations, 1662. service, Naval Medical Center, 3323. ward medical officer, 1665. Clothing: for deceased person, 2940. disinfection, 2854- Clothing—Continued, payment, 3028. sanitary regulations, 2603. sanitary report, 2699, 2700. Clubfoot, 1511. Coccyx, fracture, 1468. Cockroaches, 2864, 2886. Coin, click test, 1562. Colitis, 1535. Collecting station, 1282. Collision drill, 871. Coloboma, eye, 1489. Color field, contraction of, 1559. Color perception: (See Physical examination, eye.) (See Physical standards, vision.) Combined operation, 1202. Comfort zone, 2611. Command: hospital corpsmen, 1673. hospital ship, 1001. naval hospital, 1604. limitation of authority, 1613. Naval Medical Center, 3301. Commander in chief, 2602. Commanding officer: naval hospital, 1611, 1612. general instructions, 1611. right to communicate with, 104, 1672. ship, medical duties, 2608, 2830. Commissary: account, 3103, 8109. branch, rates, 2252. equipment, inventory, 3413. ledger. (See Property, accounting.) officer, naval hospital, 1635. stores: inspection of, 1612. maintenance, 1635. Commission, officer: (See Physical examination, commis- sion.) (See Physical standards, commission.) Commissioning: allotment, ship, 3022. outfit, 3058. Communicable disease, chapters 15, 17, 18. control, 2616. in camp, 2680. embalming, 2935. examination for, 1445. 8 c INDEX Communicable disease—Continued, nomenclature, appendix A, section II, class VIII, IX, X. prevention, 2616. reports: Form I, hospitals, 3419. letter, monthly, ship and station, 3519. sanitary report, monthly: ship, 2696. station, 2697. transportation, deceased person, 2951. Communication routing slip (Form 66), 3489. Communications: Dental Corps, 239. Medical Department, 732. naval hospital, 1612. Naval Medical Center, 3303. Nurse Corps, 471. Company, ambulance, 1232. Company aid, 1232. Company hospital corpsman, 1227. Compartment, inspection, 825. Compensation, part, for special duty, 3106. Compensation for injury: civil personnel, 1653. Naval Reserve, 171. Complement, average. (See Average complement.) Complication: change of diagnosis, 2402. of disability, 2404. existing prior to entry into service, 2410. method of reporting, 2404- prompt change to new title, 2402. of veneral disease: diagnostic title, 2408. Compressed air, disability due to, report, 2415. Computation, sick days, 2405. Computing machine, 3024, 3075. Concealed disease, examination for, 702. Concurrent disability, 2404. Conferences: board ship, 810. naval hospital, 1612. nurses, 1671. Confined patient, 1612, 1621, 1672. Confinement, prisoner, disability in- curred, 2510. Conjunctivitis, 1439. Consignee, deceased person, informa- tion for, 2959. Consolidated inventory, 3147. Consolidated table, annual issues, 3148. Constipation, 1535. Constitutional psychopathic state, 1516, 1517. Construction and Repair, Bureau of. CSee Bu. C. & R.) Consul, American, 2407. Consultation, medical and dental offi- cers, 231, 712. Consultation service, Naval Medical Center, 3305. Contacts on sick list, 2402. Contingencies and losses, 3103. Continued on sick list: abbreviation, 2403. interpretation, 2404- method of reporting, 2405. Continuous-service certificate, 639. Contract expenditure, report of, 3023. Contracted pupil, 1516. Contraction of color field, 1559. Contract, purchase. (See Property, procurement.) Convalescent patient, 1674- Convergence of vision, 1557. Convulsion, 1517. Cooks, supervision, 2608. Cooperation with other agency, 707, 1612. Cornea, disease, 1429. Coroner’s inquest, 2990. Corpse. (See Personnel, deceased.) Correspondence. (See Communica- tions.) Coryza, 1535. Course of instruction. (See Instruc- tion.) Court martial: abbreviations for health record, 2252. authority to order, 1613. Court, medical record for, 741. Cowpox virus, preservation, 2605. Cranium, abnormality of, 1516. Cremation, 2987. Creolin, 2856. tions.) 9 INDEX c Cresol, 2881. Cretinism, 1516. Crew: care of, regulations, 2603. dental examination, 261. first-aid instruction, 836. Criminalism, 1516. Curtain, tangent, 1551. Curtain, disinfection, 2854- Cyanogen-chloride gas mixture, 2864. Cycloplegia, 1403, 1432, 1560—. Cyllin, 2856. Cystitis, 1508. Cyst: hydatid, 1477. osseous, 1453. D, meaning of, 2403. Dacryocystitis, 1429. Daily personnel report, 3457. Daily ration memorandum, 3471. Daily report of sick, afloat, 825, 826. Damage control drill, 862, 867. DD, meaning of, 2403. Dead. (See Personnel, deceased.) Deafness, 1435. Death, 2901-2999: annual rates, computation of, 2702. of Fleet Naval Reserve, 2907. health record, 2202, 2206. at hospital, 2901. investigation, 2916. misconduct entry, 2501. occurring while: awaiting orders, 2905. on leave, 2407, 2905. on sick list with another disability, 2404. report, 2901. for log or journal, 731. form used, 3424. request for, 741. on sick list, 2404- veteran, 2207. Reserve: due to active-duty injury, 2911. following release from active duty, 2911. retired personnel, 2906. at St. Elizabeths Hospital, 2159, 2909. on ship, 2901. at shore station, 2901. Death—Continued. Veterans' Administration patients, 2958. Death certificate, 2904, 2908. Death gratuity, nurses, 305. Debarkation, landing operation, 1216. Deceased person. (See Personnel, de- ceased.) Deceitfulness, 1516. Decisions, misconduct, 2512. Decommissioning, medical stores, 8080. Deep-sea diving. (See Diving duty school, 1279.) Defect: correction of, 1612. disqualifying. (See Physical stand- ards.) physical. (See Physical examination.) Degassing, 868. Degeneracy stigmata, 1451, 1452, 1516. Degeneration, nervous, 2109. Delousing technique, 2885. Dementia praecox, 1516. Dental: Deformity, 1462. Diseases, nomenclature, appendix A, section II, class XXVII. Equipment: afloat, 261. allotment, 8024. inventory, annual, 3413. Examination: after appointment, 238. crew, 261. enlisted man, for recruiting duty, 1581. health record, 2312. recruit, 272. Lavatories, sanitary standards, 2621. Linen, 237. Officer: appointment, 201-208. assistance, 236. consultation, 231. duties, 231-244, 275. afloat, 261, 262. ashore, 271-274. battle-dressing station, 281, 884. dental examination, 785. treatment of civilian, 751-753. promotion, 221-225. {See also Dental Corps.) 10 I) INDEX Property: custody, 234. inventory, 262. requisition, 235. transfer, afloat, 262. Record, 2311-2319. chart, 2318. classification of teeth, 2317. examination, 2312. filling material, 2319. Form K, dental, 2316, 3420. forwarding of, with patient, 734- operation, 2313. preparation, 2311. treatment, 2314. Report: annual, 244. monthly, prosthetic treatment, 240, 274- preparation, 233. treatment other than naval, 3197. Supplies: allotment, 3024- hospital, report, 2701. ship, report, 2699. shore station, report, 2700. Technician, 236. Treatment. (See Personnel, treatment, dental.) Dependent, treatment. (See Person- nel, treatment.) Deployment, medical units, 1231. Depth perception, 1550. Dermatitis, 1450, 2413. Descriptive sheet, 2261-2263. Deserter: health record, 2206. physical examination, 1528. Desertion, method of reporting: disability incurred, 2411- sick list, 2202, 2403, 2404- Destitute person, burial, 2991. Detached duty personnel. (See Per- sonnel, treatment, other than naval.) Detachment of retina, 1429. Deviation, septal, 1455. Diabetes, 1445, 1505, 1508. Diagnoses, 2402. Diagnosis: changed, 2402-2404- from or to diagnosis undetermined, 2409. Diagnosis—Continued, changed—continued, misconduct case, 2509. report on Form F card, 2405. erroneous: correction, 2402, 2404- misconduct case, 2408, 2509. established, 2404- number, meaning, 2401. undetermined, 2402, 2409. Diagnostic examinations, report, 3426. Diagnostic title: choice, 2402. method of listing, 2401. in nomenclature, 2401, appendix A, section II. precedence of titles, 2402. wording required, 2401. Diarrhea, 1535. Diastolic murmur, 1489. Died: abbreviation, 2403. interpretation, 2404- Diet kitchen, 1635. Diet sheet (Form 18), 3460. Diets, annual sanitary report, 2701. Digestive system, diseases of: nomenclature, appendix A, section II, class III. Dilatation, heart, 1485, 1490. Dilated pupil, 1516. Diphtheria, 1481, 2616. Diplopia, 1439, 1551, 1554- Disability, dental treatment, 231. Disability, record and report: arising in desertion status, 2404, 2411. arising from therapy, 2404, 3413. civil personnel, 1653. discharge of nurse for, 394. due to misconduct, 2501-2512. due to occupational hazard, 1280. existing prior to entry into service, 2404, 2405, 2410. increased by service, 2503. incurred in confinement, 2510. incurred on leave, 2510. incurred by misconduct, 2501-2512. intervening, 2407. multiple, 2402. nature and degree, 2505. Disbursing officer: monthly return of nurses, 4^3. 11 D INDEX Disbursing officer—Continued. at naval hospital, 1638. Discharge: fingerprint record, 1571. from Hospital Corps, 615. insane patient: by medical survey, 2160. for treatment, St. Elizabeths Hos- pital, 2158. from Navy for physical disability 1618. from Nurse Corps, 451-454. for disability, 394. officer from hospital, report, 3451. patient, naval hospital, 1677. authority, 1613. report, 1672. physical examination: enlisted man, 1529. officer, 1525. Discipline, 1621. Disease: communicable, control and epidemic. (See Communicable disease.) concealed, examination for, 702. existing prior to enlistment, record of, 2508. (See Nomenclature, diseases.) prevention and control, 701-707. (See Quarantinable diseases.) Disinfectants: bichloride of mercury, 2855. boiling, 2853. burning, 2852. carboxide gas, 2862. chlorinated lime, 2860. cresol, 2881. cyanogen-chloride gas mixture, 2864. formaldehyde gas, 2858. hydrocyanic acid gas, 2863. Jime, 2859. phenol, 2856. pyrethrum, 2808, 2881. solution of formaldehyde, 2857. steam, 2854. sulphur dioxide, 2861. sunlight, 2851. Disinfecting stations, 2874. Disinfection of: baggage, 2854• book, 2854- bunk, 2887. Disinfection of—Continued, cap, 2854- clothing, 2854- curtain, 2854. fabric, 2854, 2857. fine woolens, 2854• fur, 2854• hat, 2854. leather, 2854- lifeboat, 2872. mattress, 2887. rubber, 2854- ship. (See Ships.) shower baths, 2860. silk, 2854- spit kit, 2856. stateroom, 2887. textile, 2854, 2867. Dislocation, 1510, 1511. record and report, 2412, 2414-2416. Dismissal, physical examination on, 1525. Disposition of personnel. (See Per- sonnel, disposition.) Disqualifying physical defect. (See Physical standards.) District: craft: medical material, 8044- reports, 2407. headquarters, personnel statistics, 2406. medical officer, 1101, 1102, 2906. Divine ministration, 1621. Divine service, 1621. Diving, 1276-1283. disabiltties incurred, report, 2415. physical examination, 1279, 1536, 1537. (See Physical standards.) sanitary report, 1283. Division: medical officer, 811. officer, first-aid instruction, 886. Document, official, 239, 732. Drainage: mosquito control, 2615. station, report, 2697. Dressing station, battle. (See Battle- dressing station.) Dressings, battle, 836. Drill book, Hospital Corps, 18. 12 INDEX D Drills and emergencies: abandon ship, 873. airplanes, launching, recovery, 869. chemical warfare defense, 868. collision, 871. damage control, 867. fire, 1621. fire and rescue party, 872. fire quarters, 867. gas defense, 868. general quarters, 864. landing force, 874. list of, 862. parade, medical unit, 1231. readiness for action, 864, 865, 866. Drowned person: first aid, 886. identification, 2917. resuscitation of, 886. Drug habit, 1516, 1517. Drug room, station, 1129. Drugs, custody and issue, station, 1129. Drunkenness, 742. Duane table, 1556. Ductless glands, 1404- diseases, nomenclature, appendix A, section II, class IV. Duty: absence from. (See Absence from duty.) discharge to: from hospital, 1677, 8451. from sick list: abbreviation, 2403. interpretation, 2404- medical survey, 3423. excuse from, 1621. night nurse, 1672. officer-of-the-day, 1624. return to, misconduct case, 2506. watches, 1625. Dysentery, 1494- Dysfunction, glandular, 1445. Dystrophy, muscular, 1516, 1517. Ear: diseases, nomenclature, appendix A, section II, class V. (See Physical examination, ear.) (See Physical standards, hearing.) Echelons, medical assistance, 1232. Ectropion, 1555. Eczema, 1450. Edema, 1510, 1511. Edentulous spaces, teeth, 1462. Edridge-Green lamp, 1428, 1520. Education. (See Personnel, instruc- tion.) Educational officer, 1652. Electric service. (See Property, ac- counting.) Electrocardiogram, 1481. Electrocardiograph room, 1680. Elephantiasis, 1450. Eligible list, Nurse Corps, 344. Embalming. (See Personnel, deceased.) Embarkation, base port, 1215. Emergencies and drills, afloat, 861-888. Emergency: case, retention in hospital, 752. deiital, meaning of, 8192. material and service, requisition, 3082. relief force drill, 862, 874- work request, 8041. Emotional instability, 1516. Emphysema, pulmonary, 1477. Employee, civil. (See Personnel, civil.) Employees’ Compensation Act, scope, 1653. Employees’ Compensation Commission, 1653. Reserves: deceased, 2911, 2977. medical attendance, 8174, 8175. 3179. Empyema, 1472, 1477. Endocarditis, 1490. Endocrine disturbance, 1517. Endocrinopathy, 1404, 1516, 1517. Enlisted man: candidate for Naval Academy. (See Naval Academy.) (See Personnel.) (See Physical examinations.) (See Physical standards.) Enlistment: abstract, 3435. expiration while on sick list, 2404- extension, health record, 2206. Hospital Corps. (See Hospital Corps.) (See Physical examinations.) (See Physical standards.) Entropion, 1555. Duty: 13 K INDEX Enuresis, 1608. Epidemic disease. (See Communicable disease.) Epidemiological report, 2694. hospital, 2701. intelligence, 2711-2713. ship, 2699. station, 2700. Epididymitis, 1608. Epigastric pulsation, 1481. Epilepsy, 1404, 1516, 1617. Epiphora, 1439. Epispadias, 1608, 1516. EPTE: general instructions, 2410. meaning of, 2405. Equilibrium, 1564. Equipment. (See Property.) Error: diagnosis. (See Diagnosis, errone- ous.) health record entry, 2286. refraction. (See Physical standards, vision.) Escape appliance, submarine, disability incurred, report, 2415. Escort, funeral. (See Personnel, de- ceased.) Esophagus, 1464, I466. Esophoria, 1551, 1552. Estimates of expenditures. (See Prop- erty, accounting.) Eustachian tube, 1535, 1536. Evacuation, casualties, 1217. Evacuation medical officer, 1217. Examination form, 1612. Examiner, aviation medical, 1544. Examining board. (See Board.) Executive officer, naval hospital, 1621. Exophoria, 1551, 1652. Exophthalmic goiter, 1481. Exophthalmos, 1439, 1516. Exostosis, facial, 1453. Expeditionary force: designation, 1202. health records, 2212. medical personnel, 1222. Expenditures. (See Property, account- ing.) Expense, travel. (See Transportation.) Experimental medicine, procurement, 3057. Expiration of enlistment. (See Enlist- ment.) Ex-service man. (See Personnel.) Extension of enlistment. (See Enlist- ment.) Extremities, 1510, 1511. (See Physical standards.) Eye: diseases, nomenclature, appendix A, section II, class VI. (See Physical examination, eye.) (See Physical standards, vision.) refraction: glasses, 3056, 3163. medical treatment, 3163. Fabric, disinfection, 2851,, 2867. Face, 1453, 1616. Facilities, public, use of, 762. Falling test, 1561,. Families. (See Personnel, treatment, dependents.) Fauces. (See Mouth, nose, etc.) Feces, 11,95. Federal agencies, cooperation with, 707. Federal Standard Stock Catalog mate- rial, 3037. 3100, 8103, 3109. Fee, civilian, specialist, 1653, 3046. Feet: care of, 2677. defective, 1404, 1510, 1511. flat, 1403, 1610, 1611, 1620, 1665. physical examination, 1610, 1611. Fehling test, 1620. Female diseases, nomenclature, appen- dix A, section II, class XXIV. Field of vision, 1559. Field sanitation, 2661-2680. bathing, 2672. breaking camp, 2676. camp site, 2664. clothing, 2663. communicable disease, control, 2680. food, 2608, 2609, 2668. insect control, 2675. latrines, 2671. laundry, 2673. marching troops, 2677. in tropics, 2679. mess gear, 2669. picket lines, 2674. shoes, 2663. 14 INDEX F Field sanitation—Continued, typhoid prophylaxis, 2668. vaccination for smallpox, 2668. waste, disposal, 2670. water consumption, 2666. water discipline on march, 2678. water purification, 2667. water supply, 2665. Field service, 1221-1232. battalion surgeon, 1226. company hospital corpsman, 1227. echelons of medical assistance, 1232. force surgeon, 1224. intelligence reports, 2711-2713. litter squad, 1228. medical units, deployment and func- tion, 1231. organization, 1222. plans and orders, 1230. preparation, 1229, 2663. regimental surgeon, 1225. staff surgeon, 1223. task, 1221. Filariasis, 1445. Filipino; physical standards, 1442. Filling material, teeth, 2319. Films, X-ray. (See X-ray films.) Financial reports. (See Property, ac- counting, reports.) Fingerprint: apparatus for making, 1574. procurement, 8048. deceased person, 2917. record: disposition, 1670. method of recording, 1571. preparation, 1572. use, 1573. Fingers, 1510,1511. Fire drill, naval hospital, 1621. Fire and rescue party drill, 862, 872. Fire quarters drill, 862, 870. First-aid: battle-dressing station box, 876. instruction: afloat, 836. for gas casualties, 868. package, gas defense, 886, 868. Fish: inspection, 2608, 2609. for mosquito control, 2615. Fissure: of anus; 1499. scrotal, 1516* Fistula: abdominal, 1495. anal, 1496, 1499 cervical, 1464- facial, 1455. lachrymal, 1429. salivary, 1455. urinary, 1499, 1508. Fitting out, ship, 822. Fitzsimons General Hospital. (See Hospitals.) Flag, funeral, 2999. Flat-feet. (See Feet.) Fleas, destruction, £864, 2884. Fleet. bid of health, 2842. maintenance and operation expend- itures, 8024- Marine Force, 1202. medical officer, 801-811. Reserve. (See Personnel, Naval Re- serve.) staff medical officer: attack force, 1212, 2692. base force, 1210, £692. C-in-C, 6,801-811,1209,2602,2603, 2692, 3551. transport force, 1213, 2692. Flight: duty. (See Aviation.) personnel, specialty designation, £417. surgeon: duties, 1644- junior medical officer as, 1262. physical examination, aviation per- sonnel, 1265. qualifications, 1544- recommendations, 1264,1641- study of aviation conditions, 1263. Floating cartilage, 1511. Floating kidney, 1608. Focal infection, 1451,1484. civil personnel, 1658. Food: afloat, 825. in the field, 2668. at hospital, 1685. inspection, £608, 2608, 2609. for marching troops, 2677. First-aid: 15 F INDEX Food—Continued. at shore station, report, 2697. Food handler, inspection, 2663. Footcandle values, 2614. Force medical officer. (See Fleet, staff.) Force surgeon, 1214, 1224. Forces, amphibious operations, 1202. Foreign: goods, quarantine laws, 2806. hospital, transfer to; report, 2407. naval medical establishment, sanitary report, 2712. person, quarantine laws, 2806. port, sanitary report, 2713. station, sanitary report, 2713. Form, lettered: A, 2703, 3411. B, 3023, 8034, 3081, 3412. D, 3071, 3413. E, 3076, 3081, 3086, 3087, 3414. F, card, 2405, 2407, 2412, 2413, 2416, 2417, 3415. F, monthly, 2406, 2407, 3416. H, 3418. I, 3419. K, 3420. L, dental, 240, 3421. M, 3423. N, 2904, 3424. N-Nav 1, 639. N-Nav 525, 631. N MS-aviation-1, 1539, 1543, 1546. 1547, 1548. NMS-HC-3, 635. NMS-HC-4, 637. P, 3426. Q, 3427. R, 1672, 3070, 3428. S, 3429. T, 3430. U, 3150, 3431. V, 3432. W, 3069, 3100, 3433. Wa, 3099, 3434. X, 3435, 3436. Y, 1403, 1415, 1420, 1520, 1524, 1527, 3437. Z, 3438. Form, numbered: 4, requisition and invoice, 3442. hospital, 3451-3492. Formal contract, 3035. Formal survey, property, 3074. Formaldehyde: for embalming, 2937. gas, disinfection, 2858. solution, disinfection, 2857. Forms: insurance company, 7 41. for notification of death, 2921. reports and returns: hospital, 3451-3492. lettered, 3411-3438. numbered, 3442. Bu. Nav., 3501. Bu. S. & A., 3502-3506. Fracture, 1452, 1455, 1510, 1511. first-aid instruction in, 886. record and report, 2418, 2414-8418. Frame, Stevens’, 1551. Fuel. (See Property, accounting.) Fumigation of ship, 2871-2874. Fund, Naval Hospital. (See Property, accounting.) Fund, slush, 1612. Funeral. (See Personnel, deceased.) Funeral expense. (See Property, ac- counting.) Furniture and furnishing, staff quarters, 3054. Fur, disinfection, 2854. Gall bladder, 1495. Galley, naval hospital, 1685, 2608. Garbage disposal: afloat, 2612. field service, 2670. hospital, report, 2701. station, report, 2697, 2700. Gas. (See Property, accounting.) Gas defense drill, 862, 868. Gas mask, afloat. 868. Gastric neurosis, 2109. Gastro-enterostomy, 1495. Gastro-intestinal: d'sease, treatment, 2109. disturbance, 1536. system, 1535-1537. General expense, Marine Corps: charges to, 2969, 2976, 2977. General ledger, hospital, 8094, 3098. General physique. (See Physique, gen- eral.) General-quarters drill, 862, 864-866. 16 INDEX R Genitalia, 1508. Genito-urinary system, 1502-1508. diseases, nonvenereal: nomenclature, appendix A, section II, class VII. (See Physical examination.) (See Physical standards.) Glandular dysfunction, 1445. Glaucoma, 1489, 1560. Glycosuria, 1505. Goiter, 1464, 1481, 1516. Gonococcus infection, submarine per- sonnel, 1281. Gonorrhea, 1481, 1508. Gout, 2109. Government bill of lading. (See Prop- erty, accounting.) Government hospital. (See Hospitals.) Grading of nurse, Grounds. (See Property, land and buildings.) Guam, 1528, 1582. Guard, at naval hospital, 1621, 1625. Guest, subsistence, 1686, 8109. Gun pointer, visual standards, 1480. Hair, diseases: nomenclature, appendix A, section II, class XIX. Hallucination, 1516. Hallus valgus, 1610, 1511. Hammer toe, 1511. Hand. (See Extremities.) Harbor water, sanitary regulations, 2608. Harelip, 1455, 1516. Hat, disinfection, 2854• Hay fever, 1455, 1665. Hazards: nomenclature, appendix A, section IV. occupational, disabilities due to, 1280. Head: physical examination, 1451-1452. injury, 1516. (See Physical standards.) Headquarters, medical, regimental, 1282. Head of department: definition, 8076. at naval hospital, 1664. Headstone. (See Property, procure- ment.) Health: bill of. (See Bill of health.) or crew, regulations, 2608 instruction, 704. of port, 832. unofficial certificate of, 740. Health record, 733, chapter 14. advance in rate, 2253. approval of entry, 1612. Army personnel in naval hospital, 2207. custody, 2208. dental record, 2311-2319. descriptive sheet, 2261-2263. deserter, 2206. disposition, 2211. record of, 2214. enlisted man, 8206. examination upon receipt, 2209. expeditionary force, 2212. insane person, 2216. inspection, 2215. lost health record, 2210. medical abstract, 2301. medical history sheet, 2217, 2281- 2290. midshipman, 2204. misconduct case, 2501-2511. name, 2251. Naval Reserve, 2206. nurse, 393, 2205. officer, 2202. patient received for transportation, 2218. preparation, 1576. rank or rate, 2252. record of receipt and disposition, 2214. refraction, 2881. regulations, 2201. Reserve officer, 2203. special duty abstract, 2331. straggler, 2206. supernumerary, 2207. syphilitic abstract, 2350. transfer to American Consul, 2407. transfer of patient to: hospital other than naval, 2218. (See Hospitals, other than naval.) naval hospital, 2218. transfer of personnel, 2211. 17 H INDEX Hearing. {See Physical standards, hear- ing-) Heart and blood vessels: diseases of, 1404> 1400, 1565. {See Physical examination.) {See Physical standards.) Heart rate, 1490. Heating service. {See Property, ac- counting.) Height: physical examination, 144&-1448- {See Physical standards.) table of standards, 144 Helmet, diving, disability incurred, report, 2415. Hemiparesis, 1517. Hemiplegia, 1517. Hemophilia, 1445. Hemorrhage, first-aid instruction, 836. Hemorrhoidal tags, 1520. Hemorrhoids, 1495, 1499, 1511. Hermaphroditism, 1508. Hernia, 1495. of brain, 1452. civil personnel, 1653. nomenclature, appendix A, section II, class XX. Hodgkin’s disease, 1454- Honorable discharge, nurse, 451-454- Honors, military, 1612. Hook-worm disease. {See Uncinariasis.) Hospital assistance, additional, 1232. Hospital beds, standards, 2622. Hospital Corps, 601-639. advancement in rate, 607. courses of instruction, 609. discharge, 615. disposition report, 635. drill brook, 13. duty after instruction, 611. enlistment, reenlistment, and exten- sion of, 601. Handbook of, 607. promotion to warrant rank, 621. qualification report, 633, 3509. regulations, 601 reports and returns, 631-639. retirement, 617. roster report, 637, 3511. school, accounts, 3103. service record, 639. Hospital Corps—Continued, transfer and disposition card, 635,3510. transfer: from other rating, 603. to Naval Reserve, 619. to training school, 605. Hospital corpsman: assignment, 6. continuous-service certificate, 639. as dental technician, 236. field service, 1227. first-aid instruction, 836. instruction of, 704. at naval hospital, 1673. instruction, 1612, 1671. as ward nurse, 1672. examination, 601, 607. report, 631. of ship: annual sanitary report, 2699. at shore station: annual sanitary report, 2700. training, 613. Hospital fund, naval. (See Property, accounting.) Hospital ration notice, 3502. Hospital ship, 1001-1011. medical officer, 1011. regulations, 1001. reports, 3553. transfer of wounded to, 887. {See also Hospitals, naval.) Hospital station, advanced, 1232. Hospital ticket (Form G), 3417. Hospital treatment. {See Personnel, treatment.) Hospitals, naval: Accounting officer, 1633. Accounting records. ($ee Property, accounting.) Administration, 1611-1625. Administrative officers, 1631. Alcohol, custody of, 1621, 1640, 1672. Allotment expenditures, report, 3412. Average complement: abstract of patients, 2406. annual sanitary report, 2701. statement of receipts and expendi- tures, 3414- 18 INDEX H Bed capacity, weekly report, 3419. Buildings. (See Land and buildings.) Clinical facilities, 1661-1680. Command, 1604. Commanding officer: duty, 1612. general instructions, 1611. limitation of authority, 1613. Communicable disease, weekly report 3419. Death. (See Personnel, deceased.) Dental treatment, 274. Direct admission to, 2405. Disbursing officer, 1638. Discharge from, 1613. Discipline, 1621. Divine service, 1621. Electric service. (See Property, ac- counting.) Emergency case, retention, 752. Equipment: accounting records, 8100. annual sanitary report, 2701. inventory, 3115. Establishment, 1601. Estimates of expenditures, 3012-3016. Executive officer, 1621. Expense analysis register, 3103. Fire drill, 1621. Fuel, 3097, 3104. (See Property, accounting.) Funeral arrangements, 1621. Grounds. (See Land and buildings.) Guard, 1621. Inspection, 1612, 1621, 1671, 1672. Internal administration, 5. Internship in, 112, 113. Keys, 241, 1621, 1672. Land and buildings: annual sanitary report, 2701. expense analysis register, 8103. inspection, 1612. inventory, 3114, 3413. land and buildings ledger, 3099. maintenance officer, 1632. Laundry: equipment, inventory, 3413. expense analysis register, 8103. list (Form 21), 3462. nurses uniforms, 414. sanitary report, 2701. Laundry—Continued. services for other activities, 8109. Liberty and leave, 1621. Maintenance officer, 1632. Maintenance and operation: accounting records, 3108. responsibility for 6, 11. Maintenance of contact with Bureau, 5. Marine guard, 1625. Medical material, reports and returns, 3414, 3442. Misconduct case, 2503. Mission, 1603. Morale, 1621. Narcotics, custody of, 1621, 164-0, 1672. Officer of the day, 1624. Organization, 1605. of all services, 1621. Patients, weekly report, 3419. Personnel: assignment, 1612, 1621. inspection, 1612, 1621. records, 1687. responsibility for, 6. safeguards, 1612. supervision, 1621. (See also Average complement.) Poison, custody of, 1621, 1640, 1672. Prisoner, 1621. Property, inventory, 3413. Provisions: accounting records, 8102. quarterly adjustment, 3097. quarterly expenditures, 3104- Receipts and expenditures, statement, 3414. Regulations, 1606. Reports and returns: allotment expenditures, 3412. Civilian Conservation Corps patients 8419, 3507. communicable disease, 3518. daily ration memorandum, 3471. diagnostic examinations, 3426. hospital ration notice, 3502. medical material: receipts and expenditures, 3414. requisition and invoice, 3442. patients, 3419. property inventory, 3413. 19 H INDEX Reports and returns—Continued, prosthetic dental treatment, 274- quarterly ration return, 3470. sanitary report, annual, 2701. supernumerary patients, 3508. surgical operations, 3426. syphilis cases and arsenical treat- ments, 3411. tabulated list, 3555. Veterans’ Administration patients, 3419, 3520. Sanitary standards, 2622. Service to: civil personnel, 3106. other government agency, 3111. other Medical Department activity, 3110. ships service, 3108. Special depositor, accounting record, 3107. Staff personnel, training, 1612. Subsistence, checkage, 3109. Sundry items, accounting records, 3033. Supernumerary patients, report: monthly, letter for C. C. C., 3507. quarterly, letter, 3508. weekly, Form I, 3419. Supervision, 1602. of patients, 1621. Supplies, ledger, 3101. Traffic regulations, 1621. Transfer of patient to: from ship, 829. Utilities for officers quarters, accounting records, 3105. Valuables, 1621, 1672. Veterans’ Administration patients, re- port, 3419, 3520. Visitors, 1621. Watches, 1625. Work request, 3041. additional temporary labor, 3013. Hospitals other than naval: foreign: transfer of patient to, 713, 2407. transfer of record, 2407. Governmental: Army, 2171. Army and Navy General: administration, 2103. Hospitals other than naval—Con. Governmental—Continued. Army and Navy General—Con- tinued, admission: authority, 2105. papers required, 2108. establishment, 2101. function, 2103. organization, 2102. treatment: charges, 2111. duration, 2110. eligibility for, 2104. ex-service men, 2107. retired personnel, 2106. types of case, 2109. Fitzsimons General Hospital, 2121, 2122. Naval Home, 2142, 2143. Public Health Service hospitals, 2172. St. Elizabeths Hospital: admission, 2155. records for, 2156. death of naval patient, 2159, 2909. discharge of patient, 2160. disposition of patient, 2158. receipt for person and effects, 2157. treatment, eligibility for, 2155. Veterans’ Administration facilities, 2173. for insane, 2155-2159. for pulmonary tuberculosis, 2121, 2122. Hospitals, rear. (See Rear hospitals.) Hot-water tank for barracks: sanitary standards, 2621. Hydatid cyst, 1477. Hydrocele, 1508. Hydrocyanic acid gas, 2863. Hydronephrosis, 1508. Hydrothorax, 1477. Hygiene, oral, instruction in, 238, 272. Hygienic considerations, annual sani- tary report: hospital, 2701. ship, 2699. shore station, 2700. 20 INDEX I Hygienic investigation, allotment for, 3024.. Hyperidrosis, 1510, 1511. Hyperopia, 1520. Hyperphoria, 1551. Hypertension, 1490, 1503. Hyperthyroidism, 1481. Hypospadias, 1508, 1516. Hypotonia, 1516. Hysteria, 1516, 1517. Ichthyosis, 1450. Identification record, 1570-1578. disposition, 1570. entries, 1576. fingerprint, 1570-1574- preparation, 1572, 1576. records required, 1570-1572. Identification tag, 882, 1229, 1577, 1578. on deceased person, 2917. Idiocy, 1517. Illness. (See Personnel, treatment.) Illumination, 2614. Imbecility, 1517. Immunity reaction, 2605. Immunizing agent, 705, 2604. Impetigo, 1450. Impulse, 1481. Inactive duty patient, ration report, 8472. Inactive personnel in Asiatic, ration notice, 3502. Inactive status, reserve nurse, 351. Inadequate personality, 1516. Incinerator, field service, 2670. Increase of allotment request, 8022. Incubation period, quarantinable dis- ease, 2820. Indecency, 1516. Independent duty, naval attendance not available: death, 2905. sickness report, 2407. Individual statistical report (Form F card), 2405, 2407, 3415. for aviation personnel, 2417. injury, 2412, 2416. circumstance of occurrence, 2416. key letter, 2414. poisoning, 2413, 2416. circumstance of occurrence, 2416. specialty letter, 2415. Indorsement for discharge, nurse, 454. Industrial hazards; nomenclature, ap- pendix A, section IV. Industrial safety device, 1621. Infectious disease: afloat, 28S0. nomenclature, appendix A, section II, class XIII. Influenza, 1481. Information: for next of kin of: deceased personnel. (See Person- nel, deceased.) patient, seriously ill, 1612. in service record to: person outside Navy Department, 12. service personnel, 1520, 2508. Ingrowing toenail, 1510, 1511. Injured civil personnel, 1128, 1653. Inoculation, typhoid, 2606. prior to field service, 2663. Insane patients. (See Personnel, treat- ment, insane.) Insanity, history of 1517. Insect control: cockroaches, 2886. in the field, 2675. lice, 2885. mosquito, 2615, 2675, 2864, 2882. Insecticide spray, 2808, 2881. Inspection. (See appropriate item.) Instruction: command, naval hospital, 1611. diving and submarine personnel, 1278. in first aid, duty afloat, 836, 868. to examiners, 1411-1416. in health, entire personnel, 704. of hospital corpsmen, 609, 613. at Naval Medical Center, 3313. assignment to, 3315. duty statue, 3317. professional. (See Professional in- struction.) Instrumental examinations, report, 3426. Instruments and supplies, Bu. Nav., 2976. Insurance company form, 741- Intelligence report, 2711-2713. Intention tremor, 1516. Intercurrent disability, 2404- change of diagnosis, 2402. 21 I INDEX Interne, 1612, 1666. Internship, 112, 113. Intestinal stasis, treatment, 2109. Intestines, 1495. Intoxicated person: enlistment, 1404- physical examination, 742. Invalided from service, 2303, 2404- Inventory. (See Property, inventory.) Invoice. (See Property, transfer.) Iris, synechiae of, 1439. Iritis, 1439. IS, meaning of, 2403. Ischiorectal abscess, 1499. Isolated duty. (See Personnel, treat- ment.) Issue room, inspection, 2608. Issue voucher, 3067, 3070, 3428. Issue of: medical stores, 3148. medicine to person not in Navy, 752. Izal, 2856. Jaundice, 144-9, 1495. Jaw, lower, 1516. Jeffries chart, 1559. Job order, 3023, 3096. Joint, disease of, 1510, 1511. Journal: of the officer-of-the-day, 1624. of receipts and expenditures: for hospital, 3094> 3095. for ship and shore station, 3086. Junior medical officer, 761, 762, 1666. Kahn test, 1488, 1506, 1507. serological, syphilis, 2287. Keratitis, 1439. Key letters, 2414. Keys: for dental supplies, 241. hospital ward, 1672. hospital, 1621. Kidneys: physical examination, 1508. Killed or wounded, afloat: removal, 886. report, 807, 888. Kin, next of. (See Information.) Knee jerk. (See Patellar reflex.) Knock-knee, 1511. Kyphosis, 1468. Labor, 3023, 3040. Laboratory: account, 3103. examination form, 1612. examination report (Form 27), 3466. method for physical examination, 1413, naval hospital, 1680. Naval Medical Center, services and supplies available, 3331, 3333. sanitary report, 2701. Lachrymal fistula, 1439. Lagophthalmus, 1439. Lameness, 1511. Land and buildings. (See Property, land and buildings.) Landing force: debarkation, 1216. organization of, 1202. personnel, 1216. purpose, 1203. Landing force drill, 862, 874- Larvae (mosquito) destruction, 2615. Laryngitis, 1455. Larynx. (See Mouth, nose, etc.) Latrines, 2671. Launching of airplanes, drill, 862, 869. Laundry: hospital. (See Hospitals, naval.) field service, 2673. Lavatories, sanitary standards for: barracks, 2621. hospital, 2622. ship, 2623. Laws, statutes, etc.: Bu. M. & S. act of July 16, 1862, 3. Employees’ Compensation Act, 1653. fleet surgeon, 801. Medical Corps, act of: 1916, 101. 1925, 171. 1926, 101. 1935, 101, 134. narcotics, act of: 1914, 736. naval hospitals, 1601, 1602. Naval Reserve, act of: 1938, 171. Navy Department, act of: 1798,1 1842, 1. 22 INDEX I Laws, statutes, etc.—Continued. Nurse Corps, act of: 1908, SOI, 302. 1919, SOS. 1920, 305. June 1922, 306. July 1922, 307. 1926, 309. 1930, 309. Lead poisoning, precautions, 2617. Leather, disinfection, 2854- Lea, ve. (See Personnel, leave.) Ledger: equipment, 3100. general, 3098. land and buildings, 3094, 3099. provisions, 3102. recapitulation account, 3116. supplies, 3101. Length of service, report, on Form F card, 2405. Lens, opacity of, 14%9. Leprosy, 1445, 2820, 2826. Letterheads (Form 33), 3468. Lettered forms, 3411-3438. Leukemia, 1445, 1464- Leukoplakia, 1455. Liberty: list, 1621. Form 20, 3461. treatment during, 3166. Librarian, civilian, 1647. Library, naval hospital, 1647. Library service of Naval Medical Center, 3341. Lice, 2864, 2885. Life-insurance report, deceased person, 2910. Lifeboat, fumigation of, 2872. Lighting: of battle-dressing station, 879. of ship quarters, 2614- Limb, artificial, procurement, 3056. Lime, disinfection, 2859. Line of duty: disability of nurse, 309. wound of officer, 14%0. Linen: dental operating room, 237. nurses’ mess, 418- room, 1671. Line of drift, 1226. Liquor, intoxicating, custody, 738. Litter squad, 1228. Liver, 1495. Living quarters. (See Quarters.) Local purchase, 3045, 3057. Locomotor ataxia, 1517, 2109. Log, rough. (See Rough log.) Lordosis, 1458. Loss of extremity, 1511. Lost property, survey of, 3074- Lot number, biological, 3073. Lumbosacral joint. (See Pelvis.) Lungs: diseases, 1475-1477. physical examination, 1475-1477. preliminary, for Naval Academy, 1403. standards. (See Physical standards.) Lupus, 1450. Lying, pathological, 1516. Lymphatic system, diseases of: nomenclature, appendix A, section II, class XIV. Lysol, 2856. Lyster bag, 2860. Machine, computing, 3075. Maddox-rod screen test, 1551, 1552. Maintenance and operation. (See Property, maintenance, etc.) Maintenance officer, 1632. Malaria, 1445, 1494, 1565, 2404- Malignancy, 1445. Malignant disease, hospitals for, 2176- 2178. Malingering, 2402. Malnutrition, 1445. Malocclusion, 1462. Man overboard drill, 862. Mandible, 1453. Manic-depressive insanity, 1516. Manual of the Medical Department, 13. Marching troops, 2677, 2678. Marine Corps. (See Personnel.) Marine force, fleet, 1202. Marine guard, naval hospital, 1625. Marine hospitals, 2172. Marks and scars in health record, 2262. Mask, gas, 868. Master-at-arms, naval hospital, 1625. Mastoid process, 1516. Mastoiditis, 1435. 23 X INDEX Mate-of-the-day watch, 1625. Material, inspection, 804, 1612, 1621. Material and service. (See Property, material and service.) Mattress, disinfection of, 2887. Maxilla, 1458. Maximum impulse, 1481. Maximum quantity: medical stores, 8148. medical supplies, 8069. Meals, supervision, 1685. Measles, 1481, 2616. Meat, 2608, 2609. Mediastinum, tumor of, 1477. Medical: Abstract in health record, 2801. Assistance, echelons of, 1232. Attendance. (See Personnel, treat- ment.) Books, procurement, 8051. Center, Naval. (See Naval Medical Center.) Company, 1222. Corps, 101-171. appointment to, 111-121. establishment and organization, 101- 104. promotion, 131-139. reserve. (See Naval Reserve (Medi- cal Corps).) retirement, 151. (See also Medical officers.) Department: administration, 1-13. correspondence, 732. duties: afloat, 801-888. amphibious operations, 1201-1217. ashore, 1101-1129. hospital, 1601-1680. hospital ship, 1001-1011. physical examination, 1401-1597. preventive medicine, 2601-2888. organization, 101-175. personnel. (See Personnel.) property, 3001-3155. records and reports, 3401-3555. (See also appropriate item.) Division: aviation service, 1261. diving and submarine service, 1276. Equipment. (See Property, equip- ment.) Establishment, foreign, naval, report, 2712. Examination, civil employee, 165S. Examining board. (See Board.) Headquarters, regimental, 1282. History, 2281-2290: annual, for nurse and officer, 2217. disability, officer, 1520. disqualifying for aviation duty, 1665. erroneous entry, 2286. example of entry, 2284. general instructions, 2282. minor affections, 2283. misconduct, 2289. other entries, 2285. patient in custody of civil authority, 2290. regulations, 2281. sickness on leave, 2288. syphilis, 2287. transcript for individual, 741. venereal disease, 2287. Meeting: afloat, 810. ashore, 1612. Officer: aid to civilian, 751-753. American Red Cross duty, 101. appointment, 111-121. eligibility to Fleet Naval Reserve, 171. article on professional subject, 739. assignment: to Naval Medical Center, 3315. responsibility for, 6, 10. attack force, 1212. authority of, 102. base force, 1210. beach party, 1217. care of sick, 711-713. commanding: naval hospital, 1604, 1612, 1613. Naval Medical Center, 8801. communication with commanding of- ficer, 104. correspondence, 732. distribution in grades, 101. district, 1001, 1002, 2906. diving service, 1277. 24 INDEX M Officer—Continued, duties: afloat, 801-888. ashore, 1101-1129, 2697. general, 701-762. miscellaneous, 729-742. duty relative to: alcoholic liquor, 788. aviation service, 1261-1266. bill of health, 2835-2845. care of sick, 711-713. communicable disease control, 701- 707, 2616. consultation with dental officer, 281. consultation with medical officer, 712. cooperation with other agency, 707. dental appointment, 734. emergencies, afloat, 861-888. evacuation casualties, 807, 886, 1217. field service, 1221-1232, 2663. food inspection, 2608, 2609. garbage disposal, 2612. inoculation, typhoid, 2606. insect control, 2615, 2888. instruction of personnel, 704. lighting, 2614. narcotics and poisons, 736, 738. official document, 782. operations on applicant, 753. physical examination, 1401-1597. all personnel, 735. of civil employee, 1127. for drunkenness, 742. before transfer, 703. physical fitness of personnel, 702. professional aid to civilian, 751-753. records and reports, 729-733, 740, 1428, 1520. refuse disposal, 2612. report of injury, 731, 1658. sewage disposal, 2613. staff, afloat, 802-811. staff meeting attendance, 274. submarine and diving service, 1276- 1283. transcript of medical record, 741. transfer of patient, 718, 829. treatment of civil employee, 1128. Officer—Continued, duty relative to—continued, vaccination, 705, 2605. ventilation, 2611. water, sanitation, 2610. fleet, 801, 1209. of hospital ship, 1011. instruction, 3319. interne duty, 118. junior, 761, 762, 1666. at navy yard, 1121. designation, 1121. not recommended for advancement, 134. precedence of, 102. promotion, 131-139. reserve, 171. retirement, 151. right to see commanding officer, 104. title of, 103. transport, 1213. transport force, 1211. (See also Medical Corps.) Organization, field service, 1222. Outfit, procurement, 3058. Personnel. (See Personnel.) Records: completeness, 2504. for court case, 741. field service, 1229. information from, when furnished, 12. midshipman, 2508. transcript of, 741. Responsibility, 1207. School, naval. (See Naval Medical Center.) Schools. (See Schools.) Service to civilian, report, 3474- Specialist unit, 171. Station at beach, 1217. Storeroom, afloat, 824. Stores. (See Property, stores.) Supplies. (See Property, supplies.) Supply depot: account, 8098. accounting procedure, 3142-3155. allotment estimates, 8022. biological ledger, 3073. expenditures: estimates of, 3012-3016. statement, 8150. function, 3142. 25 X INDEX Supply depot—Continued, inventory, 3147. land and buildings, ledger, 3099. procurement method. (See Property, procurement.) quarterly return of stores, 3432. receipts, statement, 3150. requisition and invoice, 3030, 3042, 3442. stores. (See Property, stores.) transfer of stores, 3152-3155. work request, 3041. Survey, 828, 3423. board. (See Board.) Watches aboard ship, 821. Medicine: issue to nonnaval person, 752. local purchase, 3045, 3057. public voucher, 3046. transfer from other Government agency, 3047. Melanism, 1516. Memorandum voucher, 3097. Mental case: transfer of, 2151. (See also Personnel, treatment.) Mental deficiency, 1514, 1516, 1517. Mercury bichloride, 738. Meritorious service, record, 1231. Mess attendant, physical examination, 1534. Mess gear: Nurse Corps, 418. sterilization, 2608, 2669. Messes, naval hospital: nurses, 1671. special, 1636. supervision, 1635. Messmen: rates, 2252. supervision, 2608. Metal scrap, disposition, 3078. Metallic poisoning, 2109. Mice, 2864- Microscope, 1413. Midshipman. (See Personnel.) Military hazards: nomenclature, appendix A, section IV. Military honors, 1612. Military phases, typical operation, 1204. Milk, 2608. Mind, diseases of: nomenclature, appendix A, section II, class XV. Minimum quantity: medical stores, 3146. medical supplies, 3069. Ministration, divine, 1621. Miscellaneous diseases: nomenclature, appendix A, section II, class XXI. Miscellaneous hazards: nomenclature, appendix A, section IV. Miscellaneous operating charges, 3024- Misconduct, 2501-2512. checkage of pay, 2509. clinical findings, 2503. decisions, 2512. determination, 2503. diagnosis, 2509. disability: degree and nature of, 2505. increased by service, 2503. incurred in confinement, 2510. incurred on leave, 2510. documentary evidence, 2503. entry: completeness, 2504. health record, 2289. importance, 2502, 2503. entry for disability, 2501-2503. in hospital at expiration of enlistment, 2507. midshipman, 2508. Navy regulations, 2501. refusal of treatment, 2505. report (Form 35-L), 3503. return to duty status, 2506. suicide, 2511. venereal disease, 2509. Missing property. (See Property, survey,) Mitral diastolic murmur, 1484- Mitral stenosis, 1481, 1489. Mole, 1453. Monoplegia, 1517. Monthly report. (See Reports.) Monthly return of nurses, 472, 473, 3476. Morale at naval hospital: activities, 1645. maintenance of, 1621. nurses, 1671. regulation, 1651. 26 INDEX N Morning report of sick, 826, 3430. Moronism, 1514, 1516, 1517. Mortician’s service, requisition, 3033. Mortuary reports, 2910. Mosquitoes, 2615, 2675, 2864, 2882. Motor system, diseases: nomenclature, appendix A, section II, class XVI. Motor vehicle, 3024, 3055, 3075. Mouth, nose, etc.: physical examination of, 1454, 1455, 1535, 1563. {See Physical standards.) Multiple: disabilities, statistical report of, 2402. neuritis, 1516. sclerosis, 1516, 1517. Murmur, heart. {See Heart, murmur.) Muscle balance, eye, 1551-1555, 1557. Muscular: atrophy, 1516, 1517. dystrophy, 1516, 1517. tremor, 1517. Musician (wind instrument), dental standards, 1458. Muster, 1621. Mycosis, 1450. Myocarditis, 1490. Myopia, 1403, 1431, 1432, 1520. Myopic astigmatism, 1403, 1431, 1432 Myxedema, 1464, 1516. NAA: Meaning of, 3470. Naevi, 1450, 1516. Nails, diseases: nomenclature, appendix A, section II, class XIX. Name of person, in health record, 2251. Narcotic drugs: antidotes, 241. custody, 738. at hospital, 1621, 1640, 1672. in Dental Corps, 241- prescription, 736. Nares. {See Mouth, nose, etc.) Nasal septum, 1455, 1520. Nasopharynx. {See Mouth, nose, etc ) Nature of: injury, 2412. violence, 2412, appendix A, section IV. Nature and cause of violence: nomenclature, 2419, appendix A, section IV. Naval: Academy: permanent medical examining board, 1403. physical examination for. (See Phys- ical examinations.) Aviation personnel. (See Aviation.) Dental School, 3301. Dispensary. (See Dispensary.) Dispensary, Washington, 5. District personnel, statistical report, U07. Hazards: nomenclature, appendix A, section IV. Home, admission, 2142, 2143. Hospital: Brooklyn, 2176. fund, 3003-3005. allotment, 3022. estimates of expenditures, annual, 3004, 3014- tentative, 3016. San Diego, 2177. Washington, 3301. Hospital. (See Hospitals, naval.) Landing force, 1202. Medical Bulletin, 13. Medical Center: Chapter 22. administrative control, 5. clinical service, 3323. command, 3301. communications, 3303. consultation service, 3305. establishment, 3301. faculty, 3311. function, 3301. instruction, 3313, 113. assignment to, 3315. as duty status, 3317. laboratory service, 3331. laboratory supplies, 3333. library service, 3341. research work, 3321. special courses, 3319. staff, 3311. {See Property for accounting and procurement methods.) Medical establishment, foreign, report, 2712. 27 N INDEX Medical School, 8801. Medical Supply Depot, 3142-3155. Brooklyn, N. Y., 8148-8155. Canacao, P. I., 8146-8148. Mare Island, Calif., 8146-8148. (See also Medical supply depots.) Patient. (See Personnel.) Prison, 2620. Reserve, 171. (See alto appropriate item.) Retiring Board, 1480, 1481. Supply account material, 8088, 8414- Vessel: equipage, 8024- quarantine. (See Quarantine regu- lations.) Navigation, Bureau of. (See Bu. Nav.) Navy as a whole account, 8098, 8108. Navy Department personnel, statistical report, £407. Neck, 1463, 1464. Necrosis, facial, 1458. Negative diagnosis, injured civil per- sonnel, 1658. Nephritis, 1508, 1508, £109. Nerve, peripheral, 1517. Nervous system: 1514-1519. diseases, nomenclature, appendix A, section II, class XVII. Neuralgia, 1458,1511,1617, £109. Neurasthenia, 1516,1517. Neuritis, 1517, £109. optic, 1489. Neuropsychiatric ailment, 8178. Neuroretinitis, 1489. Neurosyphilis, 1£81. New unit price, 3072. Next of kin. (See Information.) Night: blindness, 1489. duty, 167£. supervisor, nurse, 167 £. No disease, 2408. Nomadism, 1516. Nomenclature: Class numbers, £401. Communicable disease, appendix A, section II, class VIII, IX, X. Dental disease, appendix A, section II, class XXVII. Diagnosis number, 2401. Diagnostic title, 2402. Diseases, classified in appendix A, sec- tion II: blood, class I. circulatory system, class II. digestive system, class III. ductless glands, class IV. ear, class V. eye, class VI. female, class XXIV. genito-urinary system (nonvenereal;, class VII. hair, class XIX. hernia, class XX. infective type, class XIII. lymphatic system, class XIV. mind, class XV. miscellaneous, class XXI. motor system, class XVI. nails, class XIX. nervous system, class XVII. nose, class V. parasitic, class XXII. respiratory system, class XVIII. skin, class XIX. spleen, class IV. throat, class V. tuberculosis, class XI. tumors, class XXIII. venereal, class XXII. General plan, 2401. Injuries, appendix A, section II, class XXV. Instructions for use, 2401-2420. Key letters, 2414. Listing of titles, £401. Poisonings, appendix A, section II. class XXVI. Print style, £401. Specialty letters, 2415. Surgical operations, 2418, appendix A, section III. Violence, nature and cause, 2419, ap- pendix A, section IV. Wording of title, £401. Nonhospital expense, 810S, 8109. Nonrecurring item, 8015. Nose, diseases: nomenclature, appendix A, section II, class V. (See Mouth, nose, etc.) 28 INDEX 0 Notes, clinical. (See Clinical notes.) Notice of change in diagnosis (Form 53) 3479. Numbered forms, 3442. Nurse Corps, 301-477. administration, 6. assistant superintendent, 321, 322. chief nurse, 331-337. eligible list, 344. establishment, 301. information slip (Form 45), 3477. legislation, 301-309. monthly return, 472, 473. official communications, 471. reports and returns, 471-477. superintendent, 311. (See also Personnel.) Nurse. (See Personnel.) Nurse, chief. (See Chief nurse.) Nursing service: for civilian and dependent, 362. at naval hospital, 1670. Nystagmus, 1429, 1516, 1554, 1564- Obesity, 1445, 1585, 2109. Obligations, accounting, 8005, 3023. Observer, aviation. (See Aviation.) Occlusive dressing, 836. Occupational hazard, disability due to 12S0. Occupational therapy, 1649. Ocular palsy, 1516. Oesophagus. (See Esophagus.) Office: equipment, 3413. sanitary report, 2701. Officer, naval hospital: accounting, 1633. administrative, 1631. commissary, 1635. commanding, 1604, 1612, 1613. of-the-dav, 1624. disbursing, 1638. educational, 1652. junior medical, 1666. maintenance, 1632. personnel-record, 1637. property, 1634. ward, medical, 1665. watch, 1666. Officer of the deck, report to, 731. Officers: dental. (See Dental officers.) dental reserve, 281. division, 811, 886. medical. (See Medical officers.) medical reserve, 171. ((See Personnel.) Official communications. (See Commu- nications.) Official documents, 239, 732. Opacity, 1429. Operating expense account, 8098. Operation, military, 1201-1232. amphibious, 1201-1217. combined, 1202. field service, 1221-1232. landing, 1216. medical phases, 1205. military phases, 1204. order, 1280. Operation, surgical: expense account, 3103, 8414- nomenclature, appendix A, section III. (See Personnel, treatment.) prohibited, 753. record, 1612, 1680. room, 1680. scheduled (Form 64), 3488. Ophthalmoscopic examination, 1561. Optic nerve, atrophy of, 1429. Optic neuritis, 1429. Oral hygiene, 238, 272. Orchitis, 1508. Order: and inspection blank (Form 23), 3464. operation, 1230. point, 8069, 8146. transfer accounts (Form 4), 3453. transfer of men, 3454. transportation (Form 7), 3455. Organization, naval hospital: chart, 1605. scheme, 1612. Organization and standing order book, 730. Orthopedic appliance, 1653, 3056. Osseous cyst, 1458. Osteoarthritis of spine, 1468. Osteomyelitis, 1445. Other diseases of this class—XY, 2402. Other naval supplies acount, 8098. 29 0 INDEX Other nonhospital expense, 3103, 3109. Otitis externa, 1536. Otitis media, 1485, 1536. Out-patient service, dependents, 3103. Overseas shipment, deceased, 2939. Ozena, 1455. Pain, scar, 1495. Palate, 1455, 1516. Palsy, ocular, 1516. Panama whale, 2615. Pancreas, 1495. Pannus, 1555. Parade, medical unit, 1231. Paralysis: facial, 1453. hysterical, 1517. of soft palate, 1455. of vocal cords, 1455. Paranoid personality, 1516. Paraplegia, 1516, 1517. Parasitic diseases: nomenclature, appendix A, section II, class XXII. Paresis, 1516, 1517. Paris green, 2615. Part compensation, civil personnel, 3106. Pass book (Form 32), 3467. Passenger. {See Personnel.) Patellar reflex, 1565. Pathological lying, 1516. Patient. (See Personnel, patients.) Pay: (See Personnel.) (See Property, accounting.) Peacetime casualty, 836. Pectoris, angina, 1490. Pecuniary transactions, 1612. Pediculosis, 1449, 1450, 2885. Pellagra, 1445. Pelvis, 1498, 1499. Pemphigus, 1450. Pensioner. (See Personnel.) Perforated nasal septum, 1455. Perforated palate, 1455. Pericarditis, 1490. Pericemental areas of infection, teeth, 1462. Perimeter, self-recording, test, 1559. Periodicals: at naval hospital, 1612. Periodicals—Continued, at Naval Medical Center, 3341. requisition, 3048. Periostitis, suppurative, 1472. Peripheral circulation, 1565. Peripheral injury, 1516. Peripheral nerve, 1517. Peritoneal adhesions, 1495. Peritonitis, 1495. Permanent medical examining board, Naval Academy, 1403. Permanent watches, naval hospital, 1625. Personal effects. (See Property, per- sonal effects.) Personal equipment, field service, 1229. Personal services, allotment, 3024. Personality, paranoid, 1516. Personnel: Accounts of nurse, 412, 464. Admission to Naval Home, 2142. Admission to hospital, officer, report, 3461. Advance in rate, enlisted, 2253. Annual physical examination, nurse, 477. Applicant for service, record of physical defects, 1414, 1415. Appointment: Dental Corps, 201-208. Medical Corps, 111-121. Naval Reserve, dental, 281. Naval Reserve, medical, 171. nurse, 341-344. pharmacist, 621. Average complement, computation of, 2406. Beneficiary slip, nurse, 476. Care of dependents by nurse, 362. Checkage for hospital fund, 416, 3003. Conference, 1612, 1671. Confined patient, 1612, 1621, 1672. Deceased: autopsy, 2918. burial: at Arlington Cemetery, 2960. expense, 3024- prior to ascertaining wishes of next of kin, 2988. record (Form 38), 3473. 30 INDEX p Deceased—Continued, burial—continued. unclaimed body, 2992. casket, 2941. clothing, 2940. cremation, 2987. disposition: annual sanitary report, 2701. at naval hospital, 2979. report, 2902. embalming, 2932-2938. express: charge, 2957. shipment, 2964, 2955. fingerprint, 2917. funeral: arrangement for, 1621. ceremony, 2998. escort, 2965-2973. expense, 2975-2992. headstone, naval cemetery, 8069, 3514. identification by fingerprint, 1678. identification tag, 2917. information for: department, 2901. next of kin, 2921-2924, 2959. inspection, 2931. life insurance data, 2910. Naval Reserve, 2907, 8180. overseas shipment, 2939. personal effects, 2958. transportation: to Arlington Cemetery, 2960. escort, 2953. method, 2952. outside United States, 2989. to Philippine Islands, 2961. responsibility for, 6. rules, 2951. shipping label, 2956. transfer at junction points, 2954. Defect, physical, recording of: enlisted, 14W- officer, 1415, 1620. Disability, discharge for, nurse, 394. Discharge: of nurse, 451-454. from hospital, officer, report, 8461. from service, medical survey, enlisted, 3423. Disposition: hospital corpsman, 635, 3510. patient. naval hospital, 1677. Fitzsimons General Hospital, 2121, 2122. St. Elizabeths Hospital, 2158. Effects, inventory, 1672. Ex-service, treatment, 2107, 2178. Fitness report, nurse, 474, 3479. Folder, nurses, 1671. Health education, 238. Health record: enlisted, 2206. nurse, 393, 1671, 2205, 2217. officer, 2202, 2211, 2217. Identification record, enlisted, 1671. Ill or injured on leave, statistical report, 2407. Illness of, nurse, 391-394, 1671. Information from service record, 12. Injured civil personnel, treatment, 1653. Inoculation, typhoid, 2606. Instruction, nurse, 1671. Leave: death occurring during, 2905. disability incurred during, record, 2510. medical attendance during, 8164, 8166. nurse, 303, 371-378. record of (Form 55), 3483. sick, 2404. supervision, naval hospital, 1621, upon discharge from treatment, 2404. Living quarters, nurse, 808, 419. Manifest disability, officer, required procedure, 1620. Medical record, nurse, 393, Mental qualification, enlisted, 1404* 1616. Of naval hospital: assignment, 1612, 1621. inspection, 1612, 1621. records, 1687. responsibility for, 6. safeguards, 1612. supervision, 1621. Naval Reserve: active duty, medical attendance, 3169. 31 p INDEX Naval Reserve—Continued, death: following release from active duty, 2911. notification of, 8981. shipment of remains, 8977. dental, 281. Fleet Reserve: death, 2907. identification records, 1671. transfer of enlisted to, 619. health record: enlisted, 8806. officer, 2203. under Employees’ Compensation Commission, 3174, 3175. as corpse escort, 2972. medical, 171. medical attendance, 3169-3180. for injury: incurred on ship, 3177. incurred at shore station, 3178. other than naval, 3172, 3173. report, 8176. Night duty, nurse, 1678. Orders home, nurse, 458. Passenger, active duty, statistical re- port, 8405. Patient: aboard ship, transfer of, 829. active duty passenger, 8405. at Army hospital, 2171. dental, 734. discharge to duty, 1677. at Government hospital, 2170. method of reporting: Form F card, 2405, 8407, 3416. Form F, monthly, 2406, 8407, 3416. at naval hospital, 1674. confined or restricted, 1678. convalescent, 1674- disposition of, 1677. duties, 1674• ill 3 months, 1677. incapacitated permanently, 1677. register, 1618. responsibility for, 1618. supernumerary, 1678. supervision, 1681. transfer to other naval hospital, 1677. treatment, 1618. Patient—Continued, at naval hospital—continued, valuables, 1678. weekly report, 3419. at Public Health hospital, 2172. transfer of health record, 8818. transfer to foreign hospital, 1407. transfer to other than naval hospital, 8407. at Veterans' Administration facility, 2173. Pay: civil, 8108. nurse, 306, 309, 411—420. Reserve officer, 171. (See alto Property, accounting.) Pensioner, 751. death, notification, 8981. Probationary period, nurse, 345. Promotion: Dental Corps, 221-225. Medical Corps, 131-139. nurse, 331-333. of pharmacist, 621. Ranks and rates, 2252. Records and reports, nurses, 1671. Reserve list, nurses, 347. Responsibility for, 6. Retired: active duty, officer: health record, 8808. physical examination prior to, 1526. death, 2906, 8981. hospitalization, nurse, 465. medical attendance, 3168. Retirement of nurse, 309, 461-465. Revaccination, 8606. Service record, information from, 18+ Sick leave, nurse, 372. Subsistence, nurse, 307, 417. for guest, 417, 1686. Supernumerary: death: custody of remains, 8978. notification form, 8981. records, 8807. shipment of effects, 2958. shipment of remains, 8977. records, 8807. regulations, 1678. report: operations, 8486. Patient: 32 INDEX p Supernumerary—Continued, report— continued. quarterly, 3508. weekly, 3419. Swimming regulations, men, 2618. Temporarily away from command, sta- tistical report, 2407. Transportation nurse, 431-435. of household, effects, 308. laws, statutes, etc., 303. Treatment: at an Army hospital, 2171. at Army and Navy General Hospital: enlisted, 2104, 2110, 2111. nurse, 2104- officer, 2104, 2110, 2111. reserve, 2106. retired, 2106, 2111. declined by patient, statement re- quired, 2505. dental: appointment for, 273, 734- card (Form Z), 3438. charges, 243. civil personnel, 1653. civilian, naval facilities not avail- able, 3191. claims for, 3162, 3199. report of, 3197'. of civilian, 243, 753. emergency, 3191. health record, 2314. at naval hospital, 274. patient with syphilis, 734- personnel from another command, 734- preventive, 232. prohibited for applicant, 753. prophylactic, 3196. prosthetic: limitation, 3194- report of, 274. request for, 3195, 3421. pyorrhea], 3196. request for, 3193. of reserve, 3198. restorative, 232. at yard, 273. of dependent: nurse service, not provided, 362. T reatxnent—Continued. of dependent—continued. physical examination, tropical duty: enlisted, 1523. officer’s, 1532. at Fitzsimons General Hospital, 2121 2122. at Government hospitals, 2170, 2173. of insane: attendance during transfer, 2152. health record, 2216. hospitalization, 2151. (See Hospitals other than naval.) medical history, 2153. reserve, 2155. retired, 2173. malignant disease, 2176-2178. naval facilities not available: accounting. (See Property, ac- counting.) bills, 3167. dental, 3191. enlisted, 3166. nurse, 391. officer, 3164. report of: financial, 3162, 3173. statistical, 2407. service of specialist, 3163. at naval hospital: Civilian Conservation Corps: letter report, 3508. monthly letter report, 3507. weekly report, 3419. dependent: expense analysis register, 3103. officer: admission and discharge report- 3451. retired nurse, 465. supernumerary patient: letter report, 3508. nurse, 303, 391, 392. operation prohibited on applicant for service, 753. at Public Health hospital, 2172. sick days, reporting of, 2405, 2406. at St. Elizabeths Hospital, 2153-2160. sick days, reporting of, 2405, 2406. at St. Elizabeths Hospital, 2153-2160. at Veterans’ Administration facility, 2173. 33 p INDEX Vaccination, 2605. Personnel-record officer, 1637. Perversion, sexual, 1516. Pes cavus, 1511. Pharmacist, qualifications, 621. Pharmacist’s mates. (See Hospital corpsmen.) Pharmacy, 1640, 3108. Pharyngitis, 1585. Pharynx. (See Mouth, nose, etc.) Phenol, 738, 2856. Phimosis, 1508. Phorometer, 1551-1553. Physical examination: Abdomen, 1493-1495. Abnormality, physical, of officer: required record and procedure, 1520. Aircraft gunnery observer, 1589. For alcoholism, 742. All personnel: fundamental qualifications, 1404. governing provisions, 1417. instructions to examiners, 1417. rejection for causes not specifically noted, 1405. required prior to enlistment and ap- pointment, 1417. Annual: aviation duty, 1543. of diver, 1279. midshipman, 1521. nurse, 477, 1522. officer, 1520. Appointment, 1415, 1417. Dental Corps, 206. Medical Corps, 117. Naval Reserve, dental, 281. Naval Reserve, medical, 171. as pharmacist, 621. Nurse Corps, 343. Aviation duty, 1265, 1538-1565. aeronautical adaptability, 1565. annual, 1543. civilian applicant, 1643. disqualifying defect, 1539, 1565. equilibrium, 1564. flight personnel, on transfer, 1266. hearing, 1562. records, 1546-1548. required by, 1539. standards. (See Physical standards.) Aviation duty—Continued, temperament, 1565. vision, 1639, 1549-1561. accommodation, 1556. acuity, visual, 1549. angle of convergence, 1557. associated parallel movements, 1554. color vision, 1558. cycloplegia, 1560. depth perception, 1550. field of vision, 1559. inspection, eye, 1555. interpupillary distance, 1557. muscle balance, 1551-1553. ophthalmoscopic examination, 1561. refraction, 1560. Board of medical examiners, 1415,1430. Bureau requirements, 1418. Cardiovascular system, 1481-1492,1566. Care in conducting, 1411. Chest, 1471, 1472 measurement, 1441, 1443. Civil personnel, 1594-1597. at Navy Yard, 1127. by referee, 1658. Commission: board of medical examiners, 1415. Bureau requirements, 1418. general instructions, 1415. identification records, 1571. rejection, cause for, not specifically noted, 1405. report, 1415. Concealed disease, 702. Dependent: enlisted man’s, 1532. officer’s, 1528. Deserter, 1528. Diagnostic procedure, 1412. Discharge, man, prior to, 1529. Diver, 1536, 1537. prior to each dive, 1279. Ear, 1433-1437, 1536, 1537, 1562. Enlistment: fundamental physical qualifications, 1404. general instructions, 1 mis- governing provisions, 1417. intoxicated person, 1404• man discharged with a physical disa- bility, 1406. 34 INDEX p Enlistment—C ontinued. preliminary, for Naval Academy pre- paratory class, 1403. records to be prepared, 1423. rejection for cause not specifically noted, 1405. standards. (See Physical standards.) Esophagus. (See Mouth, nose, etc.) Examiners, 735, 1411-1416, 1419. Exercise required, 1443, 1444. Extremities, 1510, 1511. Eye: abnormality, 1429. acuity, visual, 1427. annual, officer, 1520. aviation, 1549-1561. (See Aviation duty.) color perception, 1428, 1558, 1559. defective vision, 1403, 1404- disease, 1426, 1429. method, 1427. reflexes, 1516. (See Physical standards, vision.) Face, 1453. Fauces. (See Mouth, nose, etc.) Filipino, 1442. Fingerprint, 1570-1574. Fireman, 1533. Gastro-intestinal system, 1493-1495. Genito-urinary system, 1502-1508. disease, 1502, 1507, 1508. Kahn test, 1506. method, 1502-1506. urine, 1502-1505. Gunnery duty, 1430. Head, 1451, 1452. Heart and blood vessels, 1481-1492. exercise, 1482. interpretation of findings, 1483-1488. method, 1481. murmur, 1484, 1487-1489. Height, 1442. For Hospital Corps, 601. Instructions to examiners, 1411-1416, 1419. Larynx, 1454, 1455. Lumbosacral joint, 1498, 1499. Lungs, 1475-1477. Marine Corps, 1422. officer, 1420. Mess attendant, 1534. Method of conducting, 1419. Mouth, nose, etc., 1454, 1455, 1535, 1563. Musician (wind instrument), 1458. Naval Academy candidate, 1403. (See Physical standards.) Naval Reserve, 1402, 1440. Neck, 1463, 1464. Nervous system, 1514-1519. Nurse, 1527. prior to discharge, 452. Officer: abnormality or manifest disability, 1520. prior to active duty detail, 1526. prior to discharge, dismissal, or resignation, 1525. prior to retirement, 1421. special, 1523. Pelvis, 1498, 1499. Physique, 1439-1448. Preliminary: for diving service, 1279. for Naval Academy, 1403. for service school or recruiting duty, 1531. for submarine duty, 1535. to transfer, man, 703. to transfer, man to Alaska or tropics, 1532. Prisoner, 1530. Promotion, 1420, 1524. Dental Corps, 221. Medical Corps, 132, 133, Nurse Corps, 333. pharmacist, 621. Records: aviation duty, 1546-1548. civil employee, 1594-1597, 1653. enlistment, 1423. recruiting, 3435, 3436. reenlistment, 1424. Rejection, causes for. (See Physical standards.) Report: annual, 3437. aviation, 1540, 1546. preliminary for Naval Academy, 1403. for promotion, 1524- Respiratory system, 1454, 1455, 1471- 1477. 35 p INDEX Retirement of: civil personnel, 1597. enlisted man, 1529. nurse, 1627. officer, 1421. Skin, 1449, 1450. Special Board, 1523. Spine, 1467, 1468. Standards. (See Physical standards.) Submarine duty, 1535. Submarine personnel, 1279. Tactical reconnaissance observer, 1589. Teeth, 1458-1462. annual, officer, 1520. carious teeth, 1582. defective teeth, 1616. dental examination, 231, 233, 272, 273 Throat. (See Mouth, nose, etc.). Trumpeter, 1468. Urine, 1502-1505. Venereal disease, 1502, 1507, 1508, 1585. Waiver, 1407, 1414- Weight, 1440, 1442. Women, 1442- X-ray, 1472. heart and blood vessels, 1488. mouth, etc., 1454- spine, 1467. Physical standards: Abdomen, 1495. Age: for diving duty, 1586, 1587. Dental Corps, 202. Medical Corps, 112. Nurse Corps, 809, 842. Aviation duty: general, 1565. hearing, 1562. mouth, nose, etc., 1568. vision, 1549-1561. Bugler, 1458. Cardiovascular system: aviation duty, 1565. diving duty, 1586, 1587. submarine duty, 1585. Chest, 1472. Chest measurement, 144%, aviation duty, 1565. Color perception, 1428, 1520. aviation duty, 1558. diving duty, 1586. submarine duty, 1585. Commission: abdomen, 1495. chest, 1472. chest measurement, 1442, 1446. extremities, 1511. face, 1453. genito-urinary system, 1608. head, 1462. hearing, 1436. heart and blood vessels, 1491. height, 1442, 1446- lungs, 1477. mouth, nose, etc., 1456. neck, 1464- nervous system, 1518. pelvis, 1499. physique, general, 1446. skin, 1450. spine, 1468. teeth, 1459. vision, 1481. weight, 144®, 1446- Defect, temporary, man, 1414- Diving duty, 1586, 1537. Ear. (See Hearing.) Enlistment: abdomen, 1495. chest, 1472. chest measurement, 1442, 1445. extremities 1511. face, 1458. genito-urinary system, 1508. head, 1452. hearing, 1435. heart and blood vessels, 1490. height, 1442, 1446- lungs, 1477. mouth, nose, etc., 1455. neck, I464. nervous system, 1517. pelvis, 1499. physique, general, 1445. skin, 1450. spine, 1468. teeth, 1458. vision, 1429. weight, 144%, 7446. Extremities, 1511. Eye. (See Vision.) Face, 1453. Filipino, 144%- 36 INDEX p Fundamental qualifications, all per- sonnel, 1404. Gastro-intestinal system: diving duty, 1536, 1537. submarine duty, 1535. General physique, 1439-1448. Genito-urinary system, 1507, 1508. diving duty, 1536, 1537. submarine duty, 1535. Gunnery duty, 1430. Head, 1452. Hearing, 1435-1437. acuity, auditory, 1434, 1562. aviation duty, 1562. binaural, 1436. defective, 1403, 1404. diving duty, 1536, 1537. submarine duty, 1535. Heart and blood vessels, 1490-1492. aviation duty, 1565. Height, 1443, 1445-1448. aviation duty, 1565. Lungs, 1477. Mess attendant, 1534- Mouth, nose, etc., 1455. aviation duty, 1563. submarine duty, 1535. Musician (wind instrument), 1458. Naval Academy candidate: hearing, 1437. heart and blood vessels, 1492. instructions, 1403. nervous system, 1519. physique, general, 1447. teeth, 1460. vision, 1432. Neck, 1464. aviation duty, 1565. Nervous system, 1617-1519. aviation duty, 1565. Nurse Corps. (See Women.) Officer. (See Commission.) Pelvis, 1499. Physique, general, 1445-1448. diving duty, 1536. Promotion: hearing, 1436. vision, 1431. Purpose of, 1401. Rejection, for cause not specifically noted, 1405. Respiratory system: diving duty, 1536, 1537. submarine duty, 1535. Skin, 1450. diving duty, 1536. submarine duty, 1535. Spine, 1468. Submarine duty, 1535. Teeth, 1458-1460. aviation duty, 1565. diving duty, 1536. recruiting duty, 1531. submarine duty, 1535. Temperament: aviation duty, 1565. diving duty, 1536. Trumpeter, 1458. Venereal disease, 1508. Vision, 1429-1432. aircraft gunnery observer, 1539. aviation cadet, 1431, 1539. aviation duty, 1549-1561. diving duty, 1536. submarine duty, 1535. tactical reconnaissance observer, 1539. Waiver of, 1407, 1414- Warrant, 1507. Weight, 144® > 1445, 1448. aviation duty, 1565. diving duty, 1536, 1537. submarine duty, 1535. Women, 1443, 1448. Physical therapy: room, 1680. treatment, request (Form 57), 3480. Physique, general, 1439-1448. Picket line, 2674. Pickling method, embalming, 2937. Pigeon breast, 1471. Pilot, aviation. (See Aviation.) Plague, 2694, 2812, 2820, 2823. Plan, battle, 807. Plaster of paris, 2886. Pleura, tumor of, 1477. Pleurisy, 1472, 1477. Pneumonia, 1477. Pneumothorax, 1477. Poisoning: circumstance of occurrence, 2416. key letter, 2414. method of reporting, 2413, 2416. 37 p INDEX Poisoning—Continued. nature and cause, 2419, appendix A, section IV. nomenclature, appendix A, section II, class XXVI. precaution against, 738. readmission, 2416. therapeutic, 2404, 2413. Poisons: antidotes, 241. care and custody, 241, 738. hospital 1621, 1640, 1672. prescription, 737. Pork, 2609. Port health of, 832. Postmortem examination, 2918. Posture, defective, 1403. Potency date, biologicals, 3073. Pott's disease, 1468. Poultry, inspection, 2609. Praecox, dementia, 1616. Precedence of: diagnostic titles, 2402. officers, 102, 171. Precordial impulse, 1481. Prevention of disease, 701-707. Preventive dental treatment, 232. Primary take, vaccination, 2605. Prince rule, 1556. Printing requisition, 3053. Prism divergence, 1553. Prison: naval, 2620. ship’s, 2619, 2699. at shore station, 2700. Prisoner: afloat, 2619. at naval hospital, 1621. physical examination, 1530. Probation period, nurse, 345. Proctitis, 1495. Proctoscopy, 1498. Procurement method. (See Property, procurement.) Professional examination for: appointment: Dental Corps, 207. Medical Corps, 118, 121. Naval Reserve Dental Corps, 281. Naval Reserve Medical Corps, 171. Professional examination for—Contd. Hospital Corps, 601. promotion: Dental Corps, 221-225. Medical Corps, 131-139. Nurse Corps, 333. Reserve, 171. Professional relation with civilian, 751- 753. Professional training, personnel, 16IS, 1652, 1671. Promotion: Dental Corps, 221-225. health record, 2202. Reserve officer, 2203. Hospital Corps, 621. Medical Corps, 131-139. Naval Reserve, 171. Nurse Corps, 333. (See Physical examination.) Property: Accountability, 3065. Accounting: A. P. A., 3023, S4U. adjustment account, closing of, 3112. expenditure account, closing of, 3112. expenditure invoice, 3038. authority, SOSO. in charge register, 3096. quarterly return of medical stores, 3432. replacing memorandum, 3096. statement, 3414- expenditure: analysis, 3103. Bureau estimate, 3011. care of the dead, 3002. charge register, 3103. classification, 3024. expense analysis classification, 3103. invoice memorandum, 3097. Medical Department, 3002. Naval Hospital Fund, 3004. object and subhead, 3024. provisions and fuel, 3104. report, 3023, 3412. unnecessary, 3063. expenditure, allotment, report, 3023. preparation, 3412. 38 INDEX Accounting—Continued, expenditure, estimate of, 3011-3016. annual, 3012, 3013. basis, 3013. by Bureau, 3011. field activity, 3012. form, 3014. preparation, 3015. responsibility for, 3011. Bureau responsibility, 9. tentative, for advance fiscal years, 3016. pay: civil personnel, 3103. nurse, 306, 309, 411-420. Reserve officer, 171, 281. pay and allowance: military, 3098, 3103. pay, subsistence, and transportation, 2969, 2976. payment: blood donor service, 3024, 3050. vendors bill, 3036. civilian service, 3045. recruiting station, 3046. pay roll: civil, 3096. record (Form 62), 3486. receipt account, closing of, 3112. report: adjustment account, 3112. allotment, 3023. balance sheet, 3113. allotment expenditure, 3088. receipt and expenditure, 3087. subsistence checkage, 3105. quarterly ration return, 3470. subsistence: checkage, 3109. guest, 417, 1636, 3109. nurse, 307. Red Cross representative, 3109. Accounting record: hospital, 1633, 3094-3117. balance sheet, 3113. charge register, 3094, 3096. commissary ledger, 3054- equipment inventory, 3115. equipment ledger, 3094, 3100. expense analysis register, 3094, 3103, 3491 general ledger, 3094, 3098. Accounting record—Continued, hospital—continued. journal, 3094, 3095. land and building inventory, 3114. land and building ledger, 3094, 3099. part compensation, civil personnel, 3106. permanent file of, 3094- provisions and fuel: accounting record, 3103. adjustment for, 3097. allotment, 3022. for civil personnel, part compen- sation, 3106. expenditure invoice, 3038. inspection, 2603. for officers’ quarters, 3105. quarterly adjustment, 3097. quarterly expenditure, 3104. provisions ledger, 3102. quarterly ration return, 3094, 3117. recapitulation of ledger accounts, 3094, 3116. services and utilities, 3103. accounting record, 3102. annual estimate, 3013. annual requisition, 3033. to civil personnel, 3106. maintenance, 1632. officers’ quarters, 3105. to other Government agency, 3111. to other Medical Department activity, 3110. ship’s service, 3108. water, 2610. special depositor, 3107. special duty compensation, civil personnel, 3106. subsistence checkage, 3109. supplies ledger, 3094, 3100, 3101. medical supply depot, 3142-3155. annual inventory, 3147. receipt and expenditure, statement, 3150. table of annual issue, 3148. transfer requisition, 3152-3155. ship and station, 3086-3088. receipts and expenditures: account, 3112. journal, 3086. 39 p INDEX Accounting record—Continued, ship and station—continued. receipts and expenditures—contd. of medical stores, 3150. statement, 3087. report of allotment, 3088. voucher: additional data required, 3023. civil pav roll, 3094, 3096. expenditure invoice, 3094, 3096. how long retained, 3094- inventory adjustment, 3101. land and buildings, 3094• 3096. material and supplies requisition statement, 3414- medical supply depot invoice, 3094, 3096. memorandum, 3097. numbering, 3023. other items, 3094, 3096. payable, 3098. posting, 3096, 3103. receipt and expenditure (NMS Form 37), 3094- recruiting station, 3046. replacing memorandum, charge register, 3096. stub requisition, 3094, 3096. substantiating, 3023. transfer, 3094- Alcohol, 3094- Allotment, 3022. authority for procurement under, 3030. ‘ report, 3023. expenditure, object and subhead, 3024. Annual rate of use, 3069. Annual sanitary report of: hospital, 2701. ship, 2699. station, 2700. APA material: inventory, 3413. payment, 3023. procurement, 3037. statement, 3414- Appropriation, annual, 3001, 3002. object of expenditure, 3024. obligation against, 3023. responsibility for expenditure, 3005. Care of the dead: allotment, 3022, 3023. appropriation, 3001, 3002. charge to, 2931, 2969, 2976, 2977, 2992. estimate of expenditure, 3014- expense analysis register, 3103. funeral expense: active duty personnel, 2978. appropriation chargeable, 2976, 2977. authorization, 2975. burial prior to ascertaining wishes of next of kin, 2988. clergyman’s fee, 2984. coroner’s inquest, 2990. death occurring while on leave, 2983. destitute patient, 2991. distinct from transportation ex- pense, 2980. at home: authorized, 2986. not authorized, 2985. limitation, 2981. refusal of Government service, 2982. specific provision, 2976. transportation outside United States, 2989. unclaimed body, 2992. requisition, 3023. transportation charge, 3096. Classification, 3065. Commissary ledger: cash value sheet (Form 35), 3470. expenditure and receipt voucher (Form 37), 3472. naval hospital, 3094■ Commissioning outfit, 3058. Custody, at naval hospital, 1634- Custody and care, responsibility for, 6. Disposition, upon decommissioning, 3081. District craft, 3044- Equipment: account, 3098. accountability for, 3068. allotment, 3022. battle-dressing station, 875. chargeable to other than naval funds, 3048. 40 INDEX p Equipment—Continued, for hospital: allotment, 3024. expense analysis register, 3103. survey, 3074• inventory, 3115. ledger, 3094, 3100, 3433. maintenance and repair, 3076. office, annual inventory, 3413. receipts and expenditures, state- ment, 3414. for sick bay, 3048. survey, 3074- Estimate of expenditure: annual, 3014. recurring item, 3016. tentative, 3016. Exchange of, receipt, 3071. Experimental, 3067. Field service, 1229, 1231. Furnished civil personnel, 3107. In excess, 3076 Inventory, 3413. consolidated, 3147. of equipment, 3071, 3115. of land and buildings, 3114. material, 3413. stores, 3147. ward, 1634, 1672. Land and buildings: account, 3024- accountability, 3068. alterations and repairs, 3024. classification, 3099. disposition, 3068. estimate of expenditures, 3013. inspection, 1612. inventory, 3114, 3413. ledger sheet, 3099, 3434. maintenance and operation, 1632, 3103. operating charge, 3024. sanitary report, 2691, 2701. work request, 3041. Loan, 3080. Lost or missing, 3074* Maintenance and operation: expenditure chargeable to other bu- reau, 3048. hospital, 3024, 3103. (See Material and service.) ship and station, 3024• Maintenance and operation—Contd. supply depot, 3024, 3140. Material and service: accountability, 3065. annual requisitions, 3033, 3034. appropriation purchase account, 3037, 3038. chargeable to other than Medical Department funds, 3048. emergency requisitions, 3032. expenditure invoices, 3038. furnished: civil personnel, 3106, 3107. officer’s quarters, 3105. other Government agency, 3111. other Medical Department ac- tivity, 3110. ship’s service, 3108. Marine Corps invoice, 3039. naval supply account, 3037, 3038. payment, 3023, 3036. (See Procurement.) purchase contract, 3035. subsistence checkage, 3109. transfer invoice, 3044. Maximum quantity, 3069. Minimum quantity, 3069. Officer, 1634, 3066. Order point: stores, 3146. supplies, 3069. Procurement: by expenditure invoice, 3030, 3038. by local approval, 3032. by local purchase, 3045, 3046. by Marine Corps invoice, 3030, 3039. by medical supply depot requisition and invoice, SOSO, 3042. by purchase contract, 3035. by purchase requisition: afloat (Forms 44, 44a), 3504. annual, 3033. ashore (Forms 76, 76a), 3505. authority, 3030. for civilian service, 3034. general information, 3031. local approval, 3032. wording, 3033. by requisition for labor, SOSO, 3040. special item, 3049-3059. by stub requisition, 3030, 3037. authority, 3030. Loan, 3080. 41 p INDEX Procurement—Continued. by stub requisition—continued, entry, 3096. memorandum, 3097. replacing memorandum, 3096. statement, 3474- summary 3096. subsistence checkage, 3109. by transfer, 3044. authority fdr, 3079. from other Government agency, 3047, 301+8. from other Medical Department activity, 3044. transfer invoice, 301+1+. under allotment, 3030-3042. without allotment, 3043. by work request, 3041. authority, 3030. posting, 3096. report, 3023. Quantity to be ordered, 3069. Quarterly return, stores, 3432. Rate of use, annual, 3069. Receipt and expenditure, statement, 3414. Records, 3064. Repair: buildings and grounds, 3099. equipment, 3076. request for 3487. work request, 301+1. Report: estimate of expenditure, 3011-3016. inventory, 3413. receipt and expenditure, 3414. requisition and invoice, 3442. survey, 3076. Reserve quantity, 3069. Responsibility for, 3062. Shake-down cruise, outfit, 3058. Storerooms, 3067. Stores, supply depot: accounting procedure, 3149. annual issue, 3148. available, 311+3. classification, 3143. consolidated annual issue, 3148. definition, 3142. dispatch request, 3151. expenditure, and receipt, statement, 3150. Stores, supply depot—Continued, inventory, 3147. issue, 3151. maintenance, 3146. maximum quantity, 311+6. minimum quantity, 311+6. order point, 311+6. procurement, 3145. replenishment schedule, 3144. reserve quantity, 311+3, 311+6. table of annual issue, 3148. transfer: between depots, 3152. to other Government agency, 3155. to Reserve activity, 3154. Stub requisition, 3096. Sundry items, 3033. Supplies: for Bureau, 8. of naval hospital: adjustments, 3101. allotment, 3022. commissary, 31+71, 31+71+. expense analysis register, 3103. inventory, 3071. receipts and expenditure, statement, 3414. Survey, 3074-3078, 3506. Transfer, authorization required, 3079. Unnecessary expenditure, 3063. Prophylactic dental treatment, 3196. Prophylactic quinine, 2615. Prostate gland, 1508. Prostatitis, 1508. Prosthetic appliance, dental, 3033, 3056. Prosthetic treatment, dental. (See Dental, treatment.) Provisions and fuel. (See Property, accounting.) Provisions ledger, 3102. Pruritus ani, 11+99. Psoriasis, 11+50. Psychopathy, 1516, 1517, 1536. Pterygium, 11+29, 1555. Ptosis, 11+29, 1516. of eyelid, 1555. of intestines, 11+95. of stomach, 11+95. visceral, 11+1+5. Public Health Service: cooperation with, 707. 42 INDEX R Public Health Service—Continued, hospital. (See Hospitals, other than naval.) Public voucher. (See Property, ac- counting.) Public works, 8, 2704. Publications: of the Bureau, 13. on professional subjects, 242, 739. Pulmonary emphysema, 1477. Pulmonary tuberculosis, 1477, 2121, 2122. Pulse, 1403, 1523, 1565. Pupillary reaction, 1515. Pupils, 1516, 1565. Purchase contract, 3035. Purchase requisition. (See Property, procurement.) Purpura, 1445. Pus in urine, 1508, 1520. Pyelitis, 1508, 1582. Pyonephrosis, 1508. Pyorrhea alveolaris, 1462, 1535, 1586. Pyorrheal treatment, 3196. Pyrethrum, 2808, 2881. Qualification report, Hospital Corps, 638, 3509. Quarantinable diseases, 2820. naval regulations, 2880. Public Health Service regulations, 2820-2827. Quarantine laws, 2802-2807 Quarantine regulations: for aircraft, 2808, 2834. anthrax, 2827. bill of health, 2811, 2828. certificate of naval medical officer, 2814. cholera, 2821. leprosy, 2826. naval vessel, 2828-2834. arrival in port without quarantine facilities, 2805. bill of health: between home ports, 2836. from foreign port to home port, 2839. from infected port, 2813, 2815. from United States port to Canal Zone, 2837. Quarantine regulations—Continued, naval vessel—continued, bill of health—continued, from United States port to United States dependency, 2887. from United States port to foreign port, 2838. for boarding ship, 2831. carrying a medical officer, 2812. compliance compulsory, 2829. for infectious disease, 2830. information, other than bill of health, 2845. inspection, 2833. exemption from, 2812. subject to, 2813, 2818. not carrying a medical officer, 2816. for personnel on board, 2832. radio quarantine message, 2812. persons authorized to board, 2817. for plague, 2823. for smallpox, 2824. for typhus fever, 2825. for yellow fever, 2822. Quarterly: adjustment, provisions and fuel, 3097. expenditures, provisions and fuel, 3104. inventory, of medical stores, 8071. ration return (Form 36), 8094, 3117, 3472. return, medical stores, 3432. Quarters: afloat, sanitary report, 2699. bills, 835, 862. fire, 862, 870, 1621. general, 862, 864-866. at hospital, sanitary report, 2701. for nurses, 803, 419, 420. shore station, sanitary report, 2700. Quinine, 2615. BA, meaning of, 2408. Rabies, control, 2616. Radio quarantine message, 2812. Radiographic study of lungs, 1475. Rales, moist, 1475. Ran: meaning of, 2408. method of reporting, 2404- Range finder operator, visual standards, 1480. 43 R INDEX Ranks and rates, abbreviations, 2252. Ranula, 1455. Rate, change of, for hospital corpsman, 639. Ration: inspection for balanced diet, 2608. for marching troops, 2677. rate of charge, 3109. return, quarterly, 3117, 3470. sanitary report: hospital, 2701. ship, 2699. station, 2700. Ratproofing, 2883. Rats, destruction, 2864, 2883. Raynaud’s disease, 1490. Readiness for action, 864, 865, 866. Readmission: abbreviation, 2403. date and place of previous admission, 2405, 2416. for disability: arising during desertion, 2411- existing prior to entry into service (EPTE), 2410. for injury, 2405, 2416. interpretation, 2404- for poisoning, 2405, 2416. for venereal disease, 2405, 2408. Real estate ledger sheet (Form Wa), 3434. Rear hospital, 1232. Recapitulation, of ledger accounts, 3116. Receipts and expenditures. (See Prop- erty, accounting.) Recommendations: in annual sanitary report of: hospital, 2701. ship, 2699. station, 2700. of flight surgeon, 1264. method of reporting, 3405. Record sheet, dental, 233, 272. Records: admission to St. Elizabeths Hospital, 2156. aviation, 1546-1548. case, 1612. clinical, 1612, 3482-3483. dental, 2311-2319. enlistment, 1423. for Hospital Corps, 601. Records—Continued, fingerprint, 1573, 1574. health. (See Health record.) identification, 1570-1572, 1570. information from, 12. medical. (See Medical record.) meritorious, 1231. nurses, 1671. operation, 1612, 3481. preservation, 1612. responsibility, 1637. service, 1425. Hospital Corps, 639. signed by medical officer, 1433. vaccination, 2605. venereal, 1506. Recovery of airplanes, 862, 869. Recreation: afloat, 702. at naval hospital, 1648. Recruiting: limitation of, hospital command, 1613. personnel: enlisted men, examination for, 1531. vital statistics, 2407. station: abstract of patients, 2406. allotment, 3023. procurement methods, 3046. statistics (Form X), 3435, 3436. Recruits: dental examination, 272. transfer of during vaccination, 2605. Rectum, 1495, 1499. Recurrent disability, 2404- Red Cross. (See American National Red Cross.) Reenlistment: determination of, 1424. health record, 2206. in hospital Corps, 601. identification record, 1571. inoculation, typhoid, 2606. Marine Corps, 1422, 1434- men discharged with physical dis- ability, 1406. (See Physical standards.) slight physical defect, 1404- vaccination, 2605. Reflexes, 1516, 1565. Refraction: cycloplegic, 1403, 1432, 1560. INDEX ft Refraction— Continued, health record, 2331. medical treatment, 3163. Refractive: anomaly, 1516. error, 1560. Refrigeration, food, field service, 2668. Refuse disposal: afloat, 2612. in the field, 2670. at hospital, report of, 2701. regulations, 2603, 2612. at station, report of, 2697, 2700. Regimental headquarters, medical, 1232. Regimental surgeon, duties, 1225. Register, charge, 3094, 3090. Register No. 3, preparation, 3492. Register of patients, 1612 (Form 39), 3474. Regurgitation, 1516. Rejection, causes for. (See Physical standards.) Remaining on sick list, 2403-2405. Renal calculi, 1508. Rental allowance, nurse, 420. Repair, supplies and services, 3024. Repairs. (See Property, repairs.) Replenishment, medical stores, 3144- 3146. Report: admission to naval hospital: nurse, 1672. officer, 8451. allotment, 3023, 3088. daily sick, 826. death. (*See Personnel, deceased.) dental: annual, 244. monthly, 274. discharge from naval hospital, 1672. officer, 3451. diving accident, 1280. epidemiological, 2694. experimental medical agent, 3057. financial. (See Property, accounting.) intelligence, 2711-2713. killed and wounded, 807, 888. medical attendance, other than naval, 3162. nurses, for disbursing officer (Form 49), 3478. to officer of the deck, 731. Report—Continued, patients, 2405-2407, 3419. (See Physical examination, report.) promotion of officer, 1524.. property survey, 3076. public works, 2704. receipts and expenditures, 3087. (See Sanitary report.) ship’s inspection, 806. special board, 1523. submarine accident, 1280. (See Operations, surgical.) (See also Records and chapter 23.) Reports and returns, 3401-3406. fleet, tabulated, 3551. Hospital Corps, 631-639. hospital ship, tabulated, 3553. hospital, tabulated, 3555. lettered forms, 3411-3438. numbered forms, 3442. Nurse Corps, 471-477. ship, tabulated, 3552. station, tabulated, 3554. Request and disposition form (Form 11), 3458. Request for repairs (Form 63), 3487. Request for death report, 741. Requisitions, purchase. (See Property, procurement.) Requisition for labor, 8030. Research work, 3321. Reserve, Fleet Naval. (See Naval Re- serve.) Reserve, Marine Corps. (See Marine Corps Reserve.) Reserve, Naval. (See Naval Reserve.) Reserve list of nurses, 347. Reserve nurse, 809, 845, 351, 352. probationary training, 345. rules and regulations, 351. selection in emergency, 852. Reserve personnel. (See Personnel, re- serves.) Reserve stores, 3069, 3148. Resignation: health record, 2202. physical examination prior to, 1525. Respiratory system: diseases of, nomenclature, appendix A, section II, class XVIII. (See Physical examination.) (See Physical standards.) 45 R INDEX Restorative dental treatment, 232. Restricted or confined patient, 1672. Resuscitation of apparently drowned, 836. Retina, detachment of, 1429. Retinitis, 1429. Retinoscope, use of, 1560. Retired list, Nurse Corps. {See Nurse Corps.) Retired medical officer, on active duty, 151. Retired personnel. {See Personnel, re- tired.) Retirement: from Hospital Corps, 617. from Medical Corps, 138, 184, 151. from Nurse Corps, 309, 461-465. of officer: health record, 2202. not recommended for advancement, 184- for physical disability: leave of absence preceding, 2404. medical survey, 3423. {See Physical examination.) Retiring board. {See Board.) Returned to duty. {See Duty, return to.) Return to work, injured civil personnel, 1658. Returns. {See Reports and returns.) Revaccination, 2605. Rheumatic fever, 1481. Rheumatism, 1565, 2109. Rhinitis, 1455, 1536. Ribs, 1472. Roaches, 2864, 2886. Romberg sign, 1515, 1516. Roster report, Hospital Corps, 637, 3511. Rough log, 729. Route to battle-dressing station, 881. Rubber disinfection, 2854- Rule, Prince, 1556. Sacro-iliac joint. {See Pelvis.) Safeguards: for personnel and property, 1612. of valuables, 1573, 1621. Safety device, industrial, 1621. St. Elizabeths Hospital. {See Hospitals other than naval.) Salaries and wages, 3001, S022. Salary. {See Personnel, also Property, accounting.) Salivary calculi, 1462. Salivary fistulae, 1466. Salpingitis, eustachian, 1536. Samoa, 1623, 1632. Sanitary condition, ship, 804. Sanitary inspection and standards: barracks, 2621. camp site, 2664. communicable disease control, 2616, 2680. food, 2608, 2609, 2668. garbage disposal, 2612. hospital, 2622. illumination, 2614. for lead poisoning, 2617. mosquito control, 2615, 2675. naval prison, 2620. refuse disposal, 2612, 2670. regulations, 2603. scuttle butt, 2610. sewage disposal, 2613, 2671. ship’s prison and prisoners, 2619. ship’s service, 2608. submarine, 1277. for swimming, 2613, 2618. temperature. 2611, 2621. toilet facilities, afloat, 2623. ventilation, 2611, 2621. water, 2610, 2665, 2666, 2667. Sanitary reports: annual, 2691. arsenical treatment, 2708. cases or deaths, 2702. fleet medical officer, 808, 2692. from hospital, 2701. preparation, 2698-2701. from ship, 2699. from station, 1126, 2700. submarine, 1283. syphilis, 2703. epidemiological, special, 2694. intelligence, 2712. monthly: arsenical treatment, 2703. communicable disease, 2695. from ship, 2696. from station, 2697. syphilis, 2703. notes and data, 2693. 46 INDEX s Scabies, 1450. Scanning speech, 1516. Scapulae, 1472. Scar pain, 1495. Scarlet fever, 1481, 2616. Scars, hypodermic, 1449, 1516. Schneider index, 1536, 1665. School, Naval Medical. (See Naval Medical Center.) Schools: divers, 1279. Hospital Corps, 613. duties of graduates, 611. medical, class A, 112, 113. Sciatica, 1511. Sclerosis, multiple, 1617. Scoliosis, 1468. Scrap metal, disposition, 3078. Scrotal fissure, 1516. Scuttle butt, sanitary precautions, 2610. Seaman branch, rates, 2252. Security, provisions for, 1621. Self-balancing test, equilibrium, 1564. Senior watch, naval hospital, 1625. Septal deformity, 1455, 1516. Sequela: change of diagnosis, 2402. of disability, 2404. prompt change to new title, 2402. of venereal disease, 2408. Serum sickness, 2413. Service, length of, statistical report, 2405. Service record, 1425. Hospital Corps, 639. signed by medical officer, 1433. Service school, physical examination re- quired, 1531. Service utilities, inventory, annual, 3413. Services. (See Property, materials and services). Sewage disposal: afloat, 2613. in the field, 2671. at hospital, report of, 2701. at station, report of, 2697, 2700. Sexual psychopathy, 1516. Shake down cruise, special outfit, 3058. Ship: allotment, 3022, 3023. Ship—Continued. allotment expenditures: report, 3023, 3412. average complement; computation for: abstract of patients, 2406. statement of receipts and expendi- tures, S414. commissioning outfit, 3058. communicable disease, report, 3519. death, report of, 2901, 2903, 2924. degassing, 868. drills and emergencies, 862-874. equipage, 3024. finance and accounts: annual local purchase requisition 3012. annual requisitions, 3033. fumigation, 2871-2874. injury to reserve, 3177. intelligence report, 2711-2713. Medical Department: duties in emergencies, 861-888. reports, 3552, 3553. medical officer, 801-837. medical material, 823. inventory, 3413. procurement, 3030-3069. receipts and expenditures, state- ment, 3414. survey, 3423. (See Quarantine regulations.) ratproofing, 2883. reports and returns, 3552. from hospital ship, 3553. (See Property, reports.) sanitary inspection, 804. without dental facilities: treatment of personnel, 734. without Medical Department per- sonnel. statistical report, 2407. (See also Naval vessels.) Ship's prison and prisoners, 2619. Ship’s service, 1646. sanitary inspection, 2608. services furnished, accounts, 3108. Shoes, orthopedic, 1653. Shore station: additions and improvements, 3024• allotment, 3022. report, 3023, 3412. 47 8 INDEX Shore station—Continued. average complement, computation, 2406, 2700, 3414- buildings: (See Property, land and buildings.) sanitary report, 2700. civil personnel, 1653. medical treatment, 1128. physical examination, 1127. commissioning outfit, 3058. communicable disease, report, 3519. death, report, 2901, 2903, 2923, 2924, dental officer, 271. drug room, 1129. estimates of expenditure, 3012-3014, 3016. injury to reserve, 3179. maintenance and operation, 3024• medical officer, 1121-1129. medical supplies, 3069. medical survey, report, 3423. (See Property.) reports and returns, 3554. Shower bath, disinfection, 2860. Showers, sanitary standards for: barracks, 2621. hospital, 2622. ship, 2623. Sick, care of, 711. Sick days: cases continued and remaining, 2405. changed to proper diagnosis, 2402. method of computing, 2405. Sick leave, 2404- Sick list, 826. abbreviations, 2403. disposition, method of report, 2405. medical survey, 3423. reports: binnacle list, 826. daily report of sick, 826, 3430. Form F card, 2405. Form F, monthly, 2406. supernumeraries, 3508. ward, 3457. Sickness: annual rates, calculation of, 2702. daily report, 826, 3430. facilities for treatment: afloat, report, 2699. at station, report, 2700. Sickness—Continued. facilities for treatment—continued, while on leave, 2288, 2407. Silk, disinfection, 2854. Sinusitis, 1455, 1532, 1536. Skin, diseases: nomenclature, appendix A, section II, class XIX. (See Physical examination.) (See Physical standards.) Skull, fracture, 1452. Sleeping, regulations, 2621. Slop sinks, standards, hospital, 2622. Slush fund, 1612. Small stores, payment, 3023. Smallpox, 2812, 2820, 2824. report of, 2694. vaccination, 2605. Snellen test chart, 1549, 1560. Somnambulism, 1517. Sorting of casualties, 1217. Spaces, edentulous, of teeth, 1462. Special: activities, 1201-1283. allowance, civil personnel, 3107. physical examination board, 1523. branch rates, 2252. depositor, civil, 3107. diet kitchen, 1680. diet order sheet (Form 40), 3475. duty, abstract, 2331. duty, hospital corpsman, 1673. examination form, 1612, 3480. hospital, 2101-2178. instruction, allotment, 3024- material and service, accounting, 3103, mess, 1636. outfit, dispostion, 3058. sanitary inspection, ship, 805. training, officer, 3319. Specialist: service of civilian, 1653, 3163. training, 1612. unit, medical, 171. Specialty letter, 2415. Specific gravity of urine, 1504- Speech, scanning, 1516. Spina bifida, 1468, 1516. Spine, 1467, 1468. Spit kit, disinfection, 2856. Spleen, 1494, 1495. diseases, nomenclature, appendix A, section II, class IV. 48 INDEX 8 Splints, instruction, 886. Spotter, visual standards, 1480. Sprain, 1511. Spray, pyrethrum, 2808, 2881. Squad, litter, 1228. “Staff,” meaning of, 2405. Staff medical officer: afloat, 1209-1212. district, 1101, 1102. hospital, training, 1612. with troops, 1214, 1223, 1224. Staff quarters, naval hospital: expense analysis register, 8103. furniture and furnishing, 3054. inventory, annual, 8418. service furnished, 3105. Stammering, 1616, 1517. Standards, physical. (See Physical standards.) Standing order book, 780. Staphyloma, 1429. Statement, receipts and expenditures, 3087, 3150. Stateroom, disinfection of, 2887. Station: advance-hospital, 1282. battalion-aid, 1232. battle, 835. sanitary report, 2699. battle-dressing. (See Battle-dressing station.) bills, watch, etc., 835, 862. collecting, 1282. without dental facilities, 784. foreign, sanitary report, 2713. fumigating, ship, 2874. medical, beach, 1217. placed out of commission, report, 2406. recruiting, 3436. reports, 3554. Stationery, requisition, 3053. Steam, for disinfection, 2854. Steam. (See Fuel.) Stenosis, aortic, 1481. Stenosis, mitral, 1481, 1489. Sterilization of mess gear, 2608, 2669. Sterilizer, battle-dressing station, 880. Sterilizing apparatus, hospital, report, 2701. Sternum, 1472. Steven’s frame, 1651. Stigmata, hysterical, 1517. Stigmata of degeneracy, U51, 1452, 1516. Stilling’s test, I428, 1558. aviation duty, 1589, 1558. diving duty, 1586. submarine duty, 1585. Stock and equipment ledger sheet (Form W), 3433. Stomach, diseases of, 1495. Stomatitis, 1455. Store, ship’s service, 1646. Storeroom, 1685, 3067. Stores, medical. (See Medical stores.) Stores account, 8098. Strabismus, 1429, 1516. Straggler, health record, 2206. Stretcher bearer, instruction of, 886. Stricture: rectum, 1495, 1499. urethral, 1508. Strip ship drill, 862. Stub requisition. (See Property, pro- curement.) Student, aviation. (See Aviation, etc.) Submarine service, 1276-1283. annual sanitary report, 1283. condition, study of, 1276. escape appliance, 2415. medical division, 1276. personnel: inspection, 1276, 1277. instruction, 1276. physical disability: due to occupational hazard, 1280. reporting, 2407, 2415. (See Physical standards.) physical examination, 1635. (See Physical examination.) venereal disease, 1281, 1585. sanitation: inspection, 1277. ventilation, 1282. school, 1585. Subsistence. (See Property, account- ing.). Substantiating voucher, 8028. Suicide, record, 2511. Sulphur dioxide, 2861. Sunlight, disinfection, 2851. Superintendent, Nurse Corps, 311. 49 B INDEX Superintendent, assistant, Nurse Corps, 321, 322. Supernumerary patient: grade and rate, 2252. health record, 2207. hospital treatment, 1678. reports and returns: abstract of patients, 2406. letter report, treatment, 3508. quarterly ration return, 3472. operations and diagnostic exami- nation, 3426. statistical report, 2405. Supplementary report, allotment ex- penditures, 3023. Supplementary supply table: (See Appendix B.) material. (See Property.) Supplies. (See Property.) Supplies, first-aid. (See First-aid sup- plies.) Supplies ledger, 3101. Supply department, transfer of medical stores to, 3153. Supply depot allotment estimates, 3014, 3016. Supply depot requisitions, statement. 8414• Supply depots. (See Medical Supply Depots.) Supply table: (See Appendix B.) material. (See Property.) Surgeon: battalion, 1226. flight. (See Flight surgeon.) regimental, 1225. staff, 1223. Surgeon General of the Navy, 2. assistant to, 3. orders of, 7. relief to, 3, 4- Surgical operation: on applicant prohibited, 248, 753. method of reporting, 2418, 3426, ap- pendix A, section III. nomenclature, 2418, appendix A, section III. Surgical training, minimal, 1612. Survey: medical. (See Medical survey.) medical, board. (See Board.) Survey—Continued. property. (See Property, survey.) Swimming, 2618. Sycosis, 1460. Symptomatic diagnosis, 2402. Syndactylism, 1616. Synovitis, 1611. Syphilis, 1462, 1464, 1481, 1507, 1608, 1617, 1632, 1536, 1565. arsenical treatment, report, 2703, 3411. dental patient with, 734- submarine personnel, 1281. Syphilitic abstract, 2350. Syringomyelia, 1516, 1517. Systolic murmur, 1488. T, meaning of, 2403. Tabes dorsalis, 1516. Table of annual issues, 3148. Table, accommodation, vision, 1656. Table of standards, height, etc., 1442. Tachycardia, 1489, 1516, 1535, 1636. Tags, hemorrhoidal, 1620. Tags, Identification. (See identifica- tion tags.) Tangent curtain, 1551. Tapeworm, food, 2609. Tattooing, 1450, 1676. Tear sac, imperfect drainage, 1555. Technician, Hospital Corps, 607. Teeth: classification, 2317. health record, 2311-2319. (See Physical examination, teeth.) (See Physical standards, teeth.) Temperature, sanitary, 2611, 2621. Temporary rank, health record, 2202, 2206. Tenders, complement, computation, 2406. Tendon reflex, 1516. Tension, psychomotor, 1565. Tentative estimates, advance years, 3016. Termination of service, reserve officer, record, 2203. Terminology, landing force, 1202. Textile, disinfection, 2854, 2857. Therapy: disability, resulting, 2404, 24IS. occupational, 1649- 50 INDEX T Thrill, apical, 1489. Throat, diseases of, nomenclature, ap- pendix A, section II, class V. Throat. (See Mouth, nose, etc.) Thrombophlebitis, 1490. Thumb, abnormality, 1511. Thyroid gland, 1404,1481. Tic, 1453,1565. Ticket, car and ferry, 3048. Time and pay roll record (Form 62;, 3490. Tinea, 1452. Title, diagnostic. (See Diagnostic titles.) Toenail, ingrowing, 1510, 1511. Toe. (See Extremities.) Toilet facilities, standards for: barracks, 2621. hospital, 2701. ship, 2623, 2699. station, 2700. Tombstone. (See Headstone.) Tongue, 1455. Tonsillitis, 1455,1481,1536. Tonsils, hypertrophied, 1455, 1535. Topography, 2700, 2701. Torticollis, 1484’ Tourniquet, use, 836. Trachea. (See Mouth, nose, etc.) Trachoma, 1439,1555. Traffic regulations, 1621, 2603. Training, Hospital Corps, 613, 1612, 1652. Transaction, pecuniary, 1612. Transcript, medical record, 741. Transfer: aviator, 1266. card, Hospital Corps, 635, 3510. class, reserve officer, 2203. dental property, afloat, 262. enlisted man: to Hospital Corps, 603. from hospital, report, 3452. to Fleet Reserve, 171. hospital apprentice, to training school, 605. infected man during emergency, 703. insane patient, to hospital, 2152. invoice. (See Property.) material, 3044. medical stores: between depots, 3152. Transfer—Continued. medical stores—continued. to other Government agency, 3155. to Reserve activity, 3154. to Supply Department, 3153. nurse, 363. patient: via commercial or Army transport, 2405. to foreign hospital, 2407. health record, 2213. from hospital to hospital: medical survey, 3423. on request of patient, 1677. to hospital other than naval, 713, 2407. health record, 2213. to naval hospital: for malignancy, 2178. report, 3417. via naval vessel, 2405. from ship, 829. personnel: health records, 2211. physical examination, 703. property, 3071, 3079, 3413. for prosthetic dental treatment, 240. record, physical examination, 1433. for aviation duty, 1547. recruit, vaccination, 2605. on sick list: abbreviation, 2403. interpretation, 2404• to Reserve, 2404- voucher. (See Property, accounting.) Transillumination, 1454’ Transport duty, 837, 1213. Transport force, medical officer, 1211. Transportation: active-duty personnel: to Veterans’ Administration facility, 2173. of deceased person. (See Personnel, deceased.) of ex-service personnel to: Army and Navy General Hospital, 2107. Naval Home, 2143. Veterans Administration facility> 2122. household effects, nurse, 308. injured civil personnel, 1653. 51 T INDEX Transportation—Continued. at naval hospital, accounting, 3103. nurse, 303, 431, 433, 435. services, inventory, annual, 3413. of sick, annual report, 2701. of wounded, 887. Tremor, 1516, 1517, 1565. Trial frame, phorometer, 1553. Trial lens case, 1560. Trichiasis, 1439, 1555. Trichinosis, meat, 2609. Tricresol, 2856. Troop boat, 1216. Tropical duty: marching precautions, 2679. physical examination for: enlisted man and family, 1532. officer and family, 1523. vaccination for, 2605. Trumpeter, dental standard, 1458. Truss, civil personnel, 1653. Trypanosomiasis, 1448. Tuberculosis, 1404, 1448, 1484, 1481. meat, inspection, 2609. nomenclature, appendix A, section II class XI. pulmonary, 1478, 1477, 2122. hospital for, 2121, 2122, 2173. Tumor, 1445. abdominal wall, 1495. auditory canal, 1435. bladder, 1508. breast and chest wall, 1472. extremities, 1511. eye, 1439. face, 1453. head, 1453. kidney, 1508 . lungs and pleura, 1477. malignant, hospitals for, 2176-2178. mediastinum, 1477 neck, 1484- nomenclature, appendix A, section II, class XXIII. skin, 1450. teeth, 1462. tongue, 1455. Tympanic membrane, 1434, 1435, 1437. Typewriter: procurement: afloat, 3048. ashore, 3024, 3075. Typewriter—Continued, survey, 3075. Typhoid: fever, 1481. prophylaxis, 2606. Typhus fever, 2825. incubation period, 2820. quarantine regulations, 2812. report of, 2694. Ugliness, face, 1453. Ulcer, peptic, 1532. Ulceration: cornea, 1439. face, 1453. nose, 1455. skin, 1450. Uncinariasis, 1448, 1494, 1495. Unclaimed body, burial, 2992. “Unfit for duty,” interpretation, 3423, “Unfit for service,” interpretation, 3423, Uniform: allowance, reserve officer, 171. at naval hospital, 1621. nurse, 414, 441. Unit value, 3072. Unnecessary expenditure, 3063. Unofficial certificate, 740. Urethral stricture, 1508. Urinals, sanitary standards: barracks, 2621. hospital, 2622. ship, 2623. Urinary fistula, 1499, 1508. Urine, 1502-1505, 1565. albuminuria, 1503. annual examination, officer, 1520. casts, 1503, 1520. glycosuria, 1505. specific gravity, 1504. Utensils, cleansing, 2608. Utilities, naval hospital. (See Prop- erty, accounting.) Vaccination, 2604, 2605. prior to field service, 2663. Vaccine, 2604. Valuables, safeguarding, 1621, 1672. Valvular disease, heart, 1490. Varicocele, 1508, 1511, 1520. Varicose vein, 1510, 1511, 1520. Vaso-motor disturbance, 1516. Vehicle, motor, 3055, 3075. 52 INDEX X Vehicular equipment, 3024- Vendors bill. (See Property, account- ing.) Venereal disease, 1502, 1507, 1508, 2408. checkage of pay, 2509. health record, 2287. instruction of personnel, 704- nomenclature, appendix, section II, class XII. rejection, cause for, 1508. submarine duty, 1535. submarine personnel, 1281. treatment, 2103. (See also Genito-urinary system.) Ventilation: barracks, 2621. ships quarters, 2611. submarine, 1282. Vermin, extermination, 2881. Vertebral caries, 1468. Vesical calculi, 1508. Vessel. (See Ship.) Vestibular test, 1564. Veterans’ Administration facility for: beneficiary, 2104- mental disease, 2160. tuberculosis, 2122. Veterans’ Administration patients. (See Personnel, supernumeraries.) Vincent’s stomatitis, 1462. Violence, nature and cause: nomenclature, 2419, appendix A, sec- tion IV. Visceral ptosis, 144$ • Vision: aviation, 1549-1 general, 1426-1432. (See Physical examination, eye.) (See Physical standards, vision.) Visitors, naval hospital, 1621. Vocal cords, paralysis, 1455. Volunteer Naval Reserve: Dental Corps, 281. Medical Corps, 171. Voucher. (See Property, accounting.) Waiver, 1407, 1414- health record, 2263. Naval Reserve, 171, 281. physical defect upon appointment, 117. Ward, naval hospital, 1672. annual sanitary report, 2701. expense analysis register, 3103. medical officer, 1665. report (Form 9), 3456. Warfare, chemical. (See Chemical war- fare.) Warrant officer: (See Personnel.) (See Physical examination.) (See Physical standards.) Wassermann test, 1506, 1507. Watch bill, 835, 862. Watch officer, 1666. Watches, 1625. medical officers, afloat, 821. Water, 2610. allowance: afloat, 2610. field service, 2665, 2666. closets, (See Toilet facilities.) harbor, 2603. purification, 2610, 2667. sanitation, 2603, 2610, 2667. supply: for battle-dressing station, 878. field service, 2665. sanitary report: hospital, 2701. intelligence, 2711. ship, 2699. station, 2697, 2700. Web fingers and toes, 1511. Weight, 1440, 144®- (See Physical standards, weight.) Whispered voice test, 1562. Willfulness, 1516. Women: (See Physical examination.) (See Physical standards.) Woolens, disinfection, 2854- Work request. (See Property, procure- ment.) Wound dressing, 836. Wounded, 807, 887, 888. Xerophthalmia, 1429. X-ray: accounting, 3103. equipment procurement, 3051. film, disposal, 3078. 53 X INDEX X-ray—Continued. (See Physical examination, x-ray.) room, 1680. XY, meaning, 2402. Yard: calculation of complement, 2406. craft personnel, statistical report, 2407. dental officer, 273. Y ard—Continued, labor, payment, 3023. medical officer, 1121. medical reports, 3554. Yellow fever, 2822. incubation period, 2820, 2822. quarantine laws, aircraft, 2808. quarantine regulations, 2812. report of, 2694- 54 MANUAL OF THE MEDICAL DEPARTMENT OF THE UNITED STATES NAVY APPENDIX APPENDIX A Nomenclature of Diseases and Injuries Sections II, III, and IV APPENDIX B Supply Table and Supplementary Supply Table APPENDIX C Geneva and Hague Conventions and American National Red Cross APPENDIX D Bureau Circular Letters [I] APPENDIX, MANUAL OF THE MEDICAL DEPARTMENT BUREAU DIRECTIVE July 1, 1939. The Manual of the Medical Department, 1938, will become effective July 1, 1939. The appendix of the manual is provided to include certain informa- tion and Bureau of Medicine and Surgery instructions not suitable for incorporation in the manual. Appendix A, the nomenclature, is published here for convenience in revision. It will be utilized as directed in chapter 15. The Supply Table and Supplementary Supply Table are included in appendix B for the same reason and will be utilized as directed in chapter 20. Copies of current Geneva and Hague Conventions and the function of the American Red Cross are published in appendix C for the infor- mation and guidance of Medical Department personnel. The circular letters published in appendix D are issued by the Chief of the Bureau of Medicine and Surgery as directives to personnel of the Medical Department of the Navy for information and compliance and will supersede all prior issues on July 1, 1939. These letters are presented in a form to fit into the manual for the convenience of the service and are designated by the issuing division of the Bureau. Each circular letter will be reviewed annually by the issuing division and revisions will be published to the service to take effect on July 1. Circular letters issued to the service during the interval between revisions will be added to the appropriate letter group and subject entry made in the table of contents. Corrections for the manual and appendix published to the service shall be made promptly. Inspecting officers shall assure themselves that these publications have been corrected to date. Ross T. McIntire. II APPENDIX A MANUAL OF THE MEDICAL DEPARTMENT SECTION II. NOMENCLATURE OF DIAGNOSTIC TITLES A. TITLES BY DIAGNOSTIC CLASSES B. ALPHABETICAL LISTING OF TITLES 1. Diseases and Conditions 2. Injuries t. Poisonings A. TITLES BY DIAGNOSTIC CLASSES The following lists show the classification of the nomenclature as used by the Bureau to group diseases and injuries for statistical purposes. The class in which a diagnostic title is listed sometimes furnishes a clue to the selection of a title that will best fit the case. Classification of Diseases and Injuries, United States Navy Class I. Diseases of blood. II. Diseases of circulatory system. III. Diseases of digestive system. IV. Diseases of ductless glands and spleen. (Endocrines.) V. Diseases of ear, nose, and throat. VI. Diseases of eye and adnexa. VII. Diseases of genito-urinary system (nonvenereal). VIII. Communicable diseases transmissible by oral and nasal dis- charges. IX. Communicable diseases transmissible by intestinal discharges. X. Communicable diseases transmissible by insects and other arthropods. XI. Tuberculosis (all forms). XII. Venereal diseases. XIII. Other diseases of infective type. XIV. Diseases of lymphatic system. XV. Diseases of mind. XVI. Diseases of motor system. XVII. Diseases of nervous system. XVIII. Diseases of respiratory system. 1 APPENDIX A.—DIAGNOSTIC NOMENCLATURE SEC. EL—A Class XIX. Diseases of skin, hair, and nails. XX. Hernia. XXI. Miscellaneous diseases and conditions. XXII. Parasitic diseases (fungi and certain animal parasites). XXIII. Tumors. XXIV. Female diseases and conditions. XXV. Injuries. XXVI. Poisonings. XXVII. Dental diseases and conditions. Navy diag- nosis No. lxy. Other diseases of this class. State title. 100. Anemia, Sickle Cell. 101. Anemia, Pernicious. 102. Anemia, Secondary. State cause if known. 103. Anemia, Splenic. 104. Anemia. Otherwise unclassified. State type. 105. Chlorosis. Granulocytopenia, Malignant. (See 112.) 106. Hemophilia. Jaundice, Hemolytic. (See 113.) 107. Leukemia, Acute. State type. Leukemia, Chronic. (See 114.) Mononucleosis, Infectious. (See 115.) Class I.—Diseases of blood Navy diag- nosis No. 108. Polycythemia Vera. 109. Purpura Hemorrhagica. 110. Purpura Rheumatica. 111. Purpura Simplex. 112. Granulocytopenia, Malignant. 113. Jaundice, Hemolytic. State whether acquired or famil- ial. 114. leukemia, Chronic. State type. 115. Mononucleosis, Infectious. (Glandular fever.) Navy diag- nosis No. 2xy. Other diseases of this class. State title. 200. Aneurysm, Heart. 201. Aneurysm, Varicose. State artery. 202. Aneurysm. Otherwise unclassified. State artery. 203. Aneurysmal Varix. State artery. 204. Angina Pectoris. 205. Angioneurotic Edema. 206. Aortitis. 207. Apoplexy. When cause is known re-port as Hemorrhage, Cere- bral (1720), Embolism, Cere- bral (221) or Thrombosis, Cerebral (238). 208. Hypertension, Arterial. 209. Arteriosclerosis, Cerebral. Class II.—Diseases of circulatory system Navy diag- nosis No. 210. Arteriosclerosis, General. Arteriosclerosis, Local. (See 252.) 211. Bradycardia. 212. Cardiac Arrhythmia, Auricular Fi- brillation. 213. Cardiac Arrhythmia, Auricular Flutter. Cardiac Arrhythmia, Heart Block. (See 227.) Cardiac Arrhythmia, Paroxys- mal Tachycardia. (See 254.) 214. Cardiac Arrhythmia, Premature Contractions. 215. Cardiac Arrhythmia, Sinus Ar- rhythmia. Cardiac Arrhythmia. Otherwise unclassified. (See 255.) CLASS II.—DISEASES OF CIRCULATORY SYSTEM Navy diag- nosis No. 216. Cardiac Disorder, Functional. Carditis, Acute. {See 253.) Coronary Heart Disease, Ar- teriosclerotic. {See 237.) Coronary thrombosis, acute, or coronary occlusion, acute, when due to thrombus. Report as Thrombosis, coronary artery (239). 217. Dilatation, Aortic Arch. 218. Dilatation, Cardiac, Acute. 219. Dilatation, Cardiac, Chronic. 220. Heart Disease, Congenital. State type.' 221. Embolism, Cerebral. 222. Syncope. 223. Embolism. Otherwise unclassified. State location. 224. Endarteritis. State location. 225. Endocarditis, Acute. Endocarditis, Acute Ulcera- tive. {See 250.) Endocarditis, Chronic. {See 257.) Endocarditis, Subacute Bac- terial. {See 256.) 226. Epistaxis. 227. Cardiac Arrhythmia, Heart Block. Heart Disease, Congenital. {See 220.) Hypertension, Arterial. {See 208.) Hypertensive Heart Disease. {See 258.) 228. Hypertrophy, Heart. Hypotension, Arterial. {See 259.) 229. Mediastino-pericarditis. Myocarditis, Acute. {See 260.) 230. Myocarditis, Chronic. State cause if known. Palpitation, cardiac. Report as Cardiac Disorder, Function- al (216). 231. Pericarditis, Acute. Pericarditis, Chronic. {See 248.) 232. Phlebitis. State location. Navy diag- nosis No. 233. Pneumopericardium. 234. Pneumopyopericardium. 235. Pylephlebitis. Syncope. {See 222.) 236. Tachycardia. 237. Coronary Heart Disease, Ar- teriosclerotic. Not to include acute coronary thrombosis. Thrombo-angiitis Obliterans. {See 251.) 238. Thrombosis, Cerebral. 239. Thrombosis. State vessel. 240. Trench Foot. 241. Valvular Heart Disease, Aortic In- sufficiency. 242. Valvular Heart Disease, Aortic Ste- nosis. 243. Valvular Heart Disease, Aortic and Mitral. 244. Valvular Heart Disease, Mitral In- sufficiency. 245. Valvular Heart Disease, Mitral Stenosis. 246. Valvular Heart Disease, Pulmonic. 247. Valvular Heart Disease, Tricuspid. 248. Pericarditis, Chronic. 249. Varicose Veins. State location. 250. Endocarditis, Acute Ulcerative. {Malignant.) 251. Thrombo-angiitis Obliterans. State location. 252. Arteriosclerosis, Local. State artery. 253. Carditis, Acute. 254. Cardiac Arrhythmia, Paroxys- mal Tachycardia. 255. Cardiac Arrhythmia. Other- wise unclassified. State type. 256. Endocarditis, Subacute Bac- terial. 257. Endocarditis, Chronic. 258. Hypertensive Heart Disease. 259. Hypotension, Arterial. 260. Myocarditis, Acute. State cause if known. 3 APPENDIX A.—DIAGNOSTIC NOMENCLATURE SEC. II. A system (dental conditions excluded) Navy diag- nosis No. 322. Enteritis, Acute. Not to include Food Infection (1330). Food Intoxication (1331), Food Poisoning, Bacterial (1332), or Allergy (2166). Enteritis, Chronic. (See 384.) 323. Enterocolitis, Acute. Not to include Food Infection (1330), Food Intoxication (1331), Food Poisoning, Bacterial (1332), or Allergy (2166). Enterocolitis, Chronic. (See 385). Enterolith. Report as Calculus, intestine (2116). Enteroptosis. Report as Splanch- noptosis (362). 324. Esophagitis. 325. Fissure, Anus. 326. Fistula, Biliary. 327. Fistula, Fecal. 328. Fistula in Ano. 329. Cholelithiasis. Gallstones. Report as Cholelith- iasis (329). 330. Gastritis, Acute. Gastritis, Chronic. (See 386.) 331. Gastroduodenitis. 332. Gastro-enteritis, Acute. Not to tn.- clude Food Infection (1330), Food Intoxication (13 31), Food Poisoning, Bacterial (1332), or Allergy (2166). Gastro-enteritis, allergic. Report as Allergy (2166). Gastro-enteritis, Chronic. (See 387.) 333. Gastroptosis. 334. Glossitis. 335. Hematemesis. 336. Hemorrhoids. Hepatitis, Acute. (See 388.) Hepatitis, Chronic. (See 389.) 337. Hyperchlorhydria. 338. Hypochlorhydria. Impacted feces. Report as Ob- struction, Intestinal, from Internal Causes. (342). Class III.—Diseases of digestive Navy diag- nosis No. 3xy. Other diseases of this class. State title. 300. Abscess, Periproctic. 301. Abscess, Subphrenic. 302. Achylia Gastrica. 303. Aerophagia. 304. Appendicitis, Acute. Appendicitis, Chronic. (See 378. 305. Artificial Anus. 306. Atrophy, Liver, Yellow, Acute. 307. Parotitis. Not to include Mumps (810). 308. Cardiospasm. 309. Cholangitis, Acute. Cholangitis, Chronic. (See 379. 310. Cholecystitis, Acute. Cholecystitis, Chronic. (See 380. Cholelithiasis. (See 329.) Chyle cyst of mesentery. Report as Cyst (2305). 311. Chylous Ascites, Nonfilarial. 312. Cirrhosis, Liver, Atrophic. 313. Cirrhosis, Liver, Hypertrophic. 314. Cirrhosis, Liver. Otherwise unclas- sified. State variety. 315. Colitis, Acute. Colitis, Chronic. (See 381.) Colitis, Ulcerative. (See 382.) 316. Constipation. Diarrhea, Chronic, Cause Un- known. (See 394.) Dilatation, colon, congenital (Hirschsprung’s disease). Re- port as Deformity, Congenital (2138). 317. Dilatation, Stomach, Acute. 318. Dilatation, Stomach, Chronic. 319. Displacement, Liver. 320. Diverticulitis, Intestinal. Diverticulosis, Intestinal. (See 383.) 321. Duodenitis. 4 CLASS III. DISEASES OF DIGESTIVE SYSTEM Navy diag- nosis No. 339. Inflammation, Salivary Gland. Intussusception. Report as Ob- struction, Intestinal, from External Causes (341). Irritable Colon. (See 390.) 340. Neurosis, Intestinal. Noma. Report as Stomatitis, Gangrenous (366). 341. Obstruction, Intestinal, from Ex- ternal Causes. (Angulations, kinks, adhesions, volvulus, intus- susception.) 342. Obstruction, Intestinal, from In- ternal Causes. (Stricture, gall- stones, enteroliths, foreign bod- ies, fecal masses.) 343. Obstruction, Intestinal, from Spas- tic or Paralytic Causes. (After injuries, operations, peritonitis.) 344. Obstruction, Intestinal. Otherwise unclassified. State cause if known. 345. Obstruction, Pancreatic Duct. 346. Pancreatitis, Acute. Pancreatitis, Chronic. (See 391.) Parotitis. (See 307.) 347. Perihepatitis. 348. Peritonitis, General, Acute. 349. Peritonitis, General, Chronic. 350. Peritonitis, Local, Acute. 351. Peritonitis, Local, Chronic. 352. Perversion, Appetite. 353. Proctalgia. 354. Proctitis. 355. Prolapse, Rectum. 356. Pyloric Incontinence. 357. Pylorospasm. 358. Regurgitation from Stomach. 359. Rumination. 360. Spasm, Esophagus. 361. Spasm, Rectum. 362. Splanchnoptosis. 363. Sprue. 364. Stenosis, Gall-Duct. 365. Stenosis, Pylorus. 366. Stomatitis, Gangrenous. 367. Stomatitis. Otherwise unclassified. 368. Stricture, Esophagus. Navy diag- nosis No. 369. Stricture, Intestine. 370. Stricture, Rectum. 371. Ulcer, Duodenum. Ulcer, Duodenum, Perforated. (See 392). 372. Ulcer, Intestine. 373. Ulcer, Mouth. 374. Ulcer, Rectum. 375. Ulcer, Stomach. Ulcer, Stomach, Perforated. (See 393). Visceroptosis. Report as Splanch- noptosis (362). Volvulus. Report as Obstruction, Intestinal, from External Causes (341). 376. Vomiting. 377. Xerostomia. 378. Appendicits, Chronic. 379. Cholangitis, Chronic. 380. Cholecystitis, Chronic. 381. Colitis, Chronic. 382. Colitis, Ulcerative. 383. Diverticulosis, Intestinal. 384. Enteritis, Chronic. 385. Enterocolitis, Chronic. 386. Gastritis, Chronic. 387. Gastro-enteritis, Chronic. 388. Hepatitis, Acute. 389. Hepatitis. Chronic. 390. Irritable Colon. 391. Pancreatitis, Chronic. 392. Ulcer, Duodenum, Perforated. 393. Ulcer, Stomach, Perforated. 394. Diarrhea, Chronic, Cause Un- known. 5 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—A Class IV.—Diseases of ductless glands and spleen Navy diag- nosis No. 4xy. Other diseases of this class. State title. 400. Acromegalia. 401. Addison’s Disease. 402. Adrenalitis. 403. Gigantism. 404. Diabetes Mellitus. Dysinsulinism. (See 417.) 405. Dyspituitarism. 406. Endocrinopathy. Otherwise un- classified. State variety. Gigantism. (See 403.) 407. Goiter, Simple. Goiter, Adenomatous. (See 419). 408. Goiter, Exophthalmic. Hyperparathyroidism. (See 420 409. Hyperthyroidism. Not to include Goiter, Exophthalmic (408). Hypoparathyroidism. (See 421.) Hypopituitarism. (See 422.) Navy diag- nosis No. 410. Hypothyroidism. 411. Myxedema. 412. Perisplenitis. 413. Persistent Thymus Gland. 414. Splenitis. 415. Splenoptosis. 416. Thyroiditis, Acute. Thyroiditis, Chronic. (See 418. 417. Dysinsulinism. 418. Thyroiditis, Chronic. 419. Goiter, Adenomatous. 420. Hyperparathyroidism. 421. Hypoparathyroidism. 422. Hypopituitarism. Class V.—Diseases of ear, nose, and throat Navy diag- nosis No. 5xy. Other diseases of this class. State title. 500. Abscess, Peritonsillar. 501. Abscess, Retropharyngeal. 502. Adenoids. 503. Angina, Ludwig’s. 504. Ankylosis, Ossicles. 505. Cerumen Accumulation. 506. Deafness, Bilateral. Not to in- clude Deafness Due to Heavy Firing (2515). 507. Deafness, Unilateral. State ear. Defective hearing. Report as Deaf- ness, Bilateral (506). 508. Deviation, Nasal Septum. 509. Edema, Glottis. 510. Elongation, Uvula. 511. Epiglottiditis. Ethmoiditis. Report as Sinusitis, Ethmoidal (534). 512. Laryngitis, Chronic. 513. Mastoiditis, Acute. Mastoiditis, Chronic. (See 528.) 514. Mutism. Navy diag- nosis No. 515. Myringitis, Acute. Myringitis, Chronic. (See 542.) 516. Neurosis, larynx. 517. Neurosis, Pharynx. 518. Otitis, Externa. 519. Otitis, Interna. 520. Otitis, Media, Acute. Otitis Media, Chronic. (See 543.) 521. Otosclerosis. 522. Ozena. 523. Pansinusitis. 524. Paralysis, Vocal Cords. 525. Perforated Nasal Septum. 526. Pharyngitis, Chronic. 527. Polypus, Nasal. 528. Mastoiditis, Chronic. 529. Rhinitis, Atrophic. 530. Rhinitis, Hypertrophic. 531. Rhinolith, 532. Rhinoscleroma. 533. Salpingitis, Eustachian, Acute. Salpingitis, Eustachian, Chronic. (See 544.) CLASS VI.—DISEASES OF EYE AND ADNEXA Navy diag- nosis No. 534. Sinusitis, Ethmoidal. 535. Sinusitis, Frontal. 536. Sinusitis, Maxillary. 537. Sinusitis, Sphenoidal. 538. Spur, Nasal Septum. 539. Stricture, Pharynx. 540. Tonsillitis, Chronic. 541. Ulcer, Nasal Passage. Navy diag- nosis No. 542. Myringitis, Chronic. 543. Otitis Media, Chronic. 544. Salpingitis, Eustachian, Chronic. Class VI.—Diseases of eye and adnexa Navy diag- nosis No. 6xy. Other diseases of this class. State title. 600. Amblyopia. 601. Ankyloblepharon. Aphakia. (See 673.) 602. Astigmatism, Compound Hyper- opic. Astigmatism, Compound Myopic. (See 669.) Astigmatism, Mixed. (See 670.) Astigmatism, Simple Hyperopic. (See 671.) Astigmatism, Simple Myopic. (See 672.) 603. Blepharitis. 604. Blindness, Bilateral. 605. Blindness, Unilateral. State eye. 606. Cataract. 607. Chalazion. Chorioretinitis. (See 658.) 608. Choroiditis. 609. Color Blindness. Conical cornea. Report as Kera- toconus (639). 610. Conjunctivitis, Catarrhal. 611. Conjunctivitis, Follicular. 612. Conjunctivitis, Phlyctenular. 613. Conjunctivitis, Purulent. 614. Conjunctivitis, Vernal. 615. Conjunctivitis. Otherwise unclassi- fied. State variety. 616. Uveitis. 617. Cyclitis. 618. Dacryadenitis. 619. Dacryocystitis. 620. Detachment, Choroid. Navy diag- nosis No. 621. Detachment, Retina. 622. Ectropion. 623. Entropion. 624. Epiphora. 625. Exophthalmos. 626. Glaucoma. 627. Hemianopsia. 628. Hordeolum. 629. Hyalitis. 630. Hyperemia, Conjunctiva. 631. Ptosis, Eyelid. State cause if known. 632. Hyperopia. 633. Hypopyon. 634. Insufficiency, Ocular Muscle. 635. Iridochoroiditis. 636. Iridocyclitis. 637. Iritis. 638. Keratitis. 639. Keratoconus. 640. Kerato-iritis. 641. Keratomalacia. 642. Myopia. 643. Neuritis, Optic. 644. Neuroretinitis. 645. Night Blindness. 646. Nystagmus. 647. Opacity, Cornea. 648. Opacity, Vitreous Humor. 649. Ophthalmia, Sympathetic. 650. Ophthalmoplegia. 651. Panophthalmitis. 652. Papillitis. To include papilledema or choked disk. 653. Paralysis, Ocular Muscle. 654. Presbyopia. 7 APPENDIX A.—DIAGNOSTIC NOMENCLATURE SEC. II.—A Navy diag- nosis No. 655. Pterygium. Ptosis, Etelid. {See 631.) 656. Retinitis. 657. Scleritis. 658. Chorioretinitis. Snow blindness. Report as Oph- thalmia, Actinic Rays (2569). 659. Staphyloma, Cornea. 660. Stenosis, Nasal Duct. 661. Stenosis, Punctum Lacrymale. 662. Strabismus. 663. Symblepharon. 664. Synechia. 665. Trachoma. 666. Trichiasis. Navy diag- nosis No. 667. Ulcer, Cornea. Uveitis. {See 616.) 668. Xerophthalmia. 669. Astigmatism, Compound My- opic. 670. Astigmatism, Mixed. 671. Astigmatism, Simple Hyper- opic. 672. Astigmatism, Simple Myopic. 673. Aphakia. Class VII.—Diseases of genito-urinary system, nonvenereal Navy diag- nosis No. 721. Hydronephrosis. 722. Impotence. 723. Incontinence, Urine. Not to in- clude Enuresis (711). Inflammation, spermatic cord. Re- port as Funiculitis (716). 724. Nephralgia. 725. Nephritis, Acute. Nephritis, Chronic. {See 753.) Nephrolithiasis. Report as Cal- culus, kidney (749). 726. Nephroptosis. 727. Orchitis, Acute, Nonvenereal. Orchitis, Chronic, Nonvene- real. {See 754.) 728. Paraphimosis. 729. Phimosis. Prostate, hypertrophy of. Report as Enlargement, Prostate (?10). 730. Prostatitis, Acute, Nonvenereal. Prostatitis. Chronic, Nonve- nereal. (See 755.) 731. Pyelitis, Acute. Pyelitis, Chronic. (See 756.) 732. Pyelonephritis. 733. Redundant Prepuce. 734. Redundant Scrotum. 735. Sclerosis, Corpus Cavernosum. 736. Seminal Emissions. Navy diag- nosis No. 7xy. Other diseases of this class. State title. 700. Abscess, Perinephritic. 701. Abscess, Periurethral. 702. Abscess, Perivesical. 703. Albuminuria. 704. Balanoposthitis. Calculus. Urinary system. {See 749.) 705. Chylocele, Nonfilarial. 706. Chyluria, Nonfilarial. 707. Congestion, Kidney. Cryptorchidism. {See 750.) 708. Cystinuria. 709. Cystitis, Acute, Nonvenereal. Cystitis, Chronic. {See 751.) 710. Enlargement, Prostate. Not to in- clude tumor or abscess. 711. Enuresis. {Bed-wetting.) 712. Epididymitis, Acute, Nonvenereal. Epididymitis, Chronic, Nonve- nereal. {See 752.) 713. Extravasation, Urine. 714. Fistula, Bladder. 715. Fistula, Recto-urethral. 716. Funiculitis. 717. Hematocele, Tunica Vaginalis. 718. Hematuria. 719. Hemoglobinuria. 720. Hydrocele, Tunica Vaginalis. 8 CLASS VIII. COMMUNICABLE DISEASES, ORAL, NASAL DISCHARGES Navy diag- nosis No. 737. Seminal Vesiculitis, Acute, Non- venereal. Seminal Vesiculitis, Chronic, Nonvenereal. (See 757.) 738. Spermatocele. 739. Spermatorrhea. 740. Sterility. 741. Stricture, Ureter. 742. Stricture, Urethra. 743. Suppression, Urine. 744. Ulcer, Bladder. 745. Ureteral Colic. 746. Ureteritis. 747. Urethritis, Acute, Nonvenereal. 748. Urethritis, Chronic, Nonvenereal. Varicocele. (See 758.) 749. Calculus. Urinary system. State location. 750. Cryptorchidism. Navy diag- nosis No. 751. Cystitis, Chronic, Nonvene- real. 752. Epididymitis, Chronic, Non- venereal. 753. Nephritis, Chronic. 754. Orchitis, Chronic, Nonvene- real. 755. Prostatitis, Chronic, Nonvene- real. 756. Pyelitis, Chronic. 757. Seminal Vesiculitis, Chronic, Nonvenereal. 758. Varicocele. Class VIII.—Communicable diseases transmissible by oral and nasal discharges (A) Diseases classed as communicable in standard health department practice Navy diag- nosis No. 8xy. Other diseases of this class. State title. 802. Cerebrospinal Fever, Meningococ- cic. 803. Chickenpox. 804. Diphtheria. 805. Diphtheritic Paralysis. Encephalitis, Lethargic (See 819.) 806. German Measles. 807. Glanders. 808. Influenza. Not to include influen- zal 'pneumonia. Navy diag- nosis No. 809. Measles. 810. Mumps. 811. Pneumonia, Broncho-. 812. Pneumonia, Lobar. State type if known. 813. Poliomyelitis, Anterior, Acute. 814. Scarlet Fever. Septic Sore Throat. (See 820.) 815. Smallpox. 816. Whooping Cough. 819. Encephalitis, Lethargic. 820. Septic Sore Throat. (B) Common infectious diseases of the respiratory type Navy diag- nosis No. 800. Angina, Vincent’s. 801. Catarrhal Fever, Acute. 817. Bronchitis, Acute. 818. Tonsillitis, Acute. 821. Laryngitis, Acute. 822. Pharyngitis, Acute. Navy diag- nosis No. 823. Rhinitis, Acute. Tonsillitis, Acute. (See 818.) 824. Tracheitis, Acute. 825. Tracheobronchitis, Acute. 9 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—A Class IX.—Communicable diseases transmissible by intestinal discharges Navy diag- nosis No. 9xy. Other diseases of this class. State title. 900. Cholera. 901. Dysentery, Bacillary. 902. Dysentery, Balantidic. Navy diag- nosis No. 903. Paratyphoid Fever. State type if known. 904. Typhoid Fever. Class X.—Corpmunicable diseases transmissible by insects and other arthropods Navy diag- nosis No. 10xy. Other diseases of this class. State title. Bartonellobis. {See 1014.) 1000. Blackwater Fever. {Hemoglobi- nuric fever.) 1001. Dengue. Dracontiasis. {See 1015.) 1002. Filariasis. State location and manifestation. Not to include Dracontiasis (1015) or On- chocerciasis (1016). 1003. Leishmaniasis. State species. 1004. Malaria. State type. (Benign tertian, malignant tertian, or quartan.) If induced, so state. (Par. 2404 (b).) 1005. Sandfly Fever. Onchocerciasis. {See 1016.) Oroya fever. Report as Bar- tonellosis (1014). Pappataci fever. Report as Sand- fly Fever (1005). Navy diag- nosis No. 1006. Plague. State whether bubonic, pneumonic, or septicemic. 1007. Relapsing Fever. 1008. Rocky Mountain Spotted Fever. Sandfly Fever. {See 1005.) 1009. Trench Fever. 1010. Trypanosomiasis. State species. 1011. Tularemia. 1012. Typhus Fever. Verruga 'peruviana. Report as Bartonellosis (1014). 1013. Yellow Fever. 1014. Bartonellosis. 1015. Dracontiasis. State location. 1016. Onchocerciasis. Class XI.—Tuberculosis, all forms Navy diag- nosis No. llxy. Other diseases of this class. State title. Lupus vulgaris. Report as Tu- berculosis, Skin (1106). 1100. Tuberculosis, General Miliary. 1101. Tuberculosis, Pulmonary, Acute General Miliary. 1102. Tuberculosis, Pulmonary, Acute Pneumonic. 1103. Tuberculosis, Pulmonary, Chronic, Active. State whether incipi- ent, moderately advanced, or far advanced. As based on National Tuberculosis Associa- tion classification. Navy diag- nosis No. 1104. Tuberculosis, Pulmonary, Chronic, Arrested. State whether incip- ient, moderately advanced, or far advanced. 1105. Tuberculosis. Otherwise unclassi- fied. State location. 1106. Tuberculosis, Skin. 10 CLASS XIII.—OTHER DISEASES OF INFECTIVE TYPE Class XII.—Venereal diseases Navy diag- nosis No. 1200. Chancroid. State location. 1201. Chancroidal Lymphadenitis. 1202. Gonococcus Infection, Conjunc- tiva. Gonococcus Infection, Epi- didymis. {See 1209.) 1203. Gonococcus Infection, Joint. 1204. Gonococcus Infection, Lymph Node. Gonococcus Infection, Pros- tate. {See 1210.) Gonococcus Infection, Semi- nal Vesicles. {See 1211.) 1205. Gonococcus Infection, Urethra. 1206. Gonococcus Infection. Otherwise unclassified. State location. Lymphogranuloma, Venereum. {See 1212.) 1207. Syphilis. Syphilis, Sero-positive Only. {See 1213.) Navy diag- nosis No. 1208. Verruca Acuminata, Venereal. 1209. Gonococcus Infection, Epi- didymis, 1210. Gonococcus Infection, Pros- tate. 1211. Gonococcus Infection, Semi- nal Vesicles. 1212. Lymphogranuloma,Venereum. 1213. Syphilis, Sero-positive Only. Without history, symptoms, or signs other than repeated and confirmed serological tests {blood). Not to include Neurosyphilis, Serolo- gical (1743). Navy diag- nosis No. 13xy. Other diseases of this class. State title. 1300. Abscess. Otherwise unclassified. State location. Not to include Furuncle (1312). 1301. Gas Bacillus Infection. State organism (if known) and location. 1302. Anthrax. Botulism. Report as Food In- toxication, Botulism (1303). 1303. Food Intoxication, Botulism. 1304. Carbuncle. State location. 1305. Cellulitis. State location. 1306. Dysentery. Otherwise unclassified State type. 1307. Psittacosis. 1308. Erysipelas. 1309. Fever, Cause Undetermined. Class XIII.—Other diseases of the infective type Navy diag- nosis No. 1310. Focal Infection. State location. Food Infection. (See 1330.) Food Intoxication. (See 1331.) Food Intoxication, Botulism. (See 1303.) Food poisoning, allergic. Report as Allergy {2166). Food Poisoning, Bacterial. (See 1332). 1311. Foot-and-Mouth Disease. Frambesia. Report as Yaws (1329). 1312. Furuncle. State location. The word “multiple” may be used for numerous locations. 1313. Mediastinitis. 1314. Gangrene, Infective. State or- ganism (if known) and location. Gas Bacillus Infection. (See 1301.) 11 APPENDIX A.—DIAGNOSTIC NOMENCLATURE SEC. II.—A Navy diag- nosis No. 1315. Histoplasmosis. Jaundice, Acute Infective. (See 1328.) 1316. Jaundice, Epidemic, Weil’s Dis- ease. 1317. Leprosy. Malta fever. Report as Undulant Fever (1326). Mediastinitis. (See 1313.) 1318. Miliary Fever. Psittacosis. (See 1307.) 1319. Pyemia. State organism if known. 1320. Rabies. 1321. Rat-bite Fever. 1322. Rheumatic Fever. 1323. Septicemia. State organism if known. 1324. Tetanus. Navy diag- nosis No. 1325. Toxemia, Bacterial. State organ- ism if known. 1326. Undulant Fever. 1327. Vaccinia. 1328. Jaundice, Acute, Infective. Epidemic type other than Weil’8 disease. 1329. Yaws. (Frambesia). 1330. Food Infection. State organ- ism and food. 1331. Food Intoxication. Otherwise unclassified. State organ- ism and food. 1332. Food Poisoning, Bacterial. State food. Navy diag- nosis No. 14xy. Other diseases of this class. State title. Abscess, Lymph Gland. (See 1407.) 1400. Bubo, Inguinal, Nonvenereal. 1401. Elephantiasis, Nonfilarial. Glandular fever. Report as Mono- nucleosis, Infectious (115). 1402. Hodgkin's Disease. 1403. Lymphadenitis. State location. Not to include Bubo, Inguinal, Nonvenereal (1400). Class XIV.—Diseases of lymphatic system Navy diag- nosis No. 1404. Lymphangiectasia. State loca- tion. 1405. Lymphangitis. State location. 1406. Status Lymphaticus. 1407. Abscess, Lymph Gland. State location. Class XV.—Diseases of mind Navy diag- nosis No. 15xy. Other diseases of this class. State title. 1500. Amnesia. 1501. Constitutional Psychopathic In- feriority Without Psychosis. 1502. Constitutional Psychopathic State, Criminalism. 1503. Constitutional Psychopathic State, Emotional Instability. 1504. Constitutional Psychopathic State, Inadequate Personality. Navy diag- nosis No. 1505. Constitutional Psychopathic State, Paranoid Personality. 1506. Constitutional Psychopathic State, Pathological Liar. 1507. Constitutional Psychopathic State, Sexual Psychopathy. 1508. Dementia Paralytica. (Paresis.) 1509. Dementia Praecox. (Schizophre- nia.) 1510. Dementia Pugilistica. 12 CLASS XV.—DISEASES OE MIND Navy diag- nosis No. 1511. Hypochondriasis. Idiocy. Report as Mental De- ficiency (1513). Imbecility. Report as Mental Deficiency (1513). Masturbation. (See 1541.) 1512. Melancholia, Involutional. 1513. Mental Deficiency. State whether idiot, imbecile, or moron. Moron. Report as Mental De- ficiency (1513). 1514. Nostalgia. (Homesickness.) 1515. Paranoia. 1516. Paranoid State. Paresis. Report as Dementia Paralytica (1508). Psychasthenia. Report as Psy- choneurosis, PsYCHASTHENIA (1536). 1517. Psychoneurosis, Anxiety Neu- rosis. 1518. Psychoneurosis, Compulsion Neu- rosis. Psychoneurosis, Hysteria. (See 1534.) Psychoneurosis, Neurasthe- nia. (See 1535.) Psychoneurosis, Occupational. (See 1539.) Psychoneurosis, Psychasthe- nia. (See 1536.) Psychoneurosis, Situational. (See 1521.) Psychoneurosis, Traumatic. (See 1540.) Psychoneurosis, War Neuro- sis. (See 1537.) Psychoneurosis, Unclassified. (See 1538.) 1519. Psychosis, Epileptic. 1520. Psychosis, Exhaustive. 1521. Psychoneurosis, Situational. Navy diag- nosis No. 1522. Psychosis, Intoxication, Alcoholic. 1523. Psychosis, Intoxication, Drug. State drug. 1524. Psychosis, Intoxication. Other exogenous toxins. State toxin. 1525. Psychosis, Manic Depressive. 1526. Psychosis, Senile. 1527. Psychosis, Traumatic. 1528. Psychosis with Infectious Disease. 1529. Psychosis with Organic Brain Disease. 1530. Psychosis with Other Disabilities. State disability. 1531. Psychosis, Unclassified. Schizophrenia. Report as Demen- tia Praecox (1509). 1532. Sexual Perversion. Shell shock. Report as Psycho- neurosis, War Neurosis (1537). 1533. Somnambulism. 1534. Psychoneurosis, Hysteria. 1535. Psychoneurosis, Neuras- thenia. 1536. Psychoneurosis, Psychasthe- nia. 1537. Psychoneurosis, War Neu- rosis. To include shell shock. 1538. Psychoneurosis, Unclassified. 1539. Psychoneurosis, Occupa- tional. 1540. Psychoneurosis, Traumatic. 1541. Masturbation. 13 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—A Class XVI.—Diseases of motor system Navy diag- nosis No. 16xy. Other diseases of this class. State title. 1600. Spur, Bone. State bone or joint. 1601. Ankylosis. State joint. 1602. Arthritis, Acute. State joint. Arthritis, Chronic. (See 1651.) 1603. Arthritis Deformans. State joint. 1604. Bursitis, Acute. State location. Bursitis, Chronic. (See 1652.) 1605. Calcification of Cartilage. 1606. Chondritis. State location. 1607. Chondromalacia. 1608. Contracture. State location. 1609. Coxa Valga. 1610. Coxa Vara. 1611. Cramp, Muscle. State muscle. 1612. Curvature, Spine. Epiphysitis. (See 1653.) 1613. Exuberant Callus. 1614. Flat Foot. 1615. Joint, Internal Derangement of. State joint. 1616. Fragilitas Ossium. 1617. Ganglion, Tendon Sheath. State location. 1618. Genu Recurvatum. 1619. Genu Valgum. 1620. Genu Varum. 1621. Hallux Valgus. 1622. Hallux Varus. 1623. Hammer Toe. 1624. Hernia, muscle, fascia, tendon, or sheath. State location. 1625. Hypertrophy, Bone. State loca- tion. Joint, Internal Derangement of. (See 1615.) 1626. leontiasis Ossea. 1627. loose Body in Joint. State joint. 1628. Loss of Substance of bone or cartilage. State location. Lumbago. Report as Myositis (1631 or 1654). 1629. Mallet Finger. 1630. Metatarsalgia. Navy diag- nosis No. 1631. Myositis, Acute. State location. Myositis, Chronic. (See 1654.) 1632. Myositis, Progressive, Ossifying. 1633. Myositis, Traumatic, Ossifying. State location. 1634. Myotonia, Congenita. 1635. Osgood-Schlatter Disease. 1636. Osteitis Deformans. (Paget’s disease.) Osteitis Fibrosa Cystica. (See 1655.) 1637. Osteo-arthropathy, Hypertrophic. Osteochondritis Deformans. (See 1656.) Osteochondritis Dessicans. (See 1657.) 1638. Osteomalacia. 1639. Osteomyelitis. State location. 1640. Paralysis, Muscle, Ischemic. State muscle. 1641. Perichondritis State location. 1642. Periostitis, Acute. State location Periostitis, Chronic. (See 1658.) Pes Cavus. (See 1650.) Pes planus. Report as Flat Foot (1614). 1643. Rheumatism, Muscular. 1644. Spondylitis. Spur Bone. (See 1600.) 1645. Synovitis, Acute. Nonsuppura- tive. State articulation. Synovitis, Chronic. (See 1659.) Synovitis, Suppurative. (See 1660.) 1646. Talipes. (Clubfoot.) 1647. Tenosynovitis, Acute. State lo- cation. Tenosynovitis, Chronic. (See 1649.) Torticolis. Report as Myositis (1631 or 1654). 1648. Trigger Finger. 1649. Tenosynovitis, Chronic. State location. 1650. Pes Cavus. 1651. Arthritis, Chronic. State joint. 14 CLASS XVII.—DISEASES OF NERVOUS SYSTEM Navy diag- nosis No. 1652. Bursitis, Chronic. State location. 1653. Epiphysitis. State location. 1654. Myositis, Chronic. State lo- cation. 1655. Osteitis Fibrosa Cystica. 1656. Osteochondritis Deformans. (Perthes’ or Legg’s disease.) 1657. Osteochondritis Dessicans. 1658. Periostitis, Chronic. State location. Navy diag- nosis No. 1659. Synovitis, Chronic. N o n - suppurative. State artic- ulation. 1660. Synovitis, Suppurative. State articulation. Class XVII.—Diseases of nervous system Navy diag- nosis No. 17xy. Other diseases of this class. State title. 1700. Abscess, Brain. 1701. Anosmia. 1702. Aphasia. 1703. Aphonia. 1704. Ataxia, Hereditary. (Friedreich’s disease.) 1705. Athetosis. Aviator’8 sickness or balloon sick- ness. Report as Hypobaro- PATHY (1728). 1706. Sclerosis, Combined. 1707. Catalepsy. Cerebrospinal Syphilis, Un- differentiated. (See 1744.) 1708. Chorea. 1709. Chorea, Progressive, Chronic. (Huntington’s.) Choriomeningitis, Benign, Lymphocytic. (See 1730.) 1710. Dystrophy, Progressive Muscular. 1711. Effort Syndrome. 1712. Effort Syndrome, Aviator. 1713. Encephalitis, Acute. Not to in- clude Encephalitis, Lethar- gic (819). Encephalitis, Chronic. (See 1729.) 1714. Epilepsy. Not to include Psy- chosis, Epileptic (1519). 1715. Epilepsy, Jacksonian. 1716. Hematomyelia. 1717. Hematorrhachis. Navy diag- nosis No. 1718. Hemiplegia, Old. 1719. Hemorrhage, Cerebellum. 1720. Hemorrhage, Cerebral. 1721. Hemorrhage, Epidural. 1722. Hemorrhage, Medulla. 1723. Hemorrhage, Pons. 1724. Hemorrhage, Subdural. 1725. Hernia, Brain. 1726. Hiccough. 1727. Hydrocephalus. 1728. Hypobaropathy. (Aviator's sick- ness or balloon sickness.) 1729. Encephalitis, Chronic. 1730. Choriomeningitis, Benign Lymphocytic. 1731. Meniere’s Disease. 1732. Meningitis, Cerebral. 1733. Meningitis, Cerebrospinal, Acute. Not to include Cerebrospinal Fever, Meningococcic (802). 1734. Meningitis, Cerebrospinal, Chronic. 1735. Migraine. 1736. Myasthenia Gravis. 1737. Myelitis, Disseminated. 1738. Myelitis, Transverse. Narcolepsy. (See 1740.) 1739. Neuralgia. 1740. Narcolepsy. 1741. Neuritis, Multiple. 1742. Neuritis. State nerve. 1743. Neurosyphilis, Serological. With- out neurological symptoms or signs other than laboratory findings. 15 APPENDIX A.—DIAGNOSTIC NOMENCLATURE SEC. II.—A Navy diag- nosis No. 1744. Cerebrospinal Syphilis, Un- differentiated. With symp- toms and, or, signs, hut not differentiated as to type. Not to include Tabes Dor- salis (1764) or Dementia Paralytica (1508). 1745. Spasm, Saltatory. 1746. Pachymeningitis, Cerebral. 1747. Pachymeningitis, Spinal. 1748. Paralysis Agitans. 1749. Paralysis, Ascending, Acute. 1750. Paralysis, Brown-Sequard’s. 1751. Paralysis. Otherwise unclassified. State nerve. 1752. Paramyoclonus Multiplex. 1753. Paraplegia, Ataxic. Poliomyelitis, Anterior, Chronic. (See 1758.) 1754. Raynaud’s Disease. Sciatica. Report as Neuritis, sciatic (1742). Sclerosis, Combined. (See 1706.) Navy diag- nosis No. 1755. Sclerosis, Disseminated. 1756. Sclerosis, lateral. 1757. Sclerosis, lateral Amyotrophic. 1758. Poliomyelitis, Anterior, Chronic. 1759. Spasm, Habit. 1760. Spasm, Nodding. Spasm, Saltatory. (See 1745.) 1761. Stammering. 1762. Stuttering. 1763. Syringomyelia. 1764. Tabes Dorsalis. 1765. Tic. Navv diag- nosis No. 18xy. Other diseases of this class. State title. 1800. Ankylosis, Arytenoid Cartilage. Anthracosis. (See 1826.) 1801. Asthma. Atelectasis. (See 1827.) 1802. Bronchiectasis. 1803. Bronchitis, Chronic. 1804. Chylothorax. 1805. Congestion, Lung, Acute. 1806. Edema, Lung. 1807. Emphysema, Pulmonary. Empyema. Report as Pleurisy, Suppurative (1815). 1808. Gangrene, Lung. 1809. Hay Fever. 1810. Hemoptysis. 1811. Hemothorax. 1812. Hernia, Lung. 1813. Pleurisy, Fibrinous, Acute. Pleurisy, Fibrinous, Chronic (See 1828.) Class XVIII.—Diseases of respiratory system Navy diag- nosis No. 1814. Pleurisy, Serofibrinous. 1815. Pleurisy, Suppurative. 1816. Pneumonia, Chronic, Interstitial. Pneumonia. Hypostatic. (See 1829.) 1817. Pneumoconiosis. Otherwise un- classified. State type. Not to include Anthracosis (1826) or Silicosis (1831). Pneumonitis, Acute. {See 1830.) Pneumonitis, Chronic, Non- Tuberculous. (See 1825). 1818. Pneumopyothorax. 1819. Pneumothorax. Silicosis. (See 1831.) 1820. Stenosis, Bronchus. 1821. Stenosis, larynx. 1822. Stenosis, Trachea. 1823. Tracheitis, Chronic. Tracheobronchitis, Chronic. (See 1832.) 16 CLASS XIX.—DISEASES OF SKIN, HAIR, AND NAILS Navy diag- nosisNo . 1824. Tracheocele. 1825. Pneumonitis, Chronic, Non- tuberculous. 1826. Anthracosis. 1827. Atelectasis. 1828. Pleurisy, Fibrinous, Chronic, 1829. Pneumonia, Hypostatic. Navy diag- nosis No. 1830. Pneumonitis, Acute. 1831. Silicosis. 1832. Tracheobronchitis, Chronic. Class XIX.—Diseases of skin, hair, and nails Navy diag- nosis No. 19xy. Other diseases of this class. State title. 1900. Acne. State variety and location. 1901. Albinism. 1902. Alopecia. 1903. Alopecia Areata. 1904. Anhidrosis. Bed sore. Report as Ulcer, Decubital (1965). 1905. Bromidrosis. 1906. Callosity. 1907. Chilblain. (Pernio.) 1908. Chloasma. 1909. Chromidrosis. 1910. Cicatrix, Skin. State location. 1911. Clavus. (Corn.) 1912. Comedo. Corn. Report as Clavus (1911). 1913. Cutaneous Horn. (Cornu.) 1914. Dermatitis Herpetiformis. Dermatitis, Industrial. (See 1951.) 1915. Dermatitis Seborrheica. 1916. Dermatitis Venenata. State cause. 1917. Dermatitis. Otherwise unclassi- fied. State variety. 1918. Dysidrosis. 1919. Ecthyma. 1920. Eczema. 1921. Erysipeloid. 1922. Erythema Multiforme. 1923. Erythema Nodosum. 1924. Erythema Scarlatiniforme. 1925. Erythema. Otherwise unclassi- fied. State variety. 1926. Erythrasma. 1927. Fissure, Skin. Navy diag- nosis No. 1928. Folliculitis. 1929. Folliculitis Decalvans. Granuloma Inguinale, Non- venereal. (See 1942.) 1930. Herpes. 1931. Herpes Zoster. 1932. Hyperhidrosis. 1933. Ichthyosis. 1934. Impetigo Contagiosa. 1935. Impetigo Herpetiformis. 1936. Impetigo. Otherwise unclassi- fied. State variety. 1937. Ingrowing Nail. 1938. Intertrigo. 1939. Keloid. State location. 1940. Keratoderma. 1941. Keratosis. 1942. Granuloma Inguinale, Non- venereal. Leukoderma. Report as Vitiligo i (1969). 1943. Leukoplakia. (Leukokeratosis.) 1944. Lichen Planus. 1945. Lichen Ruber. 1946. Lichen. Otherwise unclassified. State variety. 1947. Lupus Erythematosus. Lupus vulgaris. Report as Tuber- culosis, Skin (1106). 1948. Melanoderma. Miliaria. Report as Pricklt Heat (1956). 1949. Milium. • 1950. Molluscum Contagiosum. 1951. Dermatitis, Industrial. State cause. 1952. Onychauxis. APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—A Navy diag- nosis No. 1953. Onychia. 1954. Pemphigus. 1955. Pityriasis Rosea. Pityriasis simplex. Report as Dermatitis Seborrheica (1915). 1956. Prickly Heat. (Miliaria ruber.) 1957. Prurigo. 1958. Pruritis. State location. 1959. Psoriasis. 1960. Scleroderma. 1961. Seborrhea. 1962. Skin Donor. 1963. Sudamina. 1964. Sycosis. Not to include Fungus Infection Skin (2212). Navy diag- nosis No. 1965. Ulcer, Decubital. 1966. Ulcer, Skin. State location. 1967. Urticaria. (Allergic.) 1968. Urticaria, Pigmentosa. 1969. Vitiligo. 1970. Xeroderma Pigmentosa. Class XX.—Herniae Navy diag- nosis No. 20xy. Other diseases of this class. State title. 2000. Enlarged Inguinal Ring. Hernia, Diaphragmatic. (See 2012.) 2001. Hernia, Epigastric. 2002. Hernia, Femoral. 2003. Hernia, Inguinal, Indirect. (Exter- nal.) 2004. Hernia, Inguinal, Direct. (Inter- nal.) 2005. Hernia, Ischiadic. 2006. Hernia, Ischiorectal. 2007. Hernia, lumbar. 2008. Hernia, Obturator. Navy diag- nosis No. 2009. Hernia, Recurrent, After Opera- tion. State type. One of the types given in Class XX. Hernia, Strangulated. (See 2013.) Hernia, traumatic. (See title 2571 under injuries.) 2010. Hernia, Umbilical. 2011. Hernia, Ventral. 2012. Hernia, Diaphragmatic. 2013. Hernia, Strangulated. State type. One of the types given in Class XX. Class XXI.—Miscellaneous diseases and conditions Navy diag- nosis No. 21xy. Other diseases of this class. State title. 2100. Absence Acquired. State organ or part. Not to include Ampu- tation, Traumatic (2572). 2101. Absence, Congenital. State or- gan or part. Navy diag- nosis No. 2102. Accessory. State organ or part. 2103. Polypus. Otherwise unclassi- fied. State location. 2104. Adhesions. State location. 2105. Adiposis Dolorosa. 18 CLASS XXI. MISCELLANEOUS DISEASES AND CONDITIONS Navy diag- nosis No. 2106. Alcoholism, Acute. Not to in- clude Psychosis, Intoxication, Alcoholic (1522) or Deliri- um, Alcoholic (2160). Alcoholism, Chronic. (See 2159.) 2107. Alkalosis. Allergy. Otherwise unclassified. (See 2166.) 2108. Amyloid Disease. State location. 2109. Anaphylaxis. State cause. Within 24 hours. If after 24 hours report as Serum Sickness (2165). 2110. Gout, Chronic. 2111. Anti-inoculation. State disease. 2112. Atony. State organ or part. 2113. Atresia, Acquired. State loca- tion. 2114. Atrophy. State organ or part. 2115. Beriberi. Blood Donor. (<866 2167.) 2116. Calculus. Otherwise unclassified. State location. 2117. Carrier. State micro-organism. Cervical rib. Report as Acces- sory rib (2102). 2118. Concretion. State location. 2119. Defective Physical Development. 2120. Deformity, Acquired. State loca- tion. Deformity, Congenital. (See 2138.) Delirium, Alcoholic. (See 2160.) 2121. Diabetes Insipidus. 2122. Diagnosis Undetermined. State suspected disease or condition. (See par. 2409.) 2123. Diverticulum. State location. Drug Addiction. (See 2161.) 2124. Erythromelalgia. Fainting. Report as Syncope (222). 2125. Fistula. Otherwise unclassified. State location. Foreign Body, Nontraumatic. (See 2164.) Navy diag- nosis No. 2126. Hydrocele. Otherwise unclas- sified. State location. 2127. Gangrene. Otherwise unclassified. State cause (if known) and location. 2128. Mastitis, Male, Chronic. 2129. Glycosuria. 2130. Gout, Acute. Gout, Chronic. (.See 2110.) Gynecomastia. Report as Fibro- adenoma, male breast (2336). Hare lip. Report as Deformity, Congenital, lip (2138). 2131. Headache. Hematocele. Otherwise unclas- sified. (See 2134.) 2132. Hemochromatosis. 2133. Hemorrhage. Otherwise unclassi- fied. State location. Hydrocele. Otherwise unclassi- fied. (See 2126.) 2134. Hematocele. Otherwise un- classified. State location. 2135. Infarction. State location. 2136. Insomnia. 2137. lipemia. 2138. Deformity, Congenital. State organ or part. 2139. Malingering. (See par. 2402-(d).) 2140. Malnutrition. Mastitis, Male, Acute. (See 2162.) Mastitis, Male, Chronic. (See 2128.) 2141. Mikulicz’s Disease. Morphinism. Report as Drug Addiction (2161). Nausea marina. Report as Sea- sickness (2151). 2142. Necrosis. State location. Neurosis. Otherwise unclassi- fied. (See 2163.) 2143. No Disease. State reason for taking up on sick list. (See par. 2402 (e).) 2144. Obesity. If of endocrine origin report as Hypothyroidism (410), Endocrinopathy (406), etc. 19 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II. A Navy diag- nosis No. 2145. Ochronosus. 2146. Ossification. State location. 2147. Pellagra. Polypus. Otherwise unclassified. {See 2103.) 2148. Rickets. 2149. Rupture, Nontraumatic. State organ or part. Not to be used for hernia or ruptured peptic ulcer. 2150. Scurvy. 2151. Seasickness. 2152. Senility. Serum Sickness. {See 2165.) 2153. Shock. 2154. Sinus. State location. 2155. Tetany. 2156. Torsion, Nontraumatic. State location. 2157. Ulcer. Otherwise unclassified. State location. 2158. Vertigo. 2159. Alcoholism, Chronic. Not to include Psychosis, Intoxi- cation, Alcoholic (1522) or Delirium, Alcoholic (2160). 2160. Delirium, Alcoholic. Navy diag- nosis No. 2161. Drug Addiction. State drug. When associated with psy- chosis report as Psychosis, Intoxication, Drug (1523). 2162. Mastitis, Male, Acute. 2163. Neurosis. Otherwise unclas- sified. State organ or part. 2164. Foreign Body, Nontraumatic. State nature and location. 2165. Serum Sickness. After 24 hours. If within 24 hours report as Anaphylaxis (2109). 2166. Allergy. Otherwise unclassi- fied. State cause if known and manifestation. Not to include Asthma (1801), Hay Fever (1809), or Urticaria (1967). 2167. Blood Donor. Class XXII. Parasitic diseases (fungi and certain animal parasites) Navy diag- nosis No. 22xy. Other diseases of this class. State title. 2200. Abscess, Amebic. State loca- tion. 2201. Actinomycosis. State location. 2202. Amebiasis. Not to include Ab- scess, Amebic (2200) or Dysentery, Amebic (2209). Ankylostomiasis. Report as Hookworm Disease (2213). 2203. Ascariasis. 2204. Aspergillosis. Black Tongue. {See 2219.) Navy diag- nosis No. 2205. Blastomycosis. Cestoda infection. Report as Teniasis (2235). Coccidioidal Granuloma. {See 2233.) 2206. Coccidiosis. 2207. Cysticercosis. State location. 2208. Flagellate Infection, Intes- tinal. State species. 2209. Dysentery, Amebic. 2210. Trichuriasis. 20 CLASS XXIII. TUMORS Navy diag- nosis No. 2211. Echinococcosis. Epidermophytosis. Report as Fungus Infection, Skin (2212). Favus. (See 2237.) Flagellate Infection, Intes- tinal. (See 2208.) 2212. Fungus Infection, Skin. Other- wise unclassified. State loca- tion. To include trichophytosis and epidermophytosis. Giardiasis. Report as Flagel- late Infection, Intestinal (2208). 2213. Hookworm Disease. 2214. Larva Migrans. 2215. Mucormycosis. 2216. Mycetoma. 2217. Mycosis Fungoides. 2218. Myiasis. 2219. Black Tongue. 2220. Oxyuriasis. 2221. Paragonimiasis. 2222. Pediculosis. State location. 2223. Piedra. 2224. Pinta. 2225. Pityriasis Versicolor. Ringworm. Report as Fungus Infection, Skin (2212). 2226. Tungiasis. 2227. Scabies. Navy diag- nosis No. 2228. Schistosomiasis, Japonicum, Bili- ary. 2229. Schistosomiasis, Intestinal. 2230. Schistosomiasis, Urinary. 2231. Spirochetosis. Otherwise unclassi- fied. State species and loca- tion. 2232. Sporotrichosis. 2233. Coccidioidal Granuloma. 2234. Strongyloidiasis. 2235. Teniasis. (Tapeworm infection.) State species. 2236. Thrush. 2237. Favus. 2238. Trichinosis. (Trichiniasis.) Trichomoniasis. Report as Flag- ellate Infection, Intestinal (2208). Trichophytosis. Report as Fun- gus Infection, Skin (2212). Trichuriasis. (See 2210.) Tungiasis. (See 2226.) Uncinariasis. Report as Hook- worm Disease (2213). Navy diag- nosis No. 23xy. Other diseases of this class. State title. Adamantinoma. (See 2332.) Adenocarcinoma. (See 2333.) 2300. Adenoma. State location. 2301. Hemangioma. State loca- tion. Not to include Nevus (2341). 2302. Carcinoma. Otherwise unclassi- fied. State histologic type (if known) and location. To in- clude all malignant epithelial tumors not otherwise classified. Chloroma. Report as Sarcoma (2327). Class XXIII.—Tumors Navy diag- nosis No. 2303. Chondroma. State location. 2304. Chorio-epithelioma. 2305. Cyst. Otherwise unclassified. State type and location. 2306.. Cyst, Retention. State type and location. Cyst, Teratoma, Inflamed. (See 2334.) Cyst, Teratoma, Quiescent. (See 2335.) Dermoid cyst. Report as Cyst, Teratoma (2334 or 2335.) 2307. Xanthoma. State location. 2308. Endothelioma. State location. 2309. Wart. 21 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—A Class XXIII.—Tumors—Continued Navy diag- nosis No. 2310. Epithelioma. State histologic type (if known) and location. Epulis. (See 2344.) Fibroadenoma. (See 2336.) 2311. Fibroma. State histologic type (if known) and location. 2312. Glioma. State histologic type (if known) and location. Gynecomastia. Report as Fibro- adenoma, male breast (2336). Hemangioma. (See 2301.) 2313. Hematoma, nontraumatic. State location. 2314. Verruca Acuminata, nonve- nereal. 2315. Hypernephroma. 2316. Lipoma. State location. 2317. Lymphangioma. State location. 2318. Lymphoma. State location. Not to include Lymphosarcoma (2337). Lymphosarcoma. (See 2337.) Melanoma. (See 2338.) Meningioma. (See 2339.) 2319. Myeloma, Multiple. 2320. Myoma. State location. 2321. Myxoma. State location. Neuroblastoma. (See 2340.) 2322. Neuroma. State location. Nevus. (See 2341.) 2323. Odontoma. 2324. Onychoma. Osteochondroma. (See 2345.) Osteochondromatosis. (See 2342). 2325. Osteoma. State location. 2326. Papilloma. State histologic type (if known) and location. Pilonidal cyst. Report as Cyst, Teratoma (2334 or 2335). Ranula. Report as Cyst, Re- tention (2306). 2327. Sarcoma. Otherwise unclassified. State histologic type (if known) and location. To include all malignant tumors of connective tissue origin not otherwise classi- fied. Telangiectasis. (See 2343.) Navy diag- nosis No. 2328. Teratoma. State location. Report dermoid cyst or pilonidal cyst as Cyst, Teratoma (2334 or 2335). 2329. Tumor, Mixed, Benign. State variety and location. 2330. Tumor, Mixed, Malignant. State variety and location. 2331. Tumor, Mixed, Activity Unknown. State variety and location. Verruca, Acuminata, Non- venereal. (See 2314.) Wart. (See 2309.) Wen. Report as Cyst, Reten- tion (2306). Xanthoma. (See 2307.) 2332. Adamantinoma. 2333. Adenocarcinoma. State lo- cation. 2334. Cyst, Teratoma, Inflamed. State location. To include Pilonidal cyst, Dermoid cyst, etc. 2335. Cyst, Teratoma, Quiescent. State location. To include Pilonidal cyst, Dermoid cyst, etc. 2336. Fibroadenoma. State loca- tion. To include gyne- comastia (state location as male breast). 2337. Lymphosarcoma. State lo- cation. 2338. Melanoma. State location. 2339. Meningioma. 2340. Neuroblastoma. State loca- tion. 2341. Nevus. State location. 2342. Osteochondromatosis. 2343. Telangiectasis. State loca- tion. 2344. Epulis. 2345. Osteochondroma. State lo- cation. 22 CLASS XXV.—INJURIES Class XXIV.—Female diseases and conditions Navy diag- nosis No. 24xy. Other diseases of this class. State title. 2400. Amenorrhea. 2401. Displacement, Fallopian Tube. 2402. Displacement, Ovary. 2403. Displacement, Uterus. 2404. Dysmenorrhea. 2405. Endocervicitis. 2406. Endometritis. 2407. Fissure, Nipple. 2408. Fistula, Rectovaginal. 2409. Fistula, Uterovaginal. 2410. Fistula, Uterovesical. 2411. Fistula, Vesicovaginal. 2412. Hematosalpinx. 2413. Hypertrophy, Cervix Uteri. 2414. Hypertrophy, Clitoris. 2415. Hypertrophy, Vulva. 2416. Leukorrhea. 2417. Mastitis, Acute. Navy diag- nosis No. 2418. Mastitis, Chronic. 2419. Menopause. 2420. Menorrhagia. 2421. Metritis, Acute. 2422. Metritis, Chronic. 2423. Metrorrhagia. 2424. Oophoritis. 2425. Prolapse, Uterus. 2426. Relaxation, Pelvic Floor. 2427. Salpingitis, Acute. 2428. Salpingitis, Chronic. 2429. Sclerosis, Ovary. 2430. Stricture, Uterine Canal. 2431. Vaginitis, Nonvenereal. 2432. Vulvitis, Nonvenereal. Class XXV.—Injuries Navy diag- nosis No. 2511. Compression. State organ or part. Compression, Diver’s Squeeze. (See 2574.) Concussion, brain. Report as Intracranial Injury (2543). 2512. Contusion. State location. The word “multiple” may be used for numerous locations. 2513. Odontoclasis. 2514. Crush. State organ or part. 2515. Deafness Due to Heavy Firing. 2516. Decapitation. 2517. Deprivation of Water. 2518. Diagnosis Undetermined. State suspected injury. (See par. 2409.) 2519. Dislocation, Articular Cartilage, Knee. Dislocation, Chronic, Recur- rent. (See 2570.) Navy diag- nosis No. 2500. Abrasion. State location. The word “multiple” may be used for numerous locations. Amputation, Traumatic. (See 2572.) 2501. Asphyxiation. 2502. Avulsion. State organ or part. Bends. Report as Caisson Dis- ease (2573). 2503. Bite. State location. 2504. Burn, Chemical. State location. 2505. Burn, Electricity. State location. Burn, Friction. (See 2568.) 2506. Burn, Radium. State location. 2507. Burn, X-Ray. State location. 2508. Burn, Otherwise unclassified. State location. Caisson Disease. (See 2573.) 2509. Castration, Traumatic. Cataract Traumatic. (See 2530.) 2510. Cold, General Effects of. 23 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—A Navy diag- nosis No. 2520. Dislocation. Otherwise unclassi- fied. State articulation. Diver’s paralysis. Report as Cais- son Disease (2573). 2521. Drowning. 2522. Electric Shock. Embolism, Air. (See 2578.) Embolism, Air, From Subma- rine Escape Appliance. (See 2575.) Embolism, Fat. (See 2579.) 2523. Emphysema, Traumatic. State location. 2524. Epilation, Traumatio. State loca- tion. 2525. Epiphyseal Separation, Trau- matic. State bone. 2526. Exhaustion From Overexertion. 2527. Exhaustion From Overexposure. Exposure to extreme cold. Report as Cold, General Effect of (2510). 2528. Foreign Body, Traumatic. State location. 2529. Fracture, Compound. State bone or cartilage. 2530. Cataract, Traumatic. 2531. Fracture, Simple. State bone or cartilage. 2532. Frostbite. State location. 2533. Glass, Powdered, Injuries From Swallowing. 2534. Heat Cramps. 2535. Heat Exhaustion. Heat Stroke. (See 2556.) 2536. Hematocele, Traumatic, Tunica Vaginalis. Hematoma, Subdural, Chronic, Traumatic. (See 2566.) 2537. Hematoma, Traumatic. State location. 2538. Hemorrhage, Traumatic, into Eye- ball. 2539. Hemorrhage, Traumatic, Into Joint. State joint. 2540. Hemorrhage, Traumatic, Under Conjunctiva. Navy diag- nosis No. 2541. Hemorrhage, Traumatic. Other- wise unclassified. State loca- tion. Hernia, Traumatic. (See 2571.) Hyperpyrexia, induced. Report as Thermic Fever, Induced (2558). 2542. Injuries, Multiple, Extreme. 2543. Intracranial Injury. 2544. Intraspinal Injury. Iridodialysis. (See 2580.) 2545. Killed in Action, Details Not Known. Odontoclasis. (See 2513.) Ophthalmia, Actinic Rays. (See 2569.) 2546. Periostitis, Traumatic. State bone. 2547. Radio-active Bodies, Effects of. State manifestation. Not to in- clude Burn, Radium (2506). 2548. Rupture, Traumatic. State organ or part. Not to include Hernia, Traumatic (2571). Shell shock. Report as Psycho- neurosis, War Neurosis (1537). 2549. Smoke Inhalation. State substance. 2550. Sprain, Joint. State joint. 2551. Starvation. 2552. Strain, Muscular. State location. 2553. Strangulation, Respiratory. 2554. Submersion, Nonfatal. 2555. Sunburn. State location. Sunstroke. Report as Heat Stroke (2556). 2556. Heat Stroke. To include sun- stroke. 2557. Synovitis, Traumatic. State joint. 2558. Thermic Fever, Induced. (See par. 2404 (b).) 2559. Tinnitus Aurium, Traumatic. 2560. Torsion, Traumatic. State organ or part. Union of Fracture, Faulty. (See 2581.) 24 CLASS XXVI.—POISONINGS Navy diag- nosis No. 2561. Urethral Fever, Traumatic. Wound, Gunshot. (See 2576.) 2562. Wound, Incised. State location. Wound, Infected. (See 2577.) 2563. Wound, lacerated. State loca- tion. 2564. Wounds, Multiple. 2565. Wound, Punctured. State loca- tion. 2566. Subdural, Chronic, Traumatic. 2567. X-Ray, Effects of. State manifes- tation. Not to include Burn, X-Ray (2507). 2568. Burn, Friction. State loca- tion. 2569. Ophthalmia, Actinic Rays. 2570. Dislocation, Chronic, Recur- rent. State articulation. 2571. Hernia, Traumatic. State location. 2572. Amputation, Traumatic. State organ or part. To include recent and old am- putations resulting from in- jury or subsequent surgery. 2573. Caisson Disease. To include bends and diver’s paraly- sis. 2574. Compression, Diver’s Squeeze. 2575. Embolism, Air, from Sub- marine Escape Appliance. Navy diag- nosis No. 2576. Wound, Gunshot. State lo- cation. 2577. Wound, Infected. State lo- cation. Not to include Gas Bacillus Inpection (1301). 2578. Embolism, Air. State loca- tion. Not to include Em- bolism, Air, From Sub- marine Escape Appliance (2575). 2579. Embolism, Fat. State loca- tion. 2580. Iridodialysia. 2581. Union of Fracture, Faulty. (Mai-, delayed, fibrous, or non-union.) State bone or cartilage. Class XXVI.—Poisonings Navy diag- nosis No. 2600. Diagnosis Undetermined. State suspected poisoning. (See par. 2409.) Gases, effects of, except war gas. Report as Poisonino, Acute (2601) or Poisoning, Chronic (2603). 2601. Poisoning, Acute. State sub- stance. 2602. Poisoning, Anesthesia. State anesthetic. Navy diag- nosis No. 2603. Poisoning, Chronic. State sub- stance. Poisoning, ethyl alcohol. Report as Alcoholism (2106 or 2159). Poisoning, food, allergic. Report as Allergy (2166). Poisoning, food, bacterial. Report as Food Infection (1330), Food Intoxication (1331), or Food Poisoning, Baoterial (1332). 25 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—B Navy diag- nosis No. 2604. Poisoning, Therapeutic, Acute. State compound used and dis- ability treated. (See par. 2413.) 2605. Poisoning, Therapeutic, Chronic. State compound used and dis- ability treated. (See par. 2413.) Navy diag- nosis No. 2606. Poisoning, Venom. State fish, insect, snake, etc. Toadstool (mushroom) poisoning. Report as Poisoning, Acute, toadstool (2601). 2607. War Gas. State gas and effects. Navy diag- nosis No. 27xy. Other diseases of this class. State title. 2700. Abscess, Alveolar. 2701. Abscess, Periapical. 2702. Abscess, Periodontal. 2703. Absence, Acquired, Teeth (or tooth). 2704. Caries, Teeth. Epulis. (See title 2344 under Tumors, Class XXIII.) 2705. Focal Infection, Teeth. 2706. Gingivitis. 2707. Gingivitis, Vincent’s. 2708. Malocclusion, Teeth. 2709. Malposition, Teeth (or tooth). Class XXVII.— Dental diseases and conditions Navy diag- nosis No. 2710. Odontalgia. (Toothache.) Odontoclasis. (Fracture, tooth.) (See title 2513 under Injuries, Class XXV.) 2711. Odontorrhagia. 2712. Paradentosis. (Pyorrhea.) 2713. Pulpitis. Pyorrhea alveolaris. Report as Paradentosis (2712). 2714. Tooth, Impacted. 2715. Tooth, Unerupted. B. ALPHABETICAL LISTING OF TITLES L DISEASES AND CONDITIONS A Navy diag- nosis No. 2700. Abscess, Alveolar. 2200. Abscess, Amebic. State loca- tion. 1700. Abscess, Brain. 1407. Abscess, Lymph Gland. State location. 2701. Abscess, Periapical. 2702. Abscess, Periodontal. 700. Abscess, Perinephritic. 300. Abscess, Periproctic. 500. Abscess, Peritonsillar. 701. Abscess, Periurethral. 702. Abscess, Perivesical. 501. Abscess, Retropharyngeal. Navy diag- nosis No. 301. Abscess. Subphrenic. 1300. Abscess. Otherwise unclassified. State location. Not to include Furuncle (1312). 2703. Absence, Acquired, Teeth (or tooth). 2100. Absence, Acquired. State or- gan or part. Not to include Amputation, Traumatic (2572). 2101. Absence, Congenital. State organ or part. 2102. Accessory. State organ or part. 302. Achylia Gastrica. 26 DISEASES, ALPHABETICAL, A Navy diag- nosis No. 1900. Acne. State variety and loca- tion. 400. Acromegalia. 2201. Actinomycosis. State location. 2332. Adamantinoma. 401. Addison’s Disease. 2333. Adenocarcinoma. State loca- tion. 502. Adenoids. 2300. Adenoma. State location. 2104. Adhesions. State location. 2105. Adiposis Dolorosa. 402. Adrenalitis. 303. Aerophagia. 1901. ALBINI8M. 703. Albuminuria. 2106. Alcoholism, Acute. Not to in- clude Psychosis, Intoxication, Alcoholic (1522), or Delir- ium, Alcoholic (2160). 2159. Alcoholism, Chronic. Not to include Psychosis Intoxica- tion, Alcoholic (1522) or Delirium, Alcoholic (2160). 2107. Alkalosis. 2166. Allergy. Otherwise unclassified. State cause if known and mani- festation. Not to include Asthma (1801), Hay Fever (1809), or Urticaria (1967). 1902. Alopecia. 1903. Alopecia, Areata. 600. Amblyopia. 2202. Amebiasis. Not to include Ab- scess, Amebic (2200) or Dysentery, Amebic (2209). 2400. Amenorrhea. 1500. Amnesia. 4108. Amyloid Disease. State loca- tion. 2109. Anaphylaxis. State cause. Within 24 hours. If after 24 hours report as Serum Sickness (2165). 101. Anemia, Pernicious. 102. Anemia, Secondary. State cause if known. 100. Anemia, Sickle Cell. Navy diag- nosis No. 103. Anemia, Splenic. 104. Anemia. Otherwise unclassified. State type. 200. Aneurysm, Heart. 201. Aneurysm, Varicose. State ar- tery. 202. Aneurysm. Otherwise unclassi- fied. State artery. 203. Aneurysmal Varix. State ar- tery. 503. Angina, Ludwig’s. 204. Angina Pectoris. 800. Angina, Vincent’s. 205. Angioneurotic Edema. 1904. Anhidrosis. 601. Ankyloblepharon. 1800. Ankylosis, Arytenoid Car- tilage. 1601. Ankylosis. State joint. 504. Ankylosis, Ossicles. Ankylostomiasis. Report as Hook- worm Disease (2213). 1701. Anosmia. 1826. Anthracosis. 1302. Anthrax. 2111. Anti-inoculation. State dis- ease. 206. Aortitis. 673. Aihakia. 1702. Aphasia. 1703. Aphonia. 207. Apoplexy. When cause is known report as Hemorrhage, Cere- bral (1720), Embolism, Cere- bral (221), or Thrombosis, Cerebral (238). 304. Appendicitis, Acute. 378. Appendicitis, Chronic. 209. Arteriosclerosis, Cerebral. 210. Arteriosclerosis, General. 252. Arteriosclerosis, Local State artery. 1602. Arthritis, Acute. State joint. 1651. Arthritis, Chronic. State joint. 1603. Arthritis Deformans. State location. 305. Artificial Anus. 2203. Ascariasis. 27 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—B Navy diag- nosis No. 2204. Aspergillosis. 1801. Asthma. 602. Astigmatism, Compound Hy- peropic. 669. Astigmatism, Compound My- opic. 670. Astigmatism, Mixed. 671. Astigmatism, Simple Hyper- opic. 672. Astigmatism, Simple Myopic. 1704. Ataxia, Hereditary. (Fried- reich’s disease.) 1827. Atelectasis. 1705. Athetosis. 2112. Atony. State organ or part. 2113. Atresia, Acquired. State loca- tion. 306. Atrophy, Liver, Yellow, Acute. 2114. Atrophy. State organ or part. Aviator’s sickness or balloon sick- ness. Report as Hypobar- opathy (1728). B 704. Balanoposthitis. 1014. Bartonellosis. Bed sore. Report as Ulcer, De- CUBITAL (1965). 2115. Beriberi. 2219. Black Tongue. 1000. Blackwater Fever. (Hemo- globinuric fever.) 2205. Blastomycosis. 603. Blepharitis. 604. Blindness, Bilateral. 605. Blindness, Unilateral. State eye. 2167. Blood Donor. Botulism. Report as Food In- toxication, Botulism (1303). 211. Bradycardia. 1905. Bromidrosis. 1802. Bronchiectasis. 817. Bronchitis. Acute. 1803. Bronchitis, Chronic. 1400. Bubo, Inguinal, Nonvenereal. Navy diag- nosis No. 1604. Bursitis, Acute. State loca- tion. 1652. Bursitis, Chronic. State loca- tion. c 1605. Calcification of Cartilage. 749. Calculus. Urinary system. State location. 2116. Calculus. Otherwise unclassi- fied. State location. 1906. Callosity. 1304. Carbuncle. State location. 2302. Carcinoma. Otherwise unclassi- fied. State histologic type (if known) and location. To in- clude all malignant epithelial tumors not otherwise classified. 212. Cardiac Arrhythmia, Auric- ular Fibrillation. 213. Cardiac Arrhythmia, Auric- ular Flutter. 227. Cardiac Arrhythmia, Heart Block. 254. Cardiac Arrhythmia, Parox- ysmal Tachycardia. 214. Cardiac Arrhythmia, Prema- ture Contractions. 215. Cardiac Arrhythmia, Sinus Ar- rhythmia. 255. Cardiac Arrhythmia. Other- wise unclassified. State type. 216. Cardiac Disorder, Functional. 308. Cardiospasm. 253. Carditis, Acute. 2704. Caries, Teeth. 2117. Carrier. State micro-organism. 1707. Catalepsy. 606. Cataract. 801. Catarrhal Fever, Acute. 1305. Cellulitis. State location. 802. Cerebrospinal Fever, Me- NINGOCOCCIC. 1744. Cerebrospinal Syphilis, Undif- ferentiated. With symptoms and, or, signs but not differenti- ated as to type. Not to include Tabes Dorsalis (1764) or Dementia Paralytica (1508). 28 DISEASES, ALPHABETICAL, C Navy diag- nosis No. 505. Cerumen Accumulation. Cervical rib. Report as Acces- sory rib (2102). Cestoda infection. Report as Te- niasis (2235). 607. Chalazion. 1200. Chancroid. State location. 1201. Chancroidal Lymphadenitis. 803. Chickenpox. 1907. Chilblain. {Pernio.) 1908. Chloasma. Chloroma. Report as Sarcoma (2327). 105. Chlorosis. 309. Cholangitis, Acute. 379. Cholangitis, Chronic. 310. Cholecystitis, Acute. 380. Cholecystitis, Chronic. 329. Cholelithiasis. 900. Cholera. 1606. Chondritis. State location. 2303. Chondroma. State location. 1607. Chondromalacia. 1708. Chorea. 1709. Chorea, Progressive, Chronic. {Huntington’8.) 2304. Chorio-epithelioma. 1730. Choriomeningitis, Benign Lymphocytic. 658. Chorioretinitis. 608. Choroiditis. 1909. Chromidrosis. Chyle cyst of mesentery. Report as Cyst (2305). 705. Chylocele, Nonfilarial. 1804. Chylothorax. 311. Chylous Ascites, Nonfilarial. 706. Chyluria, Nonfilarial. 1910. Cicatrix, Skin. State location. 312. Cirrhosis, Liver, Atrophic. 313. Cirrhosis, Liver, Hypertro- phic. 314. Cirrhosis, Liver. Otherwise unclassified. State variety. 1911. Clavus. {Corn.) 2233. Coccidioidal Granuloma. 2206. Coccidiosis. 315. Colitis, Acute. 381. Colitis, Chronic. 382. Colitis, Ulcerative. Navy diag- nosis No. 609. Color Blindness. 1912. Comedo. 2118. Concretion. State location. 707. Congestion, Kidney. 1805. Congestion, Lung, Acute. Conical cornea. Report as Kera- toconus (639). 610. Conjunctivitis, Catarrhal. 611. Conjunctivitis, Follicular. 612. Conjunctivitis, Phlyctenular. 613. Conjunctivitis, Purulent. 614. Conjunctivitis, Vernal. 615. Conjunctivitis. Otherwise un- classified. State variety. 316. Constipation. 1501. Constitutional Psychopathic Inferiority Without Psy- chosis. 1502. Constitutional Psychopathic State, Criminalism. 1503. Constitutional Psychopathic State, Emotional Insta- bility. 1504. Constitutional Psychopathic State, Inadequate Person- ality. 1505. Constitutional Psychopathic State, Paranoid Person- ality. 1506. Constitutional Psychopathic State, Pathological Liar. 1507. Constitutional Psychopathic State, Sexual Psychopathy. 1608. Contracture. State location. Corn. Report as Clavus (1911). 237. Coronary Heart Disease, Arteriosclerotic. Not to in- clude acute coronary thrombosis. Coronary thrombosis, acute, or coronary occlusion, acute, when due to thrombus. Report as Thrombosis, coronary artery (239). 1609. Coxa Valga. 1610. Coxa Vara. 1611. Cramp, Muscle. State muscle. 750. Cryptorchidism. 1612. Curvature, Spine. 1913. Cutaneous Horn. {Cornu.) 617. Cyclitis. 29 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—B Navy diag- nosis No. 2306. Cyst, Retention. State type and location. 2334. Cyst, Teratoma, Inflamed. State location. To include pilonidal cyst, dermoid cyst, etc. 2335. Cyst, Teratoma, Quiescent. State location. To include pilonidal cyst, dermoid cyst, etc. 2305. Cyst. Otherwise unclassified. State type and location. 2207. Cysticercosis. State location. 708. Cystinuria. 709. Cystitis, Acute, Nonvenereal. 751. Cystitis, Chronic, Nonvene- real. D 618. Dacryadenitis. 619. Dacryocystitis. 506. Deafness, Bilateral. Not to include Deafness Due to Heavy Firing (2515). 507. Deafness, Unilateral. State ear. Defective hearing. Report as Deafness, Bilateral (506). 2119. Defective Physical Develop- ment. 2120. Deformity, Acquired. State lo- cation. 2138. Deformity, Congenital. State organ or part. 2160. Delirium, Alcoholic. 1508. Dementia Paralytica. (Pa- resis.) 1509. Dementia Praecox. (Schizo- phrenia.) 1510. Dementia Pugilistica. 1001. Dengue. 1914. Dermatitis Herpetiformis. 1951. Dermatitis, Industrial. State cause. 1915. Dermatitis Seborrheica. 1916. Dermatitis Venenata. State cause. 1917. Dermatitis. Otherwise unclassi- fied. State variety. Dermoid cyst. Report as Cyst, Teratoma (2334 or 2335). Navy diag- nosis No. 620. Detachment, Choroid. 621. Detachment, Retina. 508. Deviation, Nasal Septum. 2121. Diabetes Insipidus. 404. Diabetes Mellitus. 2122. Diagnosis Undetermined. State suspected disease or condition. (See par. 2409.) 394. Diarrhea, Chronic, Cause Un- known. 217. Dilatation, Aortic Arch. 218. Dilatation, Cardiac, Acute. 219. Dilatation, Cardiac, Chronic. Dilatation, colon, congenital (Hirschsprung’s disease). Re- port as Deformity, Congeni- tal (2138). 317. Dilatation, Stomach, Acute. 318. Dilatation, Stomach, Chronic. 804. Diphtheria. 805. Diphtheritic Paralysis. 2401. Displacement, Fallopian Tube. 319. Displacement. Liver. 2402. Displacement, Ovary. 2403. Displacement, Uterus. 320. Diverticulitis, Intestinal. 383. Diverticulosis, Intestinal. 2123. Diverticulum. State location. 1015. Dracontiabis. State location. 2161. Drug Addiction. State drug. When associated with psychosis report as Psychosis, Intoxi- cation, Drug (1523). 321. Duodenitis. 2209. Dysentery, Amebic. 901. Dysentery, Bacillary. 902. Dysentery, Balantidic. 1306. Dysentery. Otherwise unclassi- fied. State type. 1918. Dysidrosis. 417. Dysinsulinism. 2404. Dysmenorrhea. 405. Dyspituitarism. 1710. Dystrophy, Progressive Mus- cular. E 2211. Echinococcosis. 1919. Ecthyma. 622. Ectropion. 30 DISEASES, ALPHABETICAL, F Navy diag- nosis No. 1920. Eczema. 509. Edema, Glottis. 1806. Edema, Lung. 1711. Effort Syndrome. 1712. Effort Syndrome, Aviator. 1401. Elephantiasis, Nonfilarial. 510. Elongation, Uvula. 221. Embolism, Cerebral. 223. Embolism. Otherwise unclassified. State location. 1807. Emphysema, Pulmonary. Empyema. Report as Pleurisy, Suppurative (1815). 1713. Encephalitis, Acute. Not to indude Encephalitis, Le- thargic (819). 1729. Encephalitis, Chronic. 819. Encephalitis, Lethargic. 224. Endarteritis. State location. 225. Endocarditis, Acute. 250. Endocarditis, Acute Ulcera- tive. (Malignant.) 257. Endocarditis, Chronic. 256. Endocarditis, Subacute Bac- terial. 2405. Endocervicitis. 406. Endocrinopathy. Otherwise un- dassified. State variety. 2406. Endometritis. 2308. Endothelioma. State location. 2000. Enlarged Inguinal Ring. 710. Enlargement, Prostate. Not to include tumor or abscess. 322. Enteritis, Acute. Not to include Food Infection (1330), Food Intoxication (1331), Food Poisoning, Bacterial (1332), or Allergy (2166). 884. Enteritis, Chronic. 323. Enterocolitis, Acute. Not to indude Food Infection (1330), Food Intoxication (1331), Food Poisoning, Bacterial (1332), or Allergy (2166). 385. Enterocolitis, Chronic. Enterolith. Report as Calculus, intestine (2116). Enteroptosis. Report as Splanch- noptosis (362). 623. Entropion. Navy diag- nosis No. 711. Enuresis. (Bed-wetting). Epidermophytosis. Report as Fungus Infection, Skin (2212). 712. Epididymitis, Acute, Non- VENEREAL. 752. Epididymitis, Chronic, Non- VENEREAL. 511. Epiglottiditis. 1714. Epilepsy. Not to indude Psy- chosis, Epileptic (1519). 1715. Epilepsy, Jacksonian. 624. Epiphora. 1653. Epiphysitis. State location. 226. Epistaxis. 2310. Epithelioma. State histologic type (if known) and location. 2344. Epulis. 1308. Erysipelas. 1921. Erysipeloid. 1922. Erythema Multiforme. 1923. Erythema Nodosum. 1924. Erythema Scarlatiniforme. 1925. Erythema. Otherwise unclassi- fied. State variety. 1926. Erythrasma. 2124. Erythromelalgia. 324. Esophagitis. Ethmoiditis. Report as Sinusitis, Ethmoidal (534). 625. Exophthalmos. 713. Extravasation, Urine. 1613. Exuberant Callus. F Fainting. Report as Syncope (222). 2237. Favus. 1309. Fever, Cause Undetermined. 2336. Fibroadenoma. State location. To indude gynecomastia (state location as male breast). 2311. Fibroma. State histologic type (if known) and location. 1002. Filariasis. State location and manifestation. Not to indude Dracontiasis (1015) or Onchocerciasis (1016). 325. Fissure, Anus. 2407. Fissure, Nipple. 31 APPENDIX A. DIAGNOSTIC NOMENCLATURE SEC. II.—B Navy diag- nosis No. 1927. Fissure, Skin. 326. Fistula, Biliary. 714. Fistula, Bladder. 327. Fistula, Fecal. 328. Fistula in Ano. 715. Fistula, Recto-urethral. 2408. Fistula, Rectovaginal. 2409. Fistula, Uterovaginal. 2410. Fistula, Uterovesical. 2411. Fistula, Vesicovaginal. 2125. Fistula. Otherwise unclassified. State location. 2208. Flagellate Infection, Intes- tinal. State species. 1614. Flat Foot. 1310. Focal Infection. State loca- tion. 2705. Focal Infection, Teeth. 1928. Folliculitis. 1929. Folliculitis Decalvans. 1330. Food Infection. State organism and food. 1303. Food Intoxication, Botulism. 1331. Food Intoxication. Otherwise unclassified. State organism and food. 1332. Food Poisoning. Bacterial. State food. Food poisoning, allergic. Report as Allergy (2166). 1311. Foot-and-Mouth Disease. 2164. Foreign Body, Nontraumatic. State nature and location. 1616. Fragilitas Ossium. Frambesia. Report as Yaws (1329). 716. Funiculitis. 2212. Fungus Infection Skin. Other- wise unclassified. State loca- tion. To include trichophytosis and epidermophytosis. 1312. Furuncle. State location. The word “multiple” may be used for numerous locations. G Gallstones. Report as Chole- lithiasis (329). 1617. Ganglion, Tendon Sheath. State location. Nayy diag- nosis No. 1314. Gangrene, Infective. Stat organism (if known) and loca- tion. 1808. Gangrene, Lung. 2127. Gangrene. Otherwise unclassi- fied. State cause (if known) and location. 1301. Gas Bacillus Infection. State organism (If known) and loca- tion. 330. Gastritis, Acute. 386. Gastritis, Chronic. 331. Gastroduodenitis. 332. Gastro-enteritis, Acute. Not to include Food Infection (1330), Food Intoxication (1331), Food Poisoning, Bac- terial (1332), or Allergy (2166). Gastro-enteritis, allergic. Report as Allergy (2166). 387. Gastro-enteritis, Chronic. 333. Gastroptosis. 1618. Genu Recurvatum. 1619. Genu Valgum. 1620. Genu Varum. 806. German Measles. Giardiasis. Report as Flagel- late Infection, Intestinal (2208). 403. Gigantism. 2706. Gingivitis. 2707. Gingivitis, Vincent’s. 807. Glanders. Glandular fever. Report as Mono- nucleosis, Infectious (115). 626. Glaucoma. 2312. Glioma. State histologic type (if known) and location. 334. Glossitis. 2129. Glycosuria. 419. Goiter, Adenomatous. 408. Goiter, Exophthalmic. 407. Goiter, Simple. 1202. Gonococcus Infection, Con- junctiva. 1209. Gonococcus Infection, Epidid- ymis. 1203. Gonococcus Infection, Joint. 32 DISEASES, ALPHABETICAL H Navy diag- nosis No. 1204. Gonococcus Infection, Lymph Node. 1210. Gonococcus Infection, Pros- tate. 1211. Gonococcus Infection, Seminal Vesicles. 1205. Gonococcus Infection, Ure- thra. 1206. Gonococcus Infection. Other- wise unclassified. State loca- tion. 2130. Gout, Acute. 2110. Gout, Chronic. 112. Granulocytopenia, Malignant. 1942. Granuloma Inguinale, Non- VENEREAL. Gynecomastia. Report as Fibro- adenoma, male breast (2336). H 1621. Hallux Valgus. 1622. Hallux Varus. 1623. Hammertoe. Hare lip. Report as Deformity, Congenital, lip (2138). 1809. Hay Fever. 2131. Headache. 220. Heart Disease, Congenital. State type. 2301. Hemangioma. State location. Not to include Nevus (2341). 335. Hematemesis. 717. Hematocele, Tunica Vaginalis. 2134. Hematocele. Otherwise unclas- sified. State location. 2313. Hematoma, Nontraumatic. State location. 1716. Hematomyelia. 1717. Hematorrhachis. 2412. Hematosalpinx. 718. Hematuria. 627. Hemianopsia. 1718. Hemiplegia, Old. 2132. Hemochromatosis. 719. Hemoglobinuria. 106. Hemophilia. 1810. Hemoptysis. 17 L9. Hemorrhage, Cerebellum. 1720. Hemorrhage, Cerebral. 1721. Hemorrhage, Epidural. Navy diag- nosis No. 1722. Hemorrhage, Medulla. 1723. Hemorrhage, Pons. 1724. Hemorrhage, Subdural. 2133. Hemorrhage. Otherwise un- classified. State location. 336. Hemorrhoids. 1811. Hemothorax. 388. Hepatitis, Acute. 389. Hepatitis, Chronic. 1725. Hernia, Brain. 2012. Hernia, Diaphragmatic. 2001. Hernia, Epigrastric. 2002. Hernia, Femoral. 2004. Hernia, Inguinal, Direct. (Internal.) 2003. Hernia, Inguinal, Indirect. (External.) 2005. Hernia, Ischiadic. 2006. Hernia, Ischiorectal. 2007. Hernia, Lumbar. 1812. Hernia, Lung. 1624. Hernia, muscle, fascia, tendon or sheath. State location. 2008. Hernia, Obturator. 2009. Hernia, Recurrent, Apter Operation. State type. One of the types given in class XX, sec. 11-A. 2013. Hernia, Strangulated. State type. One of the type* given in class XX, sec. II-A. Hernia, traumatic. See title 2571 under injuries. 2010. Hernia, Umbilical 2011. Hernia, Ventral. 1930. Herpes. 1931. Herpes Zoster. 1726. Hiccough. 1315. Histoplasmosis. 1402. Hodgkin’s Disease. 2213. Hookworm Disease. 628. Hordeolum. 629. Hyalitis. 720. Hydrocele, Tunica Vaginalis. 2126. Hydrocele. Otherwise unclassi- fied. State location. 1727. Hydrocephalus. 721. Hydronephrosis. 337. Hyperchlorhydria. 630. Hyperemia, Conjunctiva. 33 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—B Navy diag- nosis No. 1932. Hyperhidrosis. 2315. Hypernephroma. 632. Hyperopia. 420. Hyperparathyroidism. 208. Hypertension, Arterial. 258. Hypertensive Heart Disease. 409. Hyperthyroidism. Not to in- clude Goiter, Exophthalmic (408). 1625. Hypertrophy, Bone. State lo- cation. 2413. Hypertrophy, Cervix Uteri. 2414. Hypertrophy, Clitoris. 228. Hypertrophy, Heart. 2415. Hypertropy, Vulva. 1728. Hypobaropathy. (Aviator's sickness or balloon sickness.) 338. Hypochlorhydria. 1511. Hypochondriasis. 421. Hypoparathyroidism. 422. Hypopituitarism. 633. Hypopyon. 259. Hypotension, Arterial. 410. Hypothyroidism. I 1933. Ichthyosis. Idiocy. Report as Mental De- ficiency (1513). Imbecility. Report as Mental Deficiency (1513). Impacted feces. Report as Ob- struction, Intestinal, from Internal Causes (342). 1934. Impetigo Contagiosa. 1935. Impetigo Herpetiformis. 1936. Impetigo. Otherwise unclassified. State variety. 722. Impotence. 723. Incontinence, Urine. Not to include Enuresis (711). 2135. Infarction. State location. 339. Inflammation, Salivary Gland. Inflammation, spermatic cord. Report as Funiculitis (716). 808. Influenza. Not to include in- fluenzal pneumonia. 1937. Ingrowing Nail. 2136. Insomnia. 634. Insufficiency, Ocular Muscle. Navy diag- nosis No. 1938. Intertrigo. Intussusception. Report as Ob- struction, Intestinal, from External Causes (341). 635. Iridochoroiditis. 636. Iridocyclitis. 637. Iritis. 390. Irritable Colon. j 1328. Jaundice, Acute Infective. Epidemic type other than Weil's disease. 1316. Jaundice, Epidemic, Weil’s Di- sease. 113. Jaundice, Hemolytic. State whether acquired or familial. 1615. Joint, Internal Derangement of. State joint. K 1939. Keloid. State location. 638. Keratitis. 639. Keratoconus. 1940. Keratoderma. 640. Kerato-iritis. 641. Keratomalacia. 1941. Keratosis. L 2214. Larva Migrans. 821. Laryngitis, Acute. 512. Laryngitis, Chronic. 1003. Leishmaniasis. State species. 1626. Leontiasis Ossea. 1317. Leprosy. 107. Leukemia, Acute. State type. 114. Leukemia, Chronic. State type Leukoderma. Report as Vitiligo (1969). 1943. Leukoplakia. (Leukokeratosis). 2416. Leukorrhea. 1944. Lichen Planus. 1945. Lichen Ruber. 1946. Lichen. Otherwise unclassified. State variety. 2137. Lipemia. 2316. Lipoma. State location. 1627. Loose Body in Joint. Stata joint. 34 DISEASES, ALPHABETICAL, M Navy diag- nosis No. 1628. Loss of Substance of bone or cartilage. State location. Lumbago. Report as Myositis (1631 or 1654). 1947. Lupus Erythematosus. Lupus vulgaris. Report as Tu- berculosis .Skin (1106). 1403. Lymphadenitis. State location. Not to include Bubo, Inguinal, Nonvenerbal (1400). 1404. Lymphangiectasib. State loca- tion. 2317. Lymphangioma. State location. 1405. Lymphangitis. State location. 2318. Lymphoma. State location. Not to include Lymphosarcoma (2337). 1212. Lymphogranuloma, Venereum. 2337. Lymphosarcoma. State location. M 1004. Malaria. State type. (Benign tertian, malignant tertian, or quartan.) If induced, so state (See par. 2404(b).) 2139. Malingering. (See par. 2402 (d).) 1629. Mallet Finger. 2140. Malnutrition. 2708. Malocclusion, Teeth. 2709. Malposition, Teeth (or tooth). Malta fever. Report as Undu- lant Fever (1326). 2417. Mastitis, Acute. 2418. Mastitis, Chronic. 2162. Mastitis, Male, Acute. 2128. Mastitis, Male, Chronic. 513. Mastoiditis, Acute. 528. Mastoiditis, Chronic. 1541. Masturbation. 809. Measles. 1313. Mediastinitis. 229. Mediastino-pericarditis. 1512. Melancholia, Involutional. 1948. Melanoderma. 2338. Melanoma. State location. 1731. Meniere’s Disease. 2339. Meningioma. 1732. Meningitis, Cerebral. Navy diag- nosis No. 1783. Meningitis, Cerebrospinal, Acute. Not to include Cere- brospinal Fever, Meningo- coccic (802). 1734. Meningitis, Cerebrospinal, Chronic. 2419. Menopause. 2420. Menorrhagia. 1513. Mental Deficiency. State whether idiot, imbecile, or moron. 1630. Metatarsalgia. 2421. Metritis, Acute. 2422. Metritis, Chronic. 2423. Metrorrhagia. 1735. Migraine. 2141. Mikulicz’s Disease. Miliaria. Report as Prickly Heat (1956). 1318. Miliary Fever. 1949. Milium. 1950. Molluscum Contagiosum. 115. Mononucleosis, Infectious (Glandular fever). Moron. Report as Mental De- ficiency (1513). Morphinism. Report as DRUG Addiction (2161). 2215. Mucormycosis. 810. Mumps. 514. Mutism. 1736. Myasthenia Gravis. 2216. Mycetoma. 2217. Mycosis Fungoides. 1737. Myelitis, Disseminated. 1738. Myelitis, Transverse. 2319. Myeloma, Multiple. 2218. Myiasis. 260. Myocarditis, Acute. State cause if known. 230. Myocarditis, Chronic. State cause if known. 2320. Myoma. State location. 642. Myopia. 1631. Myositis, Acute. State loca- tion. 1654. Myositis, Chronic. State loca- tion. 35 APPENDIX A. DIAGNOSTIC NOMENCLATURE—SEC. II.—B Navy diag- nosis No. 1632. Myositis, Progressive, Ossify- ing. 1633. Myositis, Traumatic, Ossify- ing. State location. 1634. Myotonia, Congenita. 515. Myringitis, Acute. 542. Myringitis, Chronic. 411. Myxedema. 2321. Myxoma. State location. N 1740. Narcolepsy. Nausea marina. Report as Sea- sickness (2151). 2142. Necrosis. State location. 724. Nephralgia. 725. Nephritis, Acute. 753. Nephritis, Chronic. Nephrolithiasis. Report as Cal- culus, kidney (749). 726. Nephroptosis. 1739. Neuralgia. 1741. Neuritis, Multiple. 643. Neuritis, Optic. 1742. Neuritis. State nerve. 2340. Neuroblastoma. State location. 2322. Neuroma. State location. 644. Neuroretinitis. 340. Neurosis, Intestinal. 516. Neurosis, Larynx. 517. Neurosis, Pharynx. 2163. Neurosis. Otherwise unclassified. State organ or part. 1743. Neurosyphilis, Serological. Without neurological symptoms or signs other than laboratory findings. 2341. Nevus. State location. 645. Night Blindness. 2143. No Disease. State reason for taking up on sick list. (See par. 2402 (e).) Noma. Report as Stomatitis, Gangrenous (366). 1514. Nostalgia. (Homesickness.) 646. Nystagmus. o 2144. Obesity. If of endocrine origin re- port as Hypothyroidism (410), Endocrinopathy (406), etc. Navy diag- nosis No. 341. Obstruction, Intestinal, from External Causes. (Angula- tions, kinks, adhesions, volvulus, intussusception.) 342. Obstruction, Intestinal, from Internal Causes. (Stricture, gallstones, entero.iths, foreign bodies, fecal masses.) 343. Obstruction, Intestinal, from Spastic or Paralytic Causes. (After injuries, operations, peri- tonitis.) 344. Obstruction, Intestinal. Oth- erwise unclassified. State cause if known. 345. Obstruction, Pancreatic Duct. 2145. Ochronosus. 2710. Odontalgia. (Toothache.) Odontoclasis (fracture, tooth) see title 2513 under Injuries, Class XXV. 2323. Odontoma. 2711. Odontorrhagia. 1952. Onychauxis. 1016. Onchocerciasis. 1953. Onychia. 2324. Onychoma. 2424. Oophoritis. 647. Opacity, Cornea. 648. Opacity, Vitreous Humor. 649. Ophthalmia, Sympathetic. 650. Ophthalmoplegia. 727. Orchitis, Acute, Non venereal. 754. Orchitis, Chronic, Nonvene- real. Oroya fever. Report as Bar- TONELLOSIS (1014). 1635. OsGOOD-ScHLATTER DISEASE. 2146. Ossification. State location. 1636. Osteitis Deformans. (Paget's disease.) 1655. Osteitis Fibrosa Cystica. 1637. Osteoarthropathy, Hyper- trophic. 1656. Osteochondritis Deformans. (Perthes’ or Legg's disease.) 1657. Osteochondritis Dessicans. 2345. Osteochondroma. State loca- tion. 2342. Osteochondromatosis. 36 DISEASES, ALPHABETICAL, P Navy diag- nosis No. 2325. Osteoma. State location. 1638. Osteomalacia. 1639. Osteomyelitis. State location. —xy. Other diseases of this class. State title. For definite clinical enti- ties having generally accepted titles but not included in this nomenclature. Give class num- ber in Arabic numerals preced- ing “xy.” This title is provided for all classes except XII, XXV, and XXVI. It shall not be used for disabilities which can be reported correctly under any other title appearing in this nomenclature. (See par. 2402- (b)). 518. Otitis Externa. 519. Otitis Interna. 520. Otitis Media, Acute. 543. Otitis Media, Chronic. 521. Otosclerosis. 2220. Oxyuriasis. 522. Ozena. P 1746. Pachymeningitis, Cerebral. 1747. Pachymeningitis, Spinal. F*alpitation, cardiac. Report as Cardiac Disorder, Function- al (216). 346. Pancreatitis, Acute. 391. Pancreatitis, Chronic. 651. Panophthalmitis. 523. PANSINU8ITIS. 652. Papillitis. To indude papil- ledema or choked disk. 2326. Papilloma. State histologic type (if known) and location. Pappataci fever. Report as Sand- fly Fever (1005). 2712. Paradentosis. {Pyorrhea.) 2221. PARAGONIMIASIS. 1748. Paralysis Agitans. 1749. Paralysis, Ascending, Acute. 1750. Paralysis, Brown-Sequard’s. 1640. Paralysis, Muscle, Ischemic. State muscle. 653. Paralysis, Ocular Muscle. 624. Paralysis, Vocal Cords. Navy diag- nosis No. 1751. Paralysis. Otherwise unclassi- fied. State nerve. 1752. Paramyoclonus Multiplex. 1515. Paranoia. 1516. Paranoid State. 728. Paraphimosis. 1753. Paraplegia, Ataxic. 903. Paratyphoid Fever. State type if known. Paresis. Report as Dementia Paralytica (1508). 307. Parotitis. Not to include Mumps (810). 2222. Pediculosis. State location. 2147. Pellagra. 1954, Pemphigus. 525. Perforated Nasal Septum. 231. Pericarditis, Acute. 248. Pericarditis, Chronic. 1641. Perichondritis. State location. 347. Perihepatitis. 1642. Periostitis, Acute. State loca- tion. 1658. Periostitis, Chronic. State lo- cation. 412. Perisplenitis. 348. Peritonitis, General, Acute. 349. Peritonitis, General, Chronic. 350. Peritonitis, Local, Acute. 351. Peritonitis, Local, Chronic. 413. Peristent Thymus Gland. 352. Perversion, Appetite. 1650. Pes Cavus. Pes planus. Report as Flat Foot (1614). 822. Pharyngitis, Acute. 526. Pharyngitis, Chronic. 72.9. Phimosis. 232. Phlebitis. State location. 2223. Piedra. Pilonidal cyst. Report as Cyst, Teratoma (2334 or 2335). 2224. Pinta. 1955. Pityriasis Rosea. Pityriasis simplex. Report as Dermatitis Seborrheica (1915). 2225. Pityriasis Versicolor. 1006. Plague. State whether bubon- ic, pneumonic, or septicemic. 37 APPENDIX A.—DIAGNOSTIC NOMENCLATURE SEC. II. B Navy diag- nosis No. 1813. Pleurisy, Fibrinous, Acute. 1828. Pleurisy, Fibrinous, Chronic. 1814. Pleurisy, Serofibrinous. 1815. Pleurisy, Suppurative. 1817. Pneumoconiosis. Otherwise un- classified. State type. Not to include Anthracosis (1826) or Silicosis (1831). 811. Pneumonia, Broncho-. 1816. Pneumonia, Chronic Intersti- tial. 1829. Pneumonia, Hypostatic. 812. Pneumonia, Lobar. State type if known. 1830. Pneumonitis, Acute. 1825. Pneumonitis, Chronic, Non- TUBERCULOUS. 233. Pneumopericardium. 234. Pneumopyopericardium. 1818. Pneumopyothorax. 1819. Pneumothorax. 813. Poliomyelitis, Anterior, Acute. 1758. Poliomyelitis, Anterior, Chronic. 108. Polycythemia Vera. 527. Polypus, Nasal. 2103. Polypus. Otherwise unclassified. State location. 654. Presbyopia. 1956. Prickly Heat. (Miliaria ruler.) 353. Proctalgia. 354. Proctitis. 355. Prolapse, Rectum. 2425. Prolapse, Uterus. Prostate, hpyertrophy of. Report as Enlargement, Prostate (710). 730. Prostatitis, Acute, Nonvene- real. 755. Prostatitis, Chronic, Nonvene- real. 1957. Prurigo. 1958. Pruritis. State location. 1307. Psittacosis. 1959. Psoriasis. Psychasthenia. Report as Psy- choneurosis, PSYCHASTHENIA (1536). 1517. Psychoneurosis, Anxiety Neu- rosis. Navy diag- nosis No. 1518. PSYCHONETJROSIS, COMPULSION Neurosis. 1534. Psychoneurosis, Hysteria. 1535. Psychoneurosis, Neurasthe- nia. 1539. Psychoneurosis, Occupational. 1536. Psychoneurosis, Psychasthe- NIA. 1521. Psychoneurosis, Situational. 1540. Psychoneurosis, Traumatic. 1537. Psychoneurosis, War Neuro- sis. To include shell shock. 1538. PsychojNEURosis, Unclassified. 1519. Psychosis, Epileptic. 1520. Psychosis, Exhaustive. 1522. Psychosis, Intoxication, Alco- holic. 1523. Psychosis, Intoxication, Drug. State drug. 1524. Psychosis, Intoxication. Other exogenous toxins. State toxin. 1525. Psychosis, Manic Depressive. 1526. Psychosis, Senile. 1527. Psychosis, Traumatic. 1528. Psychosis With Infectious Disease. 1529. Psychosis With Organic Brain Disease. 1530. Psychosis With Other Dis- abilities. State disability. 1531. Psychosis, Unclassified. 655. Pterygium. 631. Ptosis, Eyelid. State cause if known. 2713. Pulpitis. 109. Purpura Hemorrhagica. 110. Purpura Rheumatica. 111. Purpura Simplex. 731. Pyelitis, Acute. 756. Pyelitis, Chronic. 732. Pyelonephritis. 1319. Pyemia. State organism if known. 235. Pylephlebitis. 356. Pyloric Incontinence. 357. Pylobospasm. Pyorrhea alveolaris. Report as Paradentosis (2712). 38 DISEASES, ALPHABETICAL, R-S Navy diag- nosis No. R 1320. Rabies. Ranula. Report as Cyst, Re- tention (2306). 1321. Rat-Bite Fever. 1754. Raynaud’s Disease. 733. Redundant Prepuce. 734. Redundant Scrotum. 358. Regurgitation from Stomach. 1007. Relapsing Fever. 2426. Relaxation, Pelvic Floor. 656. Retinitis. 1322. Rheumatic Fever. 1643. Rheumatism, Muscular. 823. Rhinitis, Acute. 529. Rhinitis, Atrophic. 530. Rhinitis, Hypertrophic. 531. Rhinolith. 532. Rhinoscleroma. 2148. Rickets. Ringworm. Report as Fungus Infection, Skin (2212). 1008. Rocky Mountain Spotted Fever. 359. Rumination. 2149. Rupture, Nontraumatic. State organ or part. Not to be used for hernia or ruptured peptic ulcer. 8 2427. Salpingitis, Acute. 2428. Salpingitis, Chronic. 533. Salpingitis, Eustachian, Acute. 544. Salpingitis, Eustachian, Chronic. 1005. Sandfly Fever. 2327. Sarcoma. Otherwise unclassified. State histologic type (if known) and location. To include all malignant tumors of connective tissue origin not otherwise classi- fied. 2227. Scabies. 814. Scarlet Fever. 2229. Schistosomiasis, Intestinal. 2228. Schistosomiasis, Japonicum, Biliary. Navy diag- nosis No. 2230. Schistosomiasis, Urinary. Schizophrenia. Report as De- mentia Praecox (1509). Sciatica. Report as Neuritis, sciatic (1742). 657. Scleritis. 1960. Scleroderma. 1706. Sclerosis, Combined. 735. Sclerosis, Corpus Cavernosum. 1755. Sclerosis, Disseminated. 1756. Sclerosis, Lateral. 1757. Sclerosis, Lateral Amyotro- phic. 2429. Sclerosis, Ovary. 2150. Scurvy. 2151. Seasickness. 1961. Seborrhea. 736. Seminal Emissions. 737. Seminal Vesiculitis, Acute, Nonvenereal. 757. Seminal Vesiculitis, Chronic, Nonvenereal. 2152. Senility. 1323. Septicemia. State organism if known. 820. Septic Sore Throat. 2165. Serum Sickness. After 24 hours. If within 24 hours report as Anaphylaxis (2109). 1532. Sexual Perversion. Shell shock. Report as Psycho- neurosis, War Neurosis (1537). 2153. Shock. 1831. Silicosis. 2154. Sinus. State location. 534. Sinusitis, Ethmoidal. 535. Sinusitis, Frontal. 536. Sinusitis, Maxillary. 537. Sinusitis, Sphenoidal. 1962. Skin Donor. 815. Smallpox. Snow blindness. Report as Oph- thalmia, Actinic Rays (2569). 1533. Somnambulism. 360. Spasm, Esophagus. 1759. Spasm, Habit. 39 APPENDIX A.—DIAGNOSTIC NOMENCLATURE SEC. II.—B Navy diag- nosis No. 1760. Spasm, Nodding. 361. Spasm, Rectum. 1745. Spasm, Saltatory. 738. Spermatocele. 739. Spermatorrhea. 2231. Spirochetosis. Otherwise un- classified. State species and lo- cation. 362. Splanchnoptosis. 414. Splenitis. 415. Splenoptosis. 1644. Spondylitis. 2232. Sporotrichosis. 363. Sprue. 1600. Spur, Bone. State bone or joint. 538. Spur, Nasal Septum. 1761. Stammering. 659. Staphyloma, Cornea. 1406. Status Lymphaticus. 1820. Stenosis, Bronchus. 364. Stenosis, Gall-Duct. 1821. Stenosis, Larynx. 660. Stenosis, Nasal Duct. 661. Stenosis, Punctum Lacrymale. 365. Stenosis, Pylorus. 1822. Stenosis, Trachea. 740. Sterility. 366. Stomatitis, Gangrenous. 367. Stomatitis. Otherwise unclassi- fied. 662. Strabismus. 368. Stricture, Esophagus. 369. Stricture, Intestine. 539. Stricture, Pharynx. 370. Stricture, Rectum. 741. Stricture, Ureter. 742. Stricture, Urethra. 2430. Stricture, Uterine Canal. 2234. Strongyloidiasis. 1762. Stuttering. 1963. Sudamina. 743. Suppression, Urine. 1964. Sycosis. Not to include Fungus Infection Skin (2212). 663. Symblepharon. 222. Syncope. 664. Synechia. 1645. Synovitis, Acute. Nonsuppu- rative. State articulation. Navy diag- nosis No. 1659. Synovitis, Chronic. Non sup- purative. State articulation. 1660. Synovitis, Suppurative. State articulation. 1207. Syphilis. 1213. Syphilis, Sero-positive Only. Without history, symptoms, or signs other than repeated and confirmed serological tests (blood). Not to include Neuro- syphilis, Serological (1743). 1763. Syringomyelia. T 1764. Tabes Dorsalis. 236. Tachycardia. 1646. Talipes. (Clubfoot.) 2343. Telangiectasis. State location. 2235. Teniasis. (Tapeworm injection.) State species. 1647. Tenosynovitis, Acute. State lo- cation. 1649. Tenosynovitis, Chronic. State location. 2328. Teratoma. State location. Re- port dermoid cyst or pilonidal cyst as Cyst, Teratoma (2334 or 2335). 1324. Tetanus. 2155. Tetany. 251. Thrombo-angiitis, Obliterans. State location. 238. Thrombosis, Cerebral. 239. Thrombosis. State vessel. 2236. Thrush. 416. Thyroiditis, Acute. 418. Thyroiditis, Chronic. 1765. Tic. 818. Tonsillitis, Acute. 540. Tonsillitis, Chronic. 2714. Tooth, Impacted. 2715. Tooth, Unerupted. 2156. Torsion, Nontraumatic. State location. Torticolis. Report as Myositis (1631 or 1654). 1325. Toxemia, Bacterial. State or- ganism if known. 824. Tracheitis, Acute. 40 DISEASES, ALPHABETICAL, U-V Navy diag- nosis No. 1823. Tracheitis, Chronic. 825. Tracheobronchitis, Acute. 1832. Tracheobronchitis, Chronic. 1824. Tracheocele. 665. Trachoma. 1009. Trench Fever. 240. Trench Foot. 666. Trichiasis. 2238. Trichinosis. (Trichiniasis.) Trichomoniasis. Report as Flag- ellate Infection, Intesti- nal (2208). Trichophytosis. Report as Fun- gus Infection, Skin (2212). 2210. Trichuriasis. 1648. Trigger Finger. 1010. Trypanosomiasis. State species. 1100. Tuberculosis, General Mili- ary. 1101. Tuberculosis, Pulmonary, Acute General Miliary. 1102. Tuberculosis, Pulmonary, Acute Pneumonic. 1103. Tuberculosis, Pulmonary, Chronic, Active. State whether incipient, moderately advanced, or far advanced. As based on National Tubercu- losis Association classification. 1104. Tuberculosis, Pulmonary, Chronic, Arrested. State whether incipient, moderately advanced, or far advanced. 1106. Tuberculosis, Skin. 1105. Tuberculosis. Otherwise un- classified. State location. 1011. Tularemia. 2331. Tumor, Mixed, Activity Un- known. State variety and lo- cation. 2329. Tumor, Mixed, Benign. State variety and location. 2330. Tumor, Mixed, Malignant. State variety and location. 2226. Tungiasis. 904. Typhoid Fever. 1012. Typhus Fever. u 744. Ulcer, Bladder. 667. Ulcer, Cornea. Navy diag- nosis No. 1965. Ulcer, Decubital. 371. Ulcer, Duodenum. 392. Ulcer, Duodenum, Perfo- rated. 372. Ulcer, Intestine. 373. Ulcer, Mouth. 541. Ulcer, Nasal Passage. 374. Ulcer, Rectum. 1966. Ulcer, Skin. State location. 375. Ulcer, Stomach. 393. Ulcer, Stomach, Perforated. 2157. Ulcer. Otherwise unclassified. State location. Uncinariasis. Report as Hook- worm Disease (2213). 1326. Undulant Fever. 745. Ureteral Colic. 746. Ureteritis. 747. Urethritis, Acute, Non vene- real. 748. Urethritis, Chronic, Nqnve- nereal. 1967. Urticaria (Allergic). 1968. Urticaria, Pigmentosa. 616. Uveitis. v 1327. Vaccinia. 2431. Vaginitis, Nonvenereal. 243. Valvular Heart Disease, Aortic and Mitral. 241. Valvular Heart Disease, Aortic Insufficiency. 242. Valvular Heart Disease, Aortic Stenosis. 244. Valvular Heart Disease, Mitral Insufficiency. 245. Valvular Heart Disease, Mitral Stenosis. 246. Valvular Heart Disease, Pulmonic. 247. Valvular Heart Disease, Tricuspid. 758. Varicocele. 249. Varicose Veins. State location. 2314. Verruca Acuminata, Nonve- nereal. 1208. Verruca Acuminata, Vene- real. Verruga peruviana. Report as Bartonellosis (1014). 41 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. II.—B Navy diag- nosis No. 2158. Vertigo. Visceroptosis. Report as Splanchnoptosis (362). 1969. Vitiligo. Volvulus. Report as Obstruc- tion, Intestinal, from Ex- ternal Causes (341). 376. Vomiting. 2432. Vulvitis, Nonvenereal. w 2309. Wart. Wen. Report as Cyst, Reten- tion (2306). Navy diag- nosis No. 816. Whooping Cough. x 2307. Xanthoma. State location. 1970. Xeroderma Pigmentosa. 668. Xerophthalmia. 377. Xerostomia. Y 1329. Yaws. (Frambesia.) 1013. Yellow Fever. a Navy diag- nosis No. 2500. Abrasion. State location. The word “multiple” may be used for numerous locations. 2572. Amputation, Traumatic. State organ or part. To include recent and old amputations resulting from injury or subsequent sur- gery. 2501. Asphyxiation. 2502. Avulsion. State organ or part. B Bends. Report as Caisson Dis- ease (2573). 2503. Bite. State location. 2504. Burn, Chemical. State location. 2505. Burn, Electricity. State loca- tion. 2568. Burn, Friction. State location. 2506. Burn, Radium. State location. 2507. Burn, X-Ray. State location. 2508. Burn. Otherwise unclassified. State location. c 2573. Caisson Disease. To include bends and diver's paralysis. 2509. Castration, Traumatic. 2530. Cataract, Traumatic. 2510. Cold, General Effect of. 2511. Compression. State organ or part. 2. INJURIES Navy diag- nosis No. 2574. Compression, Diver’s Squeeze. Concussion, brain. Report as Intracranial Injury (2543). 2512. Contusion. State location. The word “multiple" may be used for numerous locations. 2514. Crush. State organ or part. D 2515. Deafness Due to Heavy Fir- ing. 2516. Decapitation. 2517. Deprivation of Water. 2518. Diagnosis Undetermined. State suspected injury. (See par. 2409.) 2519. Dislocation, Articular Carti- lage, Knee. 2570. Dislocation, Chronic, Recur- rent. State articulation. 2520. Dislocation. Otherwise unclas- sified. State articulation. Diver's paralysis. Report as Caisson Disease (2573). 2521. Drowning. E 2522. Electric Shock. 2578. Embolism, Air. State location. Not to include Embolism, Air, From Submarine Escape Ap- pliance (2575). INJURIES, ALPHABETICAL, F-S Navy diag- nosis No. 2575. Embolism, Air, from Submarine Escape Appliance. 2579. Embolism, Fat. State location. 2523. Emphysema, Traumatic. State location. 2524. Epilation, Traumatic. State lo- cation. 2525. Epiphyseal Separation, Trau- matic. State bone. 2526. Exhaustion from Overexer- tion. 2527. Exhaustion from Overexpo- sure. Exposure to extreme cold. Report as Cold, General Effect of (2510). F 2528. Foreign Body, Traumatic. State location. 2529. Fracture, Compound. State bone or cartilage. 2531. Fracture, Simple. State bone or cartilage. 2532. Frostbite. State location. G 2533. Glass, Powdered, Injuries from Swallowing. H 2534. Heat Cramps. 2535. Heat Exhaustion. 2556. Heat Stroke. To include sun- stroke. 2536. Hematocele, Traumatic, Tu- nica Vaginalis. 2566. Hematoma, Subdural, Chronic, Traumatic. 2537. Hematoma, Traumatic. State location. 2538. Hemorrhage, Traumatic, into Eyeball. 2539. Hemorrhage, Traumatic, into Joint. State joint. 2540. Hemorrhage, Traumatic, un- der Conjunctiva. 2541. Hemorrhage, Traumatic. Oth- erwise unclassified. State loca- tion. Navy diag- nosis No. 2571. Hernia, Traumatic. State lo- cation. Hyperpyrexia, induced. Report as Thermic Fever, Induced (2558). I 2542. Injuries, Multiple, Extreme. 2543. Intracranial Injury. 2544. Intraspinal Injury. 2580. Iridodialysis. K 2545. Killed in Action, Details Not Known. o 2513. Odontoclasis. 2569. Ophthalmia, Actinic Rays. p 2546. Periostitis, Traumatic. State bone. B 2547. Radioactive Bodies, Effects of. State manifestation. Not to include Burn, Radium (2506). 2548. Rupture, Traumatic. State or- gan or part. Not to include Hernia, Traumatic (2571). S Shell shock. Report as Psycho- neurosis, War Neurosis (1537). 2549. Smoke Inhalation. State sub- stance. 2550. Sprain, Joint. State joint. 2551. Starvation. 2552. Strain, Muscular. State loca- tion. 2553. Strangulation, Respiratory. 2554. Submersion, Nonfatal. 2555. Sunburn. State location. Sunstroke. Report as Heat Stroke (2556). 2557. Synovitis, Traumatic. State joint. 43 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. Ill Navy diag- nosis No. T 2558. Thermic Fever, Induced. {See par. 2404 (b).) 2559. Tinnitus Aurium, Traumatic. 2560. Torsion, Traumatic. State or- gan or part. u 2581. Union of Fracture, Faulty. {Mai-, delayed, fibrous, or non- union.) State bone or carti- lage. 2561. Urethral Fever, Traumatic. w 2576. Wound, Gunshot. State loca- tion. Navy diag- nosis No. 2562. Wound, Incised. State loca- tion. 2577. Wound, Infected. State loca- tion. Not to include Gas Bacil- lus Infection (1301). 2563. Wound, Lacerated. State lo- cation. 2565. Wound, Punctured. State lo- cation. 2564. Wounds, Multiple. x 2567. X-Ray, Effects of. State man- ifestation. Not to include Burn, X-Ray (2507). Navy diag- nosis No. 2600. Diagnosis Undetermined. State suspected poisoning. {See par. 2409.) Gases, effects of {except war gas). Report as Poisoning, Acute (2601) or Poisoning, Chronic (2603). 2601. Poisoning, Acute. State sub- stance. 2602. Poisoning, Anesthesia. State anesthetic. 2603. Poisoning, Chronic. State sub- stance. Poisoning, ethyl alcohol. Report as Alcoholism (2106 or 2159). Poisoning, food, allergic. Report as Allergy (2166). 3. POISONINGS Navy diag- nosis No. Poisoning, food, bacterial. Report as Food Infection (1330) Food Intoxication (1331), or Food Poisoning, Bacterial (1332). 2-\;04. Poisoning, Therapeutic, Acute. State compound used and dis- ability treated. (See par. 2413). 2605. Poisoning, Therapeutic, Chronic. State compound used and disability treated. (See par. 2413.) 2606. Poisoning, Venom. State fish, insect, snake, etc. Toadstool (mushroom) poisoning. Report as Poisoning, Acute, toadstool (2601). 2607. War Gas. State gas and effects. SECTION III. NOMENCLATURE OF SURGICAL OPERATIONS A Abscess, Incision and Drainage of. Adenoidectomy. Advancement of Eye Muscle. Amputation. All or in part. State part. Aneurysm, Operation on. State method. Aponeurosis, Division. Aponeurosis, Excision. Appendectomy. Appendectomy with Drainage. Arteriorrhaphy. Arterotomy. Artery, ligation of. Arthrectomy, Complete. Arthrectomy, Incomplete. Arthroclasia. Arthrodesis. Arthroplasty. Arthrotoray. 44 SURGICAL OPERATIONS, B-F Aspiration. Aspiration and Injection. Autoplasty. B Biopsy of. State tissue. Blood Vessels, Operations on. Otherwise unclassified. State type. Bone Graft, Autogenous. Bone Graft. Otherwise unclassified. State source of bone. Bone, Rebroken and Set for Faulty Union. Bone, Resection of. Brain Cyst, Excision. Brain, Operations on. Otherwise unclas- sified. State type. Breaking up of Adhesions. Bronchoscopy. c Calculus, Removal of. Otherwise unclas- sified. Canthoplasty. Canthotomy. Capsulorrhaphy. Cardiorrhaphy. Cataract, Discission. Cataract Extraction. Cataract Needling. Cauterization. Cecectomy. Cecostomy. Chalazion Operation. Cholecystectomy. Cholecystectomy and Appendectomy. Cholecystostomy. Choledochoduodenostomy. Choledocholithotomy. Choledochoplasty. Choledochostomy, Choledochotomy. Cholegastrostomy. Chondrectomy. Chondrotomy. Coccygectomy. Circumcision. Cisternal Puncture. Colectomy. Colostomy. Colotomy. Conjunctival Keratoplasty. Craniotomy. Curettage. Cystectomy, Complete. Cystectomy, Partial. Cystorrhaphy. Cystoscopy. Cystostomy, Perineal. Cystostomy, Suprapubic. Cytsotomy, Perineal. Cystotomy, Suprapubic. Cystotomy, Transperitoneal. D Debridement. Decompression. State type and loca« tion. Depressed Fragments, Elevation of. Dilatation. Dorsal Slit. Drainage. Duodenotomy. Duodenogastrectomy. E Embolectomy. Encephalography. Enterocolostomy. Entero-enterostomy. Enterorrhaphy. Enterostomy. Enterotomy. Enucleation, Simple. Enucleation With Implantation. Epididymectomy. Epididymotomy. Epilation. Esophagoscopy. Esophagostomy. Esophagotomy. Esophagus, Dilatation of. Ethmoidectomy. Excision. Otherwise unclassified. Excision and Drainage. Otherwise un- classified. Exostosis, Removal of. Exploratory Incision. State location. Exploratory laparotomy. Eye, Evisceration of. Eye Operations. Otherwise unclassified. State type. F Fasciotomy. Fixation of Spine, Operation for. State method. 45 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. Ill Foreign Body, Removal of. State loca- tion. Fracture, Treatment of: Closed Reduction. Closed Reduction with Traction. State type of traction. Open Reduction without Fixation. Open Reduction, Fixation with: Absorbable Material. Nonabsorbable Material. Fracture, Removal of Fragments. Frenumectomy. G Gastrectomy, Complete. Gastrectomy, Partial. Gastro-enterostomy. Gastro-enterostomy and Appendectomy. Gastrorrhaphy. Gastroscopy. Gastrostomy. Glaucoma, Operation for. Glossectomy, Complete. Glossectomy, Partial. H Heart, Operation on. Otherwise un- classified. State type. Hemorrhoids, Clamp and Cautery. Hemorrhoids, Ligation. Hemorrhoids, Operation for. Otherwise unclassified. State type. Hemorrhoids, Injection of. Hernia, Injection Treatment of. Hernia, Repair of. Hernia, Repair of. muscle, fascia, ten- don, or sheath. Hernia, Strangulated; Reduction of. Without incision. Herniotomy and Appendectomy. Hydrocele, Repair of. Hypodermoclysis. Hysterectomy. State whether complete or partial. I Ileostomy. Incision. Incision and Curettement. Incision and Drainage. Infusion, intravenous or intraperitoneal. Intestinal Resection. Intestines, Operation on. Otherwise un- classified. State type. Intubation. Intussusception, Reduction of. Iridectomy. Iridotomy. J Jejunostomy. Joint Dislocation: Closed Reduction. Open Reduction. L Lacrymal Sac, Exploration of. laminectomy. laryngectomy. laryngoscopy, Direct. With laryngo scope. Laryngotomy. Litholapaxy. Liver, Operation on. Otherwise un- classified. State type. Lobectomy. State whether partial or complete. Lumbar puncture. Report as spinal puncture. Lungs, Operation on. Otherwise un- classified. State type. M Magnet Extraction. Manipulation. Mastectomy. State whether partial, complete, or radical. Mastoidectomy. Mastoidotomy with Drainage. Meckels Diverticulum, Excision of. Meatotomy. Myectomy. Myorrhaphy. Myotomy. Myringotomy. N Nephrectomy. Nephrolithotomy. Nephropexy. Nephrorrhaphy. Nerve Stretching. Neurectomy. Neurolysis. Neuroplasty. 46 SURGICAL OPERATIONS, O-T Neurorrhaphy. Neurotomy. Nose, Operation on. Otherwise unclas- sified. State type. o Oophorectomy. Operation, not listed. State type and location. Operation, Undoing of. State primary operation. Operative Wound, Exploration of. Orchidectomy. Orchidopexy. Orchid otomy. Osteoplasty. Osteotomy. p Pancreas, Operation on. State type. Paracentesis. Otherwise unclassified. State location. Pericardiorrhaphy. Pericardiotomy. Pericardium, Operation on. Otherwise unclassified. State type. Perineorrhaphy. Peritoneoscopy. Pharyngotomy. Phlebectomy. Phlebotomy. Phrenicectomy. Plastic Dressing, Application of. Plastic Repair. Pleurotomy. Plication. Pneumectomy. Pneumolysis. State whether internal or external. Pneumoperitoneum, Artificial. Pneumorrhaphy. Pneumotomy. Pneumothorax, Artificial. Proctectomy. Proctoscopy. Prostatectomy, Perineal. Prostatectomy, Suprapubic. Prostatotomy. Pterygium, Operation for. Pyelolithotomy. Pylorectomy. B Radium Therapy. State whether plaque, mold, needle, or seed of radium or radon, and whether applied or inserted. Reduction. Otherwise unclassified. State location. Removal. Use this title for removal of foreign objects used in orthopedic surgery for traction or fixation such as Steinman pin, Kirschner wire, bone or ivory peg. So state. Repair. Resection. s Sclerectomy. Sclerotomy. Sequestrectomy. Sequestrotomy. Sigmoidoscopy. Sinusotomy. Sinus Tract, Exploration of. Skin Grafting. State method. Spinal Injection. Spinal Puncture. Splenectomy. Stomach Operation. Otherwise unclas- sified. State type. Submucous Resection. Suture. Suture Secondary. Sympathectomy. State location. T Tattoo, Excision of. Tendon Transplantation. Tendons, Operation on. Otherwise un- classified. State type. Tenoplasty. Tenorrhaphy. Tenosynovectomy. Tenotomy. Tenotomy of Eye Muscle. Thoracentesis. Thoracoplasty. State type. Thoracoscopy. Thoracotomy with Drainage. Thrombectomy. Thyroidectomy. Tongue Operation. Otherwise unclas- sified. State type. 47 APPENDIX A.—DIAGNOSTIC NOMENCLATURE—SEC. IV Tonsillectomy. Tonsillectomy and Adenoidectomy. Tracheotomy. Transfusion. State whether direct or indirect. Trephination. State location. Turbinectomy. u Urethrolithotomy. Urethroscopy. Urethrotomy. State whether external or internal. Uvulotomy. v Varicocelectomy. Varicose Veins, Injection of. Varicotomy. Vasectomy. Vasotomy. Vein, Ligation of. Venography. Vesiculectomy, Seminal. w Wound, Exploration of. SECTION IV. NOMENCLATURE OF NATURE AND CAUSE OF VIOLENCE Naval and Military Hazards Aeronautics. Submarines. General Naval and Military Agents and Hazards. Special Nautical Hazards. AERONAUTICS Aircraft, heavier-than-air, all types Collisions in Full Flight with Other Aircraft. Collisions in Full Flight with Objects Other Than Aircraft. Spins or Stalls Following Engine Failure. Spins or Stalls Without Engine Failure. Forced Landings. Landing Accidents. Take-off Accidents. Taxyinq Accidents. Fires in Air. Carrier, Platform, and Arresting Gear Accidents. Launching Gear Accidents. Structural Failure. Miscellaneous Accidents. Indeterminate and Doubtful Acci- dents. 48 VIOLENCE, NAVAL AND MILITARY Accidents other than defined by National Advisory Committee for Aeronautics Aircraft Ordnance Accidents. Parachute Accidents. Accidents Other Than Those De- fined by National Advisory Com- mittee for Aeronautics, all Other. Aircraft, lighter-than-air all types. Specify whether rigid or nonrigid airship or free balloon Collisions in Full Flight with Other Aircraft. Collisions in Full Flight with Objects Other Than Aircraft. Fires in Air. Structural Failure. Rough Landing. Miscellaneous Accidents. Undetermined Accidents. Ground Accidents. Aircraft Ordnance Accidents. submarines While moored Battery, Chlorine Gas. Battery Explosion. Engines, Machinery and Batteries. Falls, Other. Falls Overboard. Gangplank, Falls, on Slipping on, etc. Hatchways and Ladders, Falls on, Slipping on, etc. Torpedo, Handling of, Drills, etc. All Other Causes. Specify. While at sea—use specialty letter S Battery, Chlorine Gas. Battery Explosion. Bomb, Handling of, Drills, etc. Engines, Machinery and Batteries. Falls, Other. Falls Overboard or Washed Over- board. Guns, all Types, Drill, Mechanism of Gun. Guns, all Types, Drill, Others. Guns, all Types, Target and Battle Practice, Mechanism of Gun and Firing of. Guns, all Types, Target and Battle Practice, Others. Hatchways and Ladders, Falls on, Slipping on, etc. Mines, Handling of, Drills, etc. Sinking of, Due to Collision. Sinking of, Due to Storm at Sea. Storms at Sea, Rolling and Pitch- ing, ETC. Torpedo, Handling of, Drills, etc. All Other Causes. Specify. general naval and military agents and hazards Aerial Bombing. Antiaircraft Gun, Explosion of. Antiaircraft Gun, Gun Crew, Mechanism of Gun, Drills and Firing of. Bayonet. Blank Cartridge, Explosion of. Bomb, Explosion of. Caps and Fussfe, Explosion of. Cartridge, Explosion of. Depth Bomb. Drill, Artillery. Drill, Bayonet. Drill, Great Guns, Gun Crew, Mechanism of Gun (not target or battle practice). Drill, Great Guns, Gun Crew, Other (not target or battle practice). Drill, Gymnastic Exercises. Drill, Hand Grenade. 49 APPENDIX A.—DIAGNOSTIC NOMENCLATURE SEC. IV Drill, Infantry. Drill, Loading Machine. Drill, Miscellaneous Naval, all Others. Explosives and Projectiles, Han- dling of on Board Men-of-War, other than Conveying to Turret. Explosives and Projectiles, Ma- chinery for Conveying Same to the Turrets and Guns (Powder Hoist, Scuttle and Ammunition Hoist). Explosives and Projectiles, Trans- portation on Lighters, Ammuni- tion Ships, and Handling of other THAN ON BOARD MeN-OF-WaR. Flaming Liquid, War. Gas, War. Gun, Explosion of—Great Gun. Gun, Explosion of—Machine Gun. Gun, Explosion of—Pistol, Rifle, or Shotgun. Gun, Great, Care of. Gunpowder, Explosion of. Gunpowder, Ignition of. Hand Grenade. Machine Gun Bullet. Machine Gun, Mechanism of, Drills and Care of. Marching—not infantry drill. Mine, Land, Explosion of. Mine, Sea, Drifting, Explosion of. Mine, Sea, Laying, Sweeping or Taking Up. Mine, Sea, Mine Fields, Explosion of. Patrol, Reconnoitering Party, Guard Duty. Pistol Ball. Rifle Ball. Rifle Grenade. Saber. Saluting Gun or Charge. Shell, Explosion of. Shotgun. Shrapnel. Sinking of Ship From Military or Naval Cause. Sunburn as Result of Prescribed Uniform. Tank, Military. Target and Battle Practice, Great Guns, Gun and Turret Crew, Mechanism of Gun. Target and Battle Practice, Great Guns, Gun and Turret Crew, OTHER THAN MECHANISM OF GUN. Target and Battle Practice, Great Guns, Personnel other than Gun and Turret Crew. Target and Battle Practice, Great Guns, Target Repair and Towinq Party. Target Practice, Artillery. Target Practice, Small Arms. Torpedo, Firing of, during Target Practice. Torpedo, Handling of, Drills, Etc. Torpedo Tube, Care of, Repair, etc. Trench Mortar. Turret Accidents, not drills or target and battle practice. Other Naval or Military Agent or Hazard. Specify. special nautical hazards Anchor Gear. Ash-Hoisting Apparatus and Ash Blowers on Board Ship. Bilges, Double Bottoms, and Holds, Poor Ventilation of. Boats, Handling of, other than Machinery Accidents in Power Boats. Boats, Hoisting and Lowering of other than by Power Transmis- sion. Boats, Small, Capsizing or Sinking of. Cargo Hatch or Open Hatch, Falls Through. Cargo Sling. Caught Between Ship and Dock or Gangway. Caught between Ships or Small Boats. Coaling Ship. Collision of Ship. 50 VIOLENCE, INDUSTRIAL OR NAVAL AND MILITARY Diving, Sea, Submarine Escape Ap- pliances, etc. Specify. Fall Overboard. Falls from Elevations aboard Ship, other than Fireroom, Engine- Room and Machinery Space. (In- clude staging, scaffolding and boat- swain's chairs.) Falls, Slipping on Wet or Oily Decks aboard Ship. Gangplank, Fall on, Falls from, Slipping on, Stumbling, etc. (Not submarines). Gangplank, Rigging, Unrigging, or Handling of. Grounding of Ship. Hammock, Fall from. Hammock, Fall of. Hatch Cover. Hatchway and Ladder, Slipping, Stumbling, and Falls on. Heat Excessive, Engine Room. Heat Excessive, Evaporator Room. Heat Excessive, Fireroom. Jumped Overboard. Ladders, Vertical, on board Ship. Lead Line, Log Line, Deep-sea Sounding Machines. Lines, Cables, Fenders, not used for Power Transmission. Manholes on board Ship. Mess Tables and Benches, Handling OF. Mooring and Unmooring Ship. Neptune Initiation. Nonpoisonous Fish. Specify name of fish. Open Hatch, Engine Room, Fireroom, or Machinery Spaces on board Ship. Poibonous Fish. Specify name of fish. Poor Ventilation, Living-Spaces on board Ship. Ports, Gun Ports, Air Ports, Bat- tle Ports. Sinking of Ship Due to Collision. Sinking of Ship Due to Storm at Sea. SteeKing Gear. Storm or Heavy Weather at Sea or Result of Motion of Ship Due to. Sunburn as Result of Working Parties. Sunburn, not otherwise classified. Specify. Swimming, not Athletics or Rec- reative Sports. Towing Gear. Washed Overboard or Thrown Overboard by Motion of Ship. Water-tight Door. Other Nautical Hazards. Specify. Industrial and Miscellaneous Hazards Animals. Athletics and Recreative Sports. Boilers. Conflagrations. Cranes and Conveyors. Electricity. Elevators. Explosions. Falling Objects Not Being Handled by Injured. Falls or Near Falls of Persons. Animals. Specify. Athletics and Recreative Sports: Athletic sports, games, or exercise. Specify. Hand Tools. Handling of Objects. Hot Substances and Flames. Machinery. Miscellaneous. Poisonings. Railroad Cars and Engines. Stepping On or Striking Against Objects. Vehicles. Boilers: Firing gear, slice bars, shovels, etc. Steam boilers, escaping steam and hot water. 51 APPENDIX A.—DIAGNOSTIC NOMENCLATURE SEC. IV Boilers—Continued. Steam boilers, explosions of. Steam boilers, all other causes. Specify. Steam boilers not on board ship. Steam and hot water gauges, ex- plosions of. Steam pipes, escaping steam and hot water. Steam pipes, explosions of. Steam pipes, all other causes. Specify. Steam pipes or radiators not on board ship. Other steam pressure apparatus, explosion of. Other steam pressure apparatus, all other causes. Specify. Conflagration: All injuries as a result of general conflagration. Cranes and Conveyors: Blocks and tackles other than boat falls, windlasses, capstans, winches not anchor gear, cranes, cargo boom, and conveyors not elevators. Boats, hoisting and lowering of by power transmission. (Include boat falls, davits, and slings.) Deck winches. Electricity: Electricity from transmission wire, switchboard apparatus, motors, and generators. Radio apparatus. Elevators: Dumb-waiters. Elevators. Explosions: Explosions of explosive substances: Gasoline or other hydrocarbon products. Illuminating gas. Not otherwise classified. Spec- ify- Unknown explosive substances. Ignition of explosive substances: Gasoline, benzine, kerosene, and other hydrocarbon prod- ucts. Explosions—Continued. Ignition of explosive substances— Continued. Other substances to include alcohol, turpentine, waxes, resins, and oils. Unknown inflammable or com- bustible substances. Other: Ammonia apparatus. Gasoline blow torch or acety- lene torch. All other. Specify. Falling Objects Not Being Handled by Injured: Objects tipping over, not vehicles. Collapse of buildings, walls, etc. From elevations, miscellaneous. Falls or Near Falls of Persons: Fall from bunk. Fall from elevations ashore, mis- cellaneous. Fall from staging, scaffolding, and ladders, ashore. Falls in engine room, fireroom, and machinery spaces aboard ship: From elevations. Slipping on ladders. Slipping on wet or greasy floor plates. All others. Specify. Fall into dry dock other than from ship in dry dock. Fall into excavations, ditches, and trenches. Falls on level: Ice. Slipping, all other. Slipping on wet or waxed floors ashore. Slipping, shower space, wash- room, head, etc. Stepping into shallow holes. Stepping on or stumbling over loose objects. Stumbling over fixed objects. Stumbling over or stepping on rolling objects. All others. Specify. Falls on steps and stairs. Falls overboard from docks, piers, and sea walls. 52 VIOLENCE, INDUSTRIAL Hand Tools: In hands of injured worker. In hands of fellow worker. Flying particles set in motion by tool in hands of injured worker. Flying particles set in motion by tool in hands of fellow worker. Portable power tools in hands of injured worker. Portable power tools in hands of fellow worker. Handling Objects (exclude handling of objects by power appliances): Handling ice. Handling objects, unclassified. Specify. Handling stores on board ship (not breaking out stores). Objects dropped. Objects thrown. Sharp or rough objects, glass. Sharp or rough objects, unclassi- fied. Specify. Strain in handling. Hot Substances and Flames: Contact with hot furnaces, ranges, and stoves. Flames, clothing. Flames, all others. Specify. Flare up, coal range. Flare up, illuminating gas or gaso- line stove. Flare up, oil-burning boiler. Flare up, oil-burning range. Grease. Hot water and steam other than boilers. Molten metal. Other hot liquids. Specify. All other hot objects. Specify. Machinery: (o) Prime movers: Catapult. Diesel engine. Electric motors and dynamos. Gas or gasoline engine. Specify. Powerboat engine, backfire, cranking. Power boat engine, other. Specify. Stationary engine. Engines, repair of. M achinery—Continued. (а) Prime movers—Continued. Steam engines, specify. Steering engine. (б) Power-transmission apparatus: Bearings. Belts, pulleys, flywheels. Chains and sprockets. Cogs, cams, gears, and friotion wheels. Energizers (inertia starters). Propellers not radio generator. Ropes, cables, and drums. Set screws, keys, and bolts. Shafts. Shaft collars and couplings. (c) Power-working machinery: Dishwashing machine. Engineering and contract ma- chinery (concrete mixer, pile driver, etc.). Farm machines (harvesters, threshers, etc.). Food-products machinery: Bread cutter. Choppers, grinders, and slicers. Dough mixer. Others. Specify. Ice-making machines. Laundry machines. Printing and bookbinding ma- chinery. Metal-working machinery: Drills (include drill press). Emery wheel. Lathe. Others. Specify. Woodworking machinery: Jointer. Planer. Saws. Others. Specify. All others. Specify. (d) Machinery, other than power- working machines: Chain falls. Compressors and evaporators. Fans and blowers. Pumps. Radio generator propeller. All other. Specify. 53 APPENDIX A.—DIAGNOSTIC NOMENCLATURE SEC. IV Miscellaneous: Assault with deadly weapon. To include only firearms and sharp instruments. Assault without deadly weapon. To include blackjack, sandbag, etc. Caught (jammed) between objects, miscellaneous (not striking against). Cause unknown. Cutting and piercing instruments: Knife or razor. Knife while preparing food- stuffs. Other sharp instruments while preparing foodstuffs (exclude machinery). All other. Specify. (Exclude hand tools, handling of ob- jects, or stepping on or striking against objects.) Darkness or insufficient light. Doors, windows, covers, and gates (not hatch cover). Excessive cold. Excessive heat, sun (heatstroke and heat exhaustion from sun). Excessive heat, other than engine- room and fireroom. Specify. Excessive light. Fighting and brawling with civilian personnel. Fighting and brawling with service personnel. Flying particles not otherwise clas- sified (exclude particles from hand tools and power-working machinery). Hanging. Injury due to posture assumed (not falls). Jumping, not athletics or over- board. Landslide. Lightning. Maintaining order. Oxygen deprivation, fires and fight- ing fires. Oxygen deprivation, miscellaneous. Specify. Miscellaneous—Continued. Poisonous insect. Specify. Poisonous reptile. Specify. Resisting arrest, service patrol. Resisting arrest, civilian authori- ties. Roller coaster and other mechanical amusement device. Shoes, ill-fitting. Skylarking. Snowslide. Storms on land. Therapeutic appliance. Other miscellaneous causes not listed or classified elsewhere. Specify. Poisonings: (a) Handling or contact with: Acids. Specify. Lead, chipping paint. Lead, painting. Lye and other alkalis. Specify. Phenol, cresol and other phenol compounds. Specify. Miscellaneous handling or con- tact with. Specify. (b) Inhaling: Ammonia. Anesthetics. Carbon monoxide. Coal gas. Formaldehyde. Illuminating gas. Opium and cannabis indica. Turpentine, benzol, “wing- dope.” Miscellaneous inhaling of. Specify. (c) Swallowing: Acids. Specify. Alkalis. Specify. Cocaine and derivatives. Methyl alcohol. Opium and derivatives. Veronal (barbital), trional, sulphonal, chloral hydrate, and other sleep-producing drugs except opium and de- rivatives. Miscellaneous swallowing of. Specify. 54 VIOLENCE, INDUSTRIAL Poisonings—Continued. (d) Injection (instrumental): Arsenic compounds, antisyph- ilitic treatment. Specify. Arsenic compounds, other than for antisyphilitic treat- ment. Specify. Arsphenamine, antisyphilitic treatment. Arsphenamine, other than for antisyphilitic treatment. Cocaine and derivatives. Mercury compounds, anti- syphilitic treatment. Spec- ify- Mercury compounds, other than for antisyphilitic treat- ment. Specify. Neoarsphenamine, antisyphi- litic treatment. Neoarsphenamine, other than for antisyphilitic treatment. Opium and derivatives. Miscellaneous injection. Specify. Railroad Cars and Engines: (Specify steam or electric railroad): Caught between. Falls from or in while getting on or off, in motion. Falls from or in while getting on or off, at rest. Falls from or in while riding on. Run over by. Struck by. Tracks, stumbling, falls on, etc. Train wreck by collision. Train wreck by derailment. Train wreck by car striking objects on track without derailment. All others. Specify. Stepping on or Striking against Object: Stepping on: Glass. Nails. All others. Specify Stepping on or Striking against Objects—Continued. Striking against: Fellow worker. Glass. Nails. Other fixed objects. Splinters or sharp projections from walls or structures. All other objects. Specify. Vehicles: (o) Automobile, automobile truck, and motorcycle. Specify. Breaking of car or part, not resulting in collision or over- turning. Collision, breaking of parts. Collision, skidding. Collision, all other causes. Collision and overturning. Collision with cars or engines. Specify steam or electric. Collision with other motor vehicles. Specify. Cranking. Driving off dock or pier. Driving off embankment or cliff. Falls from, thrown from, jump- ing from, or stepping from. Objects falling from. Overturning, breaking of parts. Overturning, skidding. Overturning, all others. Repairing or overhauling. Run over by. Struck by. All other causes. Specify. (6) Other motor vehicles: Tractor, motorbus, plant truck, trailer, fire engines, and fire trucks. Specify. (c) Vehicles not power-operated: Animal-drawn vehicles, bicy- cles, hand-propelled trucks, etc. Specify. 55 APPENDIX B MANUAL OF THE MEDICAL DEPARTMENT SUPPLY TABLE AND SUPPLEMENTARY SUPPLY TABLE OF THE Medical Department, United States Navy This is issued as a separate volume entitled “Supply Catalog, Medical Depart- ment, United States Navy.” MANUAL OF THE MEDICAL DEPARTMENT APPENDIX C CONVENTIONS AND AMERICAN NATIONAL RED CROSS Section I. The Geneva Conventions of 1864 and 1868. II. Geneva Convention of July 27, 1929. III. The Hague Peace Conference of 1899. IV. Hague Convention of December 21, 1904. V. Hague Convention of October 18, 1907. VI. The American National Red Cross. The convention between the United States, Baden, Switzerland, Belgium, Denmark, Spain, France, Hesse, Italy, Netherlands, Portu- gal, Prussia, Wurttemberg, Sweden, Greece, Great Britain, Meck- lenburg-Schwerin, Turkey, Bavaria, Austria, Russia, Persia, Rumania, Salvador, Montenegro, Servia, Bolivia, Chile, Argentine Republic, Peru, and Japan; with additional articles: For the amelioration of the wounded in armies in the field, concluded August 22, 1864, ac- ceded to by the President March 1, 1882; accession concurred in by the Senate March 16, 1882; proclaimed as to the original convention but with reserve as to the additional articles, July 26, 1882, commonly known as the Geneva Convention, is as follows: SECTION I. THE GENEVA CONVENTIONS OF 1864 AND 1868 1. Original Convention. Article 1. Ambulances and military hospitals shall be acknowledged to be neuter, and as such shall be protected and respected by belligerents so long as any sick or wounded may be therein. Such neutrality shall cease if the ambulances or hospitals should be held by a military force. Art. 2. Persons employed in hospitals and ambulances, comprising the staff for superintendence, medical service, administration, transport of wounded, as well as chaplains, shall participate in the benefit of neutrality while so em- ployed and so long as there remain any wounded to bring in or to succor. Art. 3. The persons designated in the preceding article may, even after occu- pation by the enemy, continue to fulfill their duties in the hospitals or ambulances which they serve, or may withdraw in order to rejoin the corps to which they belong. Under such circumstances, when these persons shall cease from their functions, they shall be delivered by the occupying army to the outposts of the enemy. Art. 4. As the equipment of military hospitals remains subject to the laws of war, persons attached to such hospitals cannot, in withdrawing, carry away any articles but such as are their private property. 1 APPENDIX C.—CONVENTIONS Under the same circumstances an ambulance shall, on the contrary, retain its equipment. Art. 5. Inhabitants of the country who may bring help to the wounded shall be respected and shall remain free. The generals of the belligerent powers shall make it their care to inform the inhabitants of the appeal addressed to their humanity and of the neutrality which will be the consequence of it. Any wounded man entertained and taken care of in a house shall be con- sidered as a protection thereto. Any inhabitant who shall have entertained wounded men in his house shall be exempted from the quartering of troops as well as from a part of the contributions of war which may be imposed. Art. 6. Wounded or sick soldiers shall be entertained and taken care of, to whatever nation they may belong. Commanders in chief shall have the power to deliver immediately to the out- posts of the enemy soldiers who have been wounded in an engagement, when circumstances permit this to be done, and with the consent of both parties. Those who are recognized, after their wounds are healed, as incapable of serving shall be sent back to their country. The others may also be sent back on condition of not again bearing arms during the continuance of the war. Evacuations, together with the persons under whose directions they take place, shall be protected by an absolute neutrality. Art. 7. A distinctive and uniform flag shall be adopted for hospitals, ambu- lances, and evacuations. It must, on every occasion, be accompanied by the national flag. An arm badge (brassard) shall also be allowed for individuals neutralized, but the delivery thereof shall be left to military authority. The flag and the arm badge shall bear a red cross on a white ground. Art. 8. The details of execution of the present convention shall be regulated by the commanders in chief of belligerent armies, according to the instructions of their respective governments and in conformity with the general principles laid down in this convention. 2. Additional Articles. (Now generally accepted and have acquired the force and effect of an inter- national treaty.) Article 1. The persons designated in article 2 of the convention shall, after the occupation by the enemy, continue to fulfill their duties, according to their wants, to the sick and wounded in the ambulance or the hospital which they serve. When they request to withdraw, the commander of the occupying troops shall fix the time of departure, which he shall only be allowed to delay for a short time in case of military necessity. Art. 2. Arrangements will have to be made by the belligerent powers to insure to the neutralized person, fallen into the hands of the army of the enemy, the entire enjoyment of his salary. Art. 3. Under the conditions provided for in articles 1 and 4 of the convention, the name “ambulance” applies to field hospitals and other temporary establish- ments which follow the troops on the field of battle to receive the sick and wounded. Art. 4. In conformity with the spirit of article 4 of the convention, and to the reservations contained in the protocol of 1864, it is explained that for the appoint- ment of the charges relative to the quartering of troops and of the contributions of war account only shall be taken in an equitable manner of the charitable zeal displayed by the inhabitants. 2 GENEVA, 1864 AND 1868 Art. 5. In addition to article 6 of the convention, it is stipulated that, with the reservation of officers whose detention might be important to the fate of arms and within the limits fixed by the second paragraph of that article, the wounded fallen into the hands of the enemy shall be sent back to their country after they are cured, or sooner if possible, on conditions, nevertheless, of not again bearing arms during the continuance of the war. 3. Articles Concerning the Marine. Art. 6. The boats which at their own risk and peril, during and after an engagement pick up the shipwrecked or wounded, or which having picked them up, convey them on board a neutral or hospital ship, shall enjoy, until the accom- plishment of their mission, the character of neutrality, as far as the circumstances of the engagement and the position of the ships engaged will permit. The appreciation of these circumstances is intrusted to the humanity of all the combatants. The wrecked and wounded thus picked up and saved must not serve again during the continuance of the war. Art. 7. The religious, medical, and hospital staff of any captured vessel are declared neutral, and, on leaving the ship, may remove the articles and surgical instruments which are their private property. Art. 8. The staff designated in the preceding article must continue to fulfill their functions in the captured ship, assisting in the removal of the wounded made by the victorious party; they will then be at liberty to return to their country, in conformity with the second paragraph of the first additional article. The stipulations of the second additional article are applicable to the pay and allowance of the staff. Art. 9. The military hospital ships remain under martial law in all that con- cerns their stores; they become the property of the captor, but the latter must not divert them from their special appropriation during the continuance of the war. Art. 10. Any merchant ship, to whatever nation she may belong, charged exclusively with removal of sick and wounded, is protected by neutrality; but the mere fact, noted on the ship’s books, of the vessel having been visited by an enemy’s cruiser, renders the sick and wounded incapable of serving during the continuance of the war. The cruiser shall even have the right of putting on board an officer in order to accompany the convoy, and thus verify the good faith of the operation. If the merchant ship also carries a cargo, her neutrality will still protect it, provided that such cargo is not of a nature to be confiscated by the belligerents. The belligerents retain the right to interdict neutralized vessels from all com- munication, and from any course which they may deem prejudicial to the secrecy of their operations. In urgent cases special conventions may be entered into between commanders in chief, in order to neutralize temporarily and in a special manner the vessels intended for the removal of the sick and wounded. Art. 11. Wounded or sick sailors and soldiers, when embarked, to whatever nation they may belong, shall be protected and taken care of by their captors. Their return to their own country is subject to the provisions of article 6 of the convention, and of the additional article 5. Art. 12. The distinctive flag to be used with the national flag, in oraer to indicate any vessel or boat which may claim the benefits of neutrality, in virtue of the principles of this convention, is a white flag with a red cross. The belligerents may exercise in this respect any mode of verification which they may deem necessary. 3 APPENDIX 0.—CONVENTIONS Military hospital ships shall be distinguished by being painted white outside, with green strake. Art. 13. The hospital ships, which are equipped at the expense of the aid societies, recognized by the Governments signing this convention, and which are furnished with a commission emanating from the sovereign, who shall have given express authority for their being fitted out, and with a certificate from the proper naval authority that they have been placed under his control during their fitting out and on their final departure, and that they were then appro- priated solely to the purpose of their mission, shall be considered neutral, as well as the whole of their staff. They shall be recognized and protected by the belligerents. They shall make themselves known by hoisting, together with their national flag, the white flag with a red cross. The distinctive mark of their staff while performing their duties shall be an armlet of the same colors. The outer paint- ing of these hospital ships shall be white, with red strake. These ships shall bear aid and assistance to the wounded and wrecked bellig- erents, without distinction of nationality. They must take care not to interfere in any way with the movements of the combatants. During and after the battle they must do their duty at their own risk and peril. The belligerents shall have the right of controlling and visiting them. They will be at liberty to refuse their assistance, to order them to depart, and to detain them if the exigencies of the case requires such a step. The wounded and wrecked picked up by these ships can not be reclaimed by either of the combatants, and they will be required not to serve during the con- tinuance of the war. Art. 14. In naval wars, any strong presumption that either belligerent takes advantage of the benefits of neutrality with any other view than the interest of the sick and wounded gives to the other belligerent, until proof to the contrary, the right of suspending the convention as regards such belligerent. Should this presumption become a certainty, notice may be given to such belligerent that the convention is suspended with regard to him during the whole continuance of the war. Art. 15. The present act shall be drawn up in a single original copy, which shall be deposited in the archives of the Swiss Confederation. The additional articles have been acceded to by the United States, and signed on behalf of Great Britain, Austria, Baden, Bavaria, Belgium, Denmark, France, Netherlands, North Germany, Sweden, and Norway, Switzerland, Turkey, and Wurttemberg, but will not acquire full force and effect as an international treaty until the exchange of the ratification thereof between the several contracting States shall have been effected. 4 GENEVA, 19 29 SECTION II. CONVENTION OF GENEVA OF JULY 27, 1929, FOR THE AMELIORATION OF THE CONDITION OF THE WOUNDED AND SICK OF ARMIES IN THE FIELD Signed at Geneva, July 27, 1929. Proclaimed by the President of the United States, August 4, 1932 By the President of the United States of America A PROCLAMATION Whereas a Convention for the Amelioration of the Condition of the Wounded and the Sick of Armies in the Field was signed at Geneva on July 27, 1929, by the respective Plenipotentiaries of the United States of America and forty-six other countries, the original of which Convention, being in the French language, is word for word as follows: [Translation'] 1. Chapter I. The Wounded and Sick. Article 1. Officers, soldiers, and other persons officially attached to the armies who are wounded or sick shall be respected and protected in all circum- stances; they shall be humanely treated and cared for without distinction of na- tionality by the belligerent in whose power they are. A belligerent, however, when compelled to leave his wounded or sick in the hands of his adversary, shall leave with them, so far as military exigencies permit, a portion of the personnel and materiel of his sanitary service to assist in caring for them. Article 2. Subject to the care that must be taken of them under the preceding article, the wounded and sick of an army who fall into the power of the other belligerent shall become prisoners of war, and the general rules of international law in respect to prisoners of war shall become applicable to them. The belligerents shall remain free, however, to agree upon such clauses to the benefit of the wounded and sick prisoners as they may deem of value over and above already existing obligations. Article 3. After every engagement, the belligerent who remains in possession of the field of battle shall take measures to search for the wounded and the dead and to protect them from robbery and ill-treatment. A local armistice or cessation of fire to enable the removal of wounded left between the lines shall be arranged whenever circumstances permit. Article 4. Belligerents shall mutually forward to each other as soon as possible the names of the wounded, sick, and dead taken in charge or discovered by them, as well as all indications which may serve for their identification. They shall draw up and forward to each other death certificates. They shall collect and likewise forward to each other all objects of personal use found on the field of battle or on the dead, especially one-half of their identity plaque, the other half remaining attached to the body. They shall see that a careful examination, if possible medical, is made of the bodies of the dead prior to their interment or cremation, with a view to verifying 1 Based on Senate Document Executive F, Seventy-first Congress, third session. 5 APPENDIX C. CONVENTIONS their death, establishing their identity, and in order to be able to furnish a report thereon. They shall further see that they are honorably buried and that the graves are treated with respect and may always be found again. For this purpose, and at the outbreak of hostilities, they shall officially organize a service of graves in order to render any later exhumation possible and to make certain of the identity of bodies even though they may have been moved from grave to grave. Upon the termination of hostilities, they shall exchange lists of graves and of dead buried in their cemeteries and elsewhere. Article 5. The military authority may make an appeal to the charitable zeal of the inhabitants to receive and, under its supervision, to care for, the wounded or sick of the armies, granting to persons responding to such appeals special protection and certain facilities. 2. Chapter II. Sanitary Formations and Establishments. Article 6. Mobile sanitary formations, i. e., those which are intended to accompany armies in the field, and the fixed establishments belonging to the sanitary service shall be protected and respected by the belligerents. Article 7. The protection due to sanitary formations and establishments shall cease if they are used to commit acts injurious to the enemy. Article 8. A sanitary formation or establishment shall not be deprived of the protection accorded by article 6 by the fact: (1) that the personnel of the formation or establishment is armed and uses its arms in self-defense or in defense of its wounded and sick; (2) that in the absence of armed hospital attendants the formation is guarded by an armed detachment or by sentinels; (3) that hand firearms or ammunition taken from the wounded and sick and not yet turned over to the proper authorities are found in the formation or establishment; (4) that there is found in the formation or establishment personnel or materiel of the veterinary service which does not integrally belong to it. 3. Chapter III. Personnel. Article 9. The personnel charged exclusively with the removal, transporta- tion, and treatment of the wounded and sick, as well as with the administration of sanitary formations and establishments, and the chaplains attached to armies, shall be respected and protected under all circumstances. If they fall into the hands of the enemy they shall not be treated as prisoners of war. Military personnel which has received special instructions to be used when necessary as auxiliary attendants or litter bearers in the removal, transportation and treatment of the wounded and sick, and bearing an identification document, shall benefit by the same conditions as the permanent sanitary personnel if they are captured at the moment when they are fulfilling these functions. Article 10. The personnel of volunteer aid societies, duly recognized and authorized by their Government, who are employed in the same functions as the personnel contemplated in article 9, paragraph 1, are assimilated to that personnel upon condition that the said societies shall be subject to military laws and regulations. Each High Contracting Party shall make known to the other, either in time of peace or at the opening or during the progress of hostilities, and in any case before actual employment, the names of the societies which it has authorized 6 GENEVA, 19 29 to render assistance, under its responsibility, in the official sanitary service of its armies. Article 11. A recognized society of a neutral country may only lend the services of its sanitary personnel and formations to a belligerent with the prior consent of its own Government and the authority of such belligerent. The belligerent who has accepted such assistance shall be required to notify the enemy before making any use thereof. Article 12. The persons described in articles 9, 10, and 11 may not be detained after they have fallen into the power of the adversary. Unless there is an agreement to the contrary, they shall be sent back to the belligerent to whose service they are attached as soon as a way is open for their return and military exigencies permit. While waiting to be returned, they shall continue in the exercise of their func- tions under the direction of the adversary; they shall be assigned preferably to the care of the wounded and sick of the belligerent to whose service they are attached. At the time of their departure they may carry with them such effects, instru- ments, arms and means of transport as belong to them. Article 13. While they remain in their power, belligerents shall secure to the personnel mentioned in articles 9, 10, and 11, the same maintenance and quarters, pay and allowances, as to persons of corresponding rank in their own armies. At the outbreak of hostilities the belligerents shall reach an understanding on the corresponding ranks of their sanitary personnel. 4. Chapter IV. Buildings and Materiel. Article 14. If mobile sanitary formations, whatever may be their nature, fall into the power of the adversary, they shall retain their materiel, their means of transportation, and their conducting personnel. The competent military authority, however, shall have the right to employ them in caring for the wounded and sick; restitution shall take place in accord- ance with the conditions prescribed for the sanitary personnel and as far as possible at the same time. Article 15. Buildings and materiel of the fixed sanitary establishments of the army shall remain subject to the laws of war, but may not be diverted from their use so long as they are necessary for the wounded and sick. However, commanders of troops engaged in operations may use them in case of urgent military necessity if, before such use, the wounded and sick treated there have been provided for. Article 16. The buildings of aid societies admitted to the benefits of the Convention shall be regarded as private property. The materiel of these societies, irrespective of its location, shall likewise be regarded as private property. The right of requisition recognized to belligerents by the laws and customs of war shall be exercised only in case of urgent necessity and after the wounded and sick have been provided for. 5. Chapter V. Sanitary Transports. Article 17. Vehicles equipped for sanitary evacuation traveling singly or in convoy shall be treated as mobile sanitary formations subject to the following special provisions: A belligerent intercepting sanitary transportation vehicles, traveling either singly or in convoy, may, if required by military necessity, stop them and break up the convoy, charging himself in all cases with the care of the wounded and APPENDIX C. CONVENTIONS sick whom it contains. He may only utilize such vehicles in the sector wherein they were intercepted and exclusively for sanitary needs. When their local mission is at an end, these vehicles must be returned under the conditions stipu- lated in article 14. Military personnel assigned by competent orders for sanitary transportation purposes shall be returned under the conditions stipulated in article 12 for sanitary personnel, and subject to the provisions of the last paragraph of article 18. All means of transportation especially organized for evacuation purposes, as well as their appurtenances attached to the sanitary service, shall be returned in conformity with the provisions of chapter IV. Military means of transportation and their teams, other than those belonging to the sanitary service, may be captured. The civil personnel and all means of transportation obtained by requisition shall be subject to the general rules of international law. Article 18. Aircraft used as a means of sanitary transportation shall enjoy the protection of the convention during such time as they are exclusively reserved for the evacuation of wounded and sick and for the transportation of sanitary personnel and materiel. They shall be painted in white and shall bear clearly visible the distinctive sign mentioned in article 19 alongside of the national colors on their upper and lower surfaces. Excepting with special and express permission, a flight over the firing-line, as well as over the zone situated in front of the major medical dressing stations, and in general over any territory under the control of or occupied by the enemy shall be forbidden. Sanitary aircraft must comply with all summons to land. In the case of a landing thus required or made accidentally upon territory occupied by the enemy, the wounded and sick, as well as the sanitary personnel and materiel, including the aircraft, shall benefit by the provisions of the present Convention. The pilot, mechanics, and wireless operators who have been captured shall be returned on condition of only being utilized in the sanitary service until the termination of hostilities. 6. Chapter VI. The Distinctive Sign. Article 19. Out of respect to Switzerland the heraldic emblem of the red cross on a white ground, formed by the reversal of the Federal colors, is continued as the emblem and distinctive sign of the sanitary service of armies. However, for countries which already use, as a distinctive sign, in place of the red cross, the red crescent or the red lion and sun on a white field, these emblems shall likewise be recognized within the meaning of the present convention. Article 20. The emblem shall appear on flags and brassards, as well as upon all materiel, appertaining to the sanitary service, with the permission of the competent military authority. Article 21. The personnel protected in virtue of the first paragraph of article 9 and articles 10 and 11 shall wear attached to the left arm a brassard bearing the distinctive sign, issued and stamped by a competent military authority. The personnel mentioned in article 9, paragraphs 1 and 2, shall be furnished with an identification document consisting either of an inscription in their mili- tary booklet or a special document. 8 GENEVA, 1929 Persons mentioned in articles 10 and 11 who do not wear military uniform shall be furnished by competent military authority with a certificate of identity con- aining their photograph and attesting to their sanitary status. Identification documents must be uniform and of the same type in each army. The sanitary personnel may in no case be deprived of their insignia nor of their own identification papers. In case of loss they shall have the right to obtain duplicates. Article 22. The distinctive flag of the convention may only be displayed over the sanitary formations and establishments which the convention provides shall be respected, and with the consent of the military authorities. In fixed establish- ments it shall, and in mobile formations it may, be accompanied by the national flag of the belligerent to whose service the formation or establishment is attached. Sanitary formations which have fallen into the power of the enemy, however, shall fly no other flag than that of the convention as long as they continue in that situation. The belligerents, in so far as military exigencies allow, shall take such measures as may be necessary to render the distinctive emblems marking sanitary forma- tions and establishments plainly visible to the land, air and sea forces of the enemy, with a view to preventing the possibility of any aggressive action. Article 23. The sanitary formations of neutral countries which, under the conditions set forth in article 11, have been authorized to render their services, shall fly, with the flag of the convention, the national flag of the belligerent to which they are attached. They shall have the right during such time as they are rendering service to a belligerent to fly their own national flag also. The provisions of the second paragraph of the preceding article are applicable to them. Article 24. The emblem of the red cross on a white ground and the words Red Cross or Geneva Cross may be used, whether in time of peace or war, only to protect or designate sanitary formations and establishments, the personnel and materiel protected by the convention. The same shall apply with respect to the emblems mentioned in the second paragraph of article 19 for such countries as use them. Moreover, the volunteer aid societies provided for under article 10 may, in conformity with their national legislation, employ the distinctive emblem for their humanitarian activities in time of peace. As an exceptional measure and with the specific authorization of one of the national Red Cross Societies (Red Crescent, Red Lion and Sun), the use of the emblem of the convention may be allowed in peace time to designate the location of relief stations reserved exclusively to giving free assistance to wounded or sick. 7. Chapter VII. The Application and Execution of the Convention. Article 25. The provisions of the present convention shall be respected by the High Contracting Parties under all circumstances. If, in time of war, a belligerent is not a party to the convention, its provisions shall nevertheless remain in force as between all the belligerents who are parties to the convention. Article 26. It shall be the duty of the commanders-in-chief of the belligerent armies to provide for the details of execution of the foregoing articles, as well as for unforeseen cases, in accordance with the instructions of their respective Governments, and conformably to the general principles of this convention. 9 APPENDIX C. CONVENTIONS Article 27. The High Contracting Parties shall take the necessary steps to acquaint their troops, and particularly the protected personnel, with the pro- visions of this convention, and to make them known to the people at large. 8. Chapter VIII. The Repression of Abuses and Infractions. Article 28. The Governments of the High Contracting Parties whose legisla- tion may not now be adequate shall take or shall recommend to their legislatures such measures as may be necessary at all times: (a) to prevent the use by private persons or by societies other than those upon which this convention confers the right thereto, of the emblem or of the name of the Red Cross or Geneva Cross, as well as any other 6ign or designation consti- tuting an imitation thereof, whether for commercial or other purposes; (b) by reason of the homage rendered to Switzerland as a result of the adoption of the inverted Federal colors, to prevent the use, by private persons or by organi- zations, of the arms of the Swiss Confederation or of signs constituting an imita- tion thereof, whether as trade-marks, commercial labels, or portions thereof, or in any way contrary to commercial ethics, or under conditions wounding Swiss national pride. The prohibition mentioned in subparagraph (o) of the use of signs or designa- tions constituting an imitation of the emblem or designation of the Red Cross or Geneva Cross, as well as the prohibition mentioned in subparagraph (6) of the use of the arms of the Swiss Confederation or signs constituting an imitation thereof, shall take effect from the time set in each act of legislation and at the latest five years after this convention goes into effect. After such going into effect it shall be unlawful to take out a trade-mark or commercial label contrary to such prohibitions. Article 29. The Governments of the High Contracting Parties whose penal laws may not be adequate, shall likewise take or recommend to their legislatures the necessary measures to repress in time of war all acts in contravention of the provisions of the present convention. They shall communicate to one another through the Swiss Federal Council the measures taken with a view to such repression, not later than five years from the date of the ratification of the present convention. Article 30. At the request of a belligerent, an investigation must be held, in such manner as shall be agreed upon by the interested parties, concerning any alleged violation of the convention; whenever such a violation is proved, the belligerents shall put an end to it and repress it as promptly as possible. 9. Final Provisions. Article 31. The present convention, which will bear the date of this day, may be signed up to February 1, 1930, on behalf of all the countries represented at the Conference which opened at Geneva on July 1, 1929, as well as by the countries not represented at the Conference which are parties to the Geneva Conventions of 1864 or of 1906. Article 32. The present convention shall be ratified as soon as possible. The ratifications shall be deposited at Berne. A record of the deposit of each instrument of ratification shall be prepared, a duly certified copy of which shall be forwarded by the Swiss Federal Council to the Governments of all the countries on whose behalf the convention has been signed or notification of adhesion made. Article 33. The present convention shall become effective six months after the deposit of at least two instruments of ratification. 10 HAGUE, 18 99 Subsequently, it shall become effective for each High Contracting Party six months after the deposit of its instrument of ratification. Article 34. The present convention shall replace the conventions of August 22, 1864, and of July 6, 1906, in the relations between the High Contracting Parties. Article 35. From the date on which it becomes effective, the present conven- tion shall be open for adhesions given on behalf of any country in whose name this convention was not signed. Article 36. Adhesions shall be given by written notification addressed to the Swiss Federal Council and shall take effect six months after the date of their receipt. The Swiss Federal Council shall communicate adhesions to the Governments of all the countries on whose behalf the convention was signed or notification of adhesion made. Article 37. A state of war shall give immediate effect to ratifications deposited or adhesions notified by belligerent Powers prior to or after the outbreak of hostilities. The communication of ratifications or adhesions received from Powers at war shall be made by the Swiss Federal Council by the most rapid method. Article 38. Each of the High Contracting Parties shall have the right to denounce the present convention. The denunciation shall not take effect until one year after notification has been made in writing to the Swiss Federal Council. The latter shall communicate such notification to the Governments of all the High Contracting Parties. The denunciation shall have effect only with respect to the High Contracting Party which gave notification of it. Moreover, such denunciation shall not take effect during a war in which the denouncing Power is involved. In this case, the present convention shall con- tinue in effect, beyond the period of one year, until the conclusion of peace. Article 39. A duly certified copy of the present convention shall be deposited in the archives of the League of Nations by the Swiss Federal Council. Likewise, ratifications, adhesions, and denunciations of which the Swiss Federal Council has been notified shall be communicated by it to the League of Nations. In faith whereof, the Plenipotentiaries named above have signed the present convention. Done at Geneva, the twenty-seventh of July, one thousand nine hundred and twenty-nine, in a single copy, which shall remain in the archives of the Swiss Confederation and duly certified copies of which shall be forwarded to the Governments of all the countries invited to the Conference. (Here follow the signatures.) SECTION III. THE HAGUE PEACE CONFERENCE OF 1899 The convention between the United States and certain powers for the adaptation to maritime warfare of the principles of the Geneva convention of August 22, 1864, signed at The Hague, July 29, 1899, and proclaimed November 1, 1901, is as follows: Article 1. Military hospital ships, that is to say, ships constructed or assigned by States specially and solely for the purpose of assisting the wounded, sick, or 11 APPENDIX C. CONVENTIONS shipwrecked, and the names of which shall have been communicated to the belligerent powers at the beginning or during the course of hostilities, and in any case before they are employed, shall be respected and can not be captured while hostilities last. These ships, moreover, are not on the same footing as men-of-war as regards their stay in a neutral port. Art. 2. Hospital ships, equipped wholly or in part at the cost of private in- dividuals or officially recognized relief societies, shall likewise be respected and exempt from capture, provided the belligerent power to whom they belong has given them an official commission and has notified their names to the hostile power at the commencement of or during hostilities, and in any case before they are employed. These ships must be furnished with a certificate from the competent authori- ties, declaring that they had been under their control while fitting out and on final departure. Art. 3. Hospital ships, equipped wholly or in part at the cost of private in- dividuals or officially recognized societies of neutral countries, shall be respected and exempt from capture, if the neutral power to whom they belong has given them an official commission and notified their names to the belligerent powers at the commencement of or during hostilities, and in any case before they are employed. Art. 4. The ships mentioned in articles 1, 2, and 3 shall afford relief and assist- ance to the wounded, sick, and shipwrecked of the belligerents independently of their nationality. The Governments engage not to use these ships for any military purpose. These ships must not in any way hamper the movements of the combatants. During and after an engagement they will act at their own risk and peril. The belligerents will have the right to control and visit them; they can refuse to help them, order them off, make them take a certain course, and put a com- missioner on board; they can even detain them, if important circumstances require it. As far as possible the belligerents shall inscribe in the sailing papers of the hospital ships the orders they give them. Art. 5. The military hospital ships shall be distinguished by being painted white outside with a horizontal band of green about a meter and a half in breadth. The ships mentioned in articles 2 and 3 shall be distinguished by being painted white outside with a horizontal band of red about a meter and a half in breadth. The boats of the ships above mentioned, as also small craft which may be used for hospital work, shall be distinguished by similar painting. All hospital ships shall make themselves known by hoisting, together with their national flag, the white flag with a red cross provided by the Geneva con- vention. Art. 6. Neutral merchantmen, yachts, or vessels having or taking on board sick, wounded, or shipwrecked of the belligerents, can not be captured for so doing, but they are liable to capture for any violation of neutrality they may have committed. Art. 7. The religious, medical or hospital staff of any captured ship is in- violable, and its members can not be made prisoners of war. On leaving the ship they take with them the objects and surgical instruments which are their own private property. This staff shall continue to discharge its duties while necessary, and can after- wards leave when the commander in chief considers it possible. 12 HAGUE, 1904 The belligerents must guarantee to the staff that has fallen into their hands the enjoyment of their salaries intact. Art. 8. Sailors and soldiers who are taken on board when sick or wounded, to whatever nation they belong, shall be protected and looked after by the captors. Art. 9. The shipwrecked, wounded, or sick of one of the belligerents who fall into the hands of the other are prisoners of war. The captor must decide, accord- ing to circumstances, if it is best to keep them or send them to a port of his own country, to a neutral port, or even to a hostile port. In the last case, prisoners thus repatriated can not serve as long as the war lasts. Art. 10. (Excluded.) Art. 11. The rules contained in the above articles are binding only on the con- tracting powers in case of war between two or more of them. The said rules shall cease to be binding from the time when, in a war between the contracting powers, one of the belligerents is joined by a noncontracting power. Art. 14. In the event of one of the high contracting parties denouncing the present convention, such denunciation shall not take effect until a year after the notification made in writing to the Netherlands Government, and forthwith communicated by it to all the other contracting powers. This denunciation shall only affect the notifying power. SECTION IV. CONVENTION BETWEEN CERTAIN POWERS REGARD- ING THE EXEMPTION OF HOSPITAL SHIPS, IN TIME OF WAR, FROM THE PAYMENT OF ALL DUES AND TAXES IMPOSED FOR THE BENEFIT OF THE STATE, SIGNED AT THE HAGUE DECEM- BER 21, 1904; PROCLAIMED MAY 21, 1907 Article 1. Hospital ships, concerning which the conditions set forth in arti- cles 1, 2, and 3 of the convention concluded at The Hague on July 29, 1899, for the adaptation to maritime warfare of the principles of the Geneva convention of August 22, 1864, are fulfilled, shall be exempted, in time of war, from all dues and taxes imposed on vessels for the benefit of the State, in the ports of the contracting parties. Art. 2. The provision of the foregoing article does not prevent the application, by means of visitation or other formalities, of fiscal or other laws in force at said ports. Art. 3. The rule laid down in article 1 is binding only on the contracting powers in case of war between two or more of them. The said rule shall cease to be binding from the time when a noncontracting power shall join one of the belligerents in a war between contracting powers. Art. 4. The present convention, which bearing the date of this day, may be signed until the 1st of October 1905, by the powers expressing their desire to do so, shall be ratified as soon as possible. The ratification shall be deposited at The Hague. A proems verbal of the deposit of the ratifications shall be drawn up and a copy thereof, duly certified, shall be delivered through the diplomatic channel to all the contracting powers. Art. 5. The nonsignatory powers are permitted to adhere to the present con- vention after October 1, 1905. They shall, to that end, make their adhesion known to the contracting powers, by means of a written notification addressed to the Government of the Nether- lands and communicated by the latter to the other contracting powers. 13 APPENDIX C.—CONVENTIONS Art. 6. In the event of one of the high contracting powers denouncing the present convention, such denunciation shall not take effect until one year after the notification made in writing to the Government of the Netherlands and imme- diately communicated by the latter to all the other contracting powers. This denunciation shall only affect the notifying power. Final act.—At the moment of proceeding to sign the convention having for its object the exemption of hospital ships in time of war in the ports of the contract- ing parties from all dues and taxes imposed on vessels for the benefit of the State, the plenipotentiaries signing the present act express the wish that, in view of the highly humanitarian mission of these ships, the contracting governments may take the measures necessary in order to exempt these ships within a short time also from the payment of the dues and taxes collected in their ports for the benefit of others than the State, especially those collected for the benefit of municipalities or of private companies or persons. SECTION V. HAGUE CONVENTION OF OCTOBER 18, 1907, FOR THE ADAPTATION OF THE PRINCIPLES OF THE GENEVA CONVENTION OF JULY 6, 1906, TO MARITIME WARFARE Article 1. Military hospital ships, that is to say, ships constructed or assigned by States specially and solely with a view to assisting the wounded, sick, and shipwrecked, the names of which have been communicated to the belligerent powers at the commencement or during the course of hostilities, and in any case before they are employed, shall be respected, and can not be captured while hostilities last. These ships, moreover, are not on the same footing as warships as regards their stay in a neutral port. Art. 2. Hospital ships, equipped wholly or in part at the expense of private individuals or officially recognized relief societies, shall be likewise respected and exempt from capture, if the belligerent power to whom they belong has given them an official commission and has notified their names to the hostile power at the commencement of or during hostilities, and in any case before they are employed. These ships must be provided with a certificate from the competent authorities declaring that the vessels have been under their control while fitting out and on final departure. Art. 3. Hospital ships, equipped wholly or in part at the expense of private individuals or officially recognized sociteies of neutral countries, shall be respected and exempt from capture, on condition that they are placed under the control of one of the belligerents, with the previous consent of their own Government and with the authorization of the belligerent himself, and that the latter has notified their names to his adversary at the commencement of or during hostilities, and in any case before they are employed. Art. 4. The ships mentioned in articles 1, 2, and 3 shall afford relief and assistance to the wounded, sick, and shipwrecked of the belligerents without distinction of nationality. The Governments undertake not to use these ships for any military purpose. These vessels must in no wise hamper the movements of the combatants. During and after an engagement they will act at their own risk and peril. The belligerents shall have the right to control and search them; they can refuse to help them, order them off, make them take a certain course, and put a 14 HAGUE, 1907 commissioner on board; they can even detain them, if important circumstances require it. As far as possible, the belligerents shall enter in the log of the hospital ships the orders which they give them. Art. 5. Military hospital ships shall be distinguished by being painted white outside with a horizontal band of green about a meter and a half in breadth. The ships mentioned in articles 2 and 3 shall be distinguished by being painted white outside with a horizontal band of red about a meter and a half in breadth. The boats of the ships above mentioned, as also small craft which may be used for hospital work, shall be distinguished by similar painting. All hospital ships shall make themselves known by hoisting, with their national flag, the white flag with a red cross provided by the Geneva convention, and further, if they belong to a neutral State, by flying at the mainmast the national flag of the belligerent under whose control they are placed. Hospital ships which, in the terms of article 4, are detained by the enemy, must haul down the national flag of the belligerent to whom they belong. The ships and boats above mentioned which wish to insure by night the free- dom from interference to which they are entitled must, subject to the assent of the belligerent they are accompanying, take the necessary measures to render their special painting sufficiently plain. Art. 6. The distinguishing signs referred to in article 5 can only be used, whether in time of peace or war, for protecting or indicating the ship therein mentioned. Art. 7. In the case of a fight on board a warship, the sick wards shall be respected and spared as far as possible. The said sick wards and the material belonging to them remain subject to the laws of war; they cannot, however, be used for any purpose other than that for which they were originally intended, so long as they are required for the sick and wounded. The commander, however, into whose power they have fallen may apply them to other purposes, if the military situation requires it, after seeing that the sick and wounded on board are properly provided for. Art. 8. Hospital ships and sick wards of vessels are no longer entitled to protection if they are employed for the purpose of injuring the enemy. The fact of the staff of the said ships and sick wards being armed for main- taining order and for defending the sick and wounded, and the presence of wire- less telegraphy apparatus on board, is not a sufficient reason for withdrawing protection. Art. 9. Belligerents may appeal to the charity of the commanders of neutral merchant ships, yachts, or boats to take on board and tend the sick and wounded. Vessels responding to this appeal, and also vessels which have of their own accord rescued sick, wounded, or shipwrecked men, shall enjoy special protection and certain immunities. In no case can they be captured for having such persons on board, but, apart from special undertakings that have been made to them, they remain liable to capture for any violations of neutrality they may have committed. Art. 10. The religious, medical, and hospital staff of any captured ship is inviolable, and its members cannot be made prisoners of war. On leaving the ship they take away with them the objects and surgical instruments which are their own private property. 15 APPENDIX C.—CONVENTIONS This staff shall continue to discharge its duties while necessary, and can after- wards leave, when the commander in chief considers it possible. The belligerents must guarantee to the said staff, when it has fallen into their hands, the same allowances and pay which are given to the staff of corresponding rank in their own navy. Art. 11. Sailors and soldiers on board, when sick or wounded, as well as other persons officially attached to fleets or armies, whatever their nationality, shall be respected and tended by the captors. Art. 12. Any warship belonging to a belligerent may demand that sick, wounded, or shipwrecked men on board military hospital ships, hospital ships belonging to relief societies or to private individuals, merchant ships, yachts, or boats, whatever the nationality of these vessels, should be handed over. Art. 13. If sick, wounded, or shipwrecked persons are taken on board a neutral warship, every possible precaution must be taken that they do not again take part in the operations of the war. Art. 14. The shipwrecked, wounded or sick of one of the belligerents who fall into the power of the other belligerent are prisoners of war. The captor must decide, according to the circumstances, whether to keep them, send them to a port of his own country, to a neutral port, or even to an enemy port. In this last case prisoners thus repatriated cannot serve again while the war lasts. Art. 15. The shipwrecked, sick, or wounded, who are landed at a neutral port with the consent of the local authorities must, unless an arrangement is made to the contrary between the neutral State and the belligerent States, be guarded by the neutral State so as to prevent their again taking part in the operations of the war. The expenses of tending them in hospital and interning them shall be borne by the State to which the shipwrecked, sick, or wounded persons belong. Art. 16. After every engagement, the two belligerents, so far as military interests permit, shall take steps to look for the shipwrecked, sick, and wounded, and to protect them, as well as the dead, against pillage and ill-treatment. They shall see that the burial, whether by. land or sea, or cremation of the dead shall be preceded by a careful examination of the corpse. Art. 17. Each belligerent shall send, as early as possible, to the authorities of their country, navy or army, the military marks or documents of identity found on the dead and the description of the sick and wounded picked up by him. The belligerents shall keep each other informed as to internments and transfers as well as to the admissions into hospital and deaths which have occurred among the sick and wounded in their hands. They shall collect all the objects of per- sonal use, valuables, letters, etc., which are found in the captured ships or which have been left by the sick or wounded who died in hospital, in order to have them forwarded to the persons concerned by the authorities of their own country. Art. 18. The provisions of the present convention do not apply except between contracting powers, and then only if all the belligerents are parties to the con- vention. Art. 19. The commanders in chief of the belligerent fleets must see that the above articles are properly carried out; they will have also to see to cases not covered thereby in accordance with the instructions of their respective Govern- ments and in conformity with the general principles of the present convention. Art. 20. The signatory powers shall take the necessary measures for bring- ing the provisions of the present convention to the knowledge of their naval forces, and especially of the members entitled thereunder to immunity, and for making them known to the public. 16 HAGUE, 1907 Art. 21. The signatory powers likewise undertake to enter or to propose to to their legislatures, if their criminal laws are inadequate, the measures necessary for checking in time of war individual acts of pillage and ill-treatment in respect to the sick and wounded in the fleet, as well as for punishing, as an unjustifiable adoption of naval or military marks, the unauthorized use of the distinctive marks mentioned in article 5 by vessels not protected by the present convention. They will communicate to each other through the Netherlands Government, the enactments for preventing such acts at the latest within five years of the ratification of the present convention. Art. 22. In the case of operations of war between the land and sea forces of belligerents, the provisions of the present convention do not apply except between the forces actually on board ship. Art. 23. The present convention shall be ratified as soon as possible. The ratifications shall be deposited at The Hague. The first deposit of ratifications shall be recorded in a proems verbal signed by the representatives of the powers taking part therein and by the Nether- lands minister of foreign affairs. Subsequent deposits of ratifications shall be made by means of a written notification addressed to the Netherlands Government and accompanied by the instrument of ratification. A certified copy of the proems verbal relative to the first deposit of ratifica- tions, of the notifications mentioned in the preceding paragraph, as well as of the instruments of ratifications, shall be at once sent by the Netherlands Gov- ernment through the diplomatic channel to the powers invited to the Second Peace Conference, as well as to the other powers which have adhered to the convention. In the cases contemplated in the preceding paragraph the said Government shall inform them at the same time of the date on which it received the notification. Art. 24. Nonsignatory powers which have accepted the Geneva Convention of the 6th July, 1906, may adhere to the present convention. The power which desires to adhere notifies its intention to the Netherlands Government in writing, forwarding to it the act of adhesion, which shall be deposited in the archives of the said Government. The said Government shall at once transmit to all other powers a duly certi- fied copy of the notification as well as of the act of adhesion, mentioning the date on which it received the notification. Art. 25. The present convention, duly ratified, shall replace as between con- tracting powers, the convention of the 29th of July, 1899, for the adaptation to maritime warfare of the principles of the Geneva convention. The convention of 1899 remains in force as between the powers which signed it, but which do not also ratify the present convention. Art. 26. The present convention shall come into force, in the case of the powers which were a party to the first deposit of ratifications 60 days after the date of the proems verbal of this deposit, and in the case of the powers which ratify subsequently or which adhere 60 days after the notification of their rati- fication or of their adhesion has been received by the Netherlands Government. Art. 27. In the event of one of the contracting powers wishing to denounce the present convention, the denunciation shall be notified in writing to the Netherlands Government, which shall at once communicate a duly certified copy of the notification to all the other powers, informing them at the same time of the date on which it was received. 17 APPENDIX C.—CONVENTIONS The denunciation shall only have effect in regard to the notifying power, and one year after the notification has reached the Netherlands Government. Art. 28. A register kept by the Netherlands ministry for foreign affairs shall give the date of the deposit of ratifications made in virtue of article 23, para- graphs 3 and 4, as well as the date on which the notifications of adhesion (art. 24, par. 2) or of denunciation (art. 27, par. 1) have been received. Each contracting party is entitled to have access to this register and to be supplied with duly certified extracts from it. In faith whereof the plenipotentiaries have appended their signatures to the present convention. Done at The Hague, the 18th of October, 1907, in a single copy, which shall remain deposited in the archives of the Netherlands Government, and duly certified copies of which shall be sent, through the diplomatic channel, to the powers which have been invited to the Second Peace Conference. SECTION VI. THE AMERICAN NATIONAL RED CROSS 1. General Provisions. (a) Organization and functions.—The American Red Cross was created by act of Congress January 5, 1905 (36 U. S. Code 1), as the agency of the Gov- ernment for the fulfillment of certain treaty obligations into which the United States entered when it became signatory to the treaty of the Red Cross, or the treaty of Geneva of August 22, 1864. The number of national Red Cross socie- ties officially recognized by the International Red Cross Committee is 63, includ- ing the American National Red Cross. The International Red Cross Committee is entrusted with the maintenance of fundamental Red Cross principles and its essential characteristic is its absolute neutrality under the Geneva conventions. Under these conventions the national societies are recognized by their govern- ments as auxiliaries to the medical departments of their fighting services. They are pledged to prepare themselves in peacetime for necessary wartime work. (b) Act of incorporation.—The act of January 5, 1905, sets forth the follow- ing designation and purposes: (1) Designation— Sec. 2. That the name of this corporation shall be “The American National Red Cross * * (2) Purposes.—Sec. 3. That the purposes of this corporation are and shall be: First, to furnish volunteer aid to the sick and wounded of armies in time of war, in accordance with the spirit and conditions of the conference of Geneva of October. 1863, and also of the treaty of the Red Cross, or the treaty of Geneva of August 22, 1864, to which the United States of America gave its adhesion on March 1, 1882. Second, and for said purposes to perform all the duties devolved upon a national society by each nation which has acceded to said treaty. Third, to succeed to all the rights and property which have been hitherto held and to all the duties which have heretofore been performed by the American National Red Cross as a corporation duly incorporated by act of Congress June 6, 1900, which act is hereby repealed and the organization created thereby is hereby dissolved. Fourth, to act in matters of voluntary relief and in accord with the military and naval authorities as a medium of communication between the people of the United States of America and their Army and Navy, and to act in such matters between similar national societies of other governments through the “Comite International de Secours” and the Government and the people and the Army and Navy of the United States of America. Fifth, and to continue and carry on a system of national and international relief in time of peace and apply the same in mitigating the sufferings caused by pestilence, famine, fire, floods, and other great national calamities, and to devise and carry on measures for preventing the same 18 AMERICAN NATIONAL RED CROSS (c) The act of April 24,1912 (36 U. S. Code 10,11), is as follows: That whenever in time of war, or when war is imminent, the President[may deem the cooperation and use of the American National Red Cross with the sanitary service of the land and naval forces to be necessary, he is authorized to accept the assistance tendered by the said Red Cross and to employ the same under the sanitary services of the Army and Navy in conformity with such rules and regulations as he may pre- scribe. Sec. 2. That when the Red Cross cooperation and assistance with the land and naval forces in time o war or threatened hostilities shall have been accepted by the President, the personnel entering upon duty specified in section one of this act shall, while proceeding to their place of duty, while serving thereat, and! while returning therefrom, be transported and subsisted at the cost and charge of the United States as civilian employees employed with the said forces, and the Red Cross supplies that may be tendered as a gift and accepted for use in the sanitary service shall be transported at the cost and charge of the United States. 2. In Time of Peace. (a) Red Cross aid at naval hospitals and naval dispensaries.—(1) Sub- ject to the provisions hereinafter set forth and such instructions not inconsistent therewith as may be issued by the commanding officer, the Red Cross will conduct a program of home service for the able-bodied and hospital and social service for patients at naval hospitals and certain naval dispensaries. (2) Where duly accredited Red Cross representatives are assigned to naval hospitals or naval dispensaries, such representatives will coordinate all local Red Cross activities through the commanding officer. (3) It is the Bureau’s policy not to accept aid for naval hospitals except through the agency of the American Red Cross. This policy is not to be construed as excluding individuals or representatives of other recognized organizations from visiting the hospitals, nor to prohibit the acceptance of personal gifts or services by patients from individuals or other recognized organizations when approved by the commanding officer. (4) Red Cross field directors and other personnel are assigned by the National Headquarters on request of the commanding officer and approval by the Surgeon General. The status of these Red Cross representatives is that of members of the hospital staff. Suitable office space should be provided to promote the efficient operation of this activity, afford accessibility to medical staff and patients, and privacy for interviews. The Red Cross will not be expected to provide office equipment and supplies when such are available from Government sources. (5) Commanding officers are authorized to extend the privilege of messing at the hospital to duly accredited Red Cross representatives. (See par. 1636, Manual, Medical Department.) (b) Home service.—The home service for the able-bodied will consist princi- pally of the following: (1) To arrange for furnishing relief in distress among families of naval personnel. (2) To assist in locating families. (3) To arrange helpful advice on welfare matters for families. (4) To assist in securing employment for members of families. (5) To locate men in the service for inquiring families. (6) To encourage communication between personnel and their families. (7) To make loans to return home on account of distress, sickness, or death in the immediate family when an enlisted man or his family is without sufficient funds; such loans to be made only upon the recommendation of commanding officers and after verification of need has been made by the Red Cross. (8) To assist in solving business problems of personnel and their families. 19 APPENDIX C.—CONVENTIONS (9) To furnish information about particulars of the Government’s program, such as insurance, allowances, pension, compensation, allotments, etc., and to assist in handling difficulties in which they are involved. (10) To arrange helpful advice to discharged disabled personnel returning home and to assist them in reestablishing themselves in civilian life. (11) To secure report on home conditions at the request of commanding officers for confidential information needed in considering welfare questions and furloughs necessitated by emergencies at home. (12) To secure report on home conditions at the request of the Navy Depart- ment, Bureau of Navigation, for confidential information needed in considering applications for discharge on dependency grounds. (13) To act as a medium of communication in transmitting messages of an emergency nature to families at home, or from families to men on sea duty utilizing the naval radio facilities where available. (c) Hospital and social service for patients. In addition to that outlined above, the Red Cross will render the following service for patients, subject to the direction of the commanding officer or 6uch officer or officers as he may designate, and without duplicating or paralleling the work of the Medical Department: (1) To coordinate and conduct recreational and entertainment activities for convalescents in hospitals of the Navy. (2) To furnish writing material and to write letters for patients unable to do so themselves and encourage families to write cheerful letters to them. (3) To look after the comfort and interest of relatives who may be summoned to the bedside of patients. (4) Upon the recommendation of medical officers to make loans to patients to enable them to take advantage of furloughs for the purpose of recuperating from illness when they and their families are without sufficient funds for the purpose. (5) When requested by the medical officer in charge, to visit patients for the purpose of bringing to light personal problems which may be retarding recovery, and to work out the solution of such problems with the cooperation of the medical officer. (d) Medical-social case reports.—(1) An important phase of the assistance rendered to the Medical Department of the Navy by the Red Cross consists in the medical-social case work done by the Red Cross personnel attached to a number of the naval hospitals and by the local chapters of the Red Cross. Social histories so obtained often may be of great value in diagnosis and treatment and in deter- mination of ultimate disposition. (2) Red Cross social case histories usually are obtained by local chapters and cooperating civilian agencies and individuals with the understanding and pledge that the information will be held and treated as confidential; violation of this understanding would jeopardize the obtaining of such data. (3) Medical-social case reports obtained from or through the Red Cross shall be held as strictly confidential, and provision shall be made to prevent the reports from falling into the hands of unauthorized persons. Under no condition shall information as to the contents of a Red Cross report, or the fact that such a report has been made, be communicated to the patient, his relatives or friends; and the contents of such reports shall not be copied into health records or other official reports or records. In utilizing these data the medical officer may embody the information so obtained, without reference to its source, in health records or other official papers in the same manner that laboratory or X-ray findings would be recorded. 20 AMERICAN NATIONAL RED CROSS (e) Extension of activities.—The activities, functions, and duties above set forth may be extended in time of war. 3. In Time of War. (a) Authorization and administration.—In time of war or when war is imminent the Secretary of the Navy, in his discretion, acting through the Bureau of Medicine and Surgery, will arrange through the Red Cross for the organiza- tion and equipment of such units or personnel as may be required for the sanitary service, specifying: (1) The character of the service required. (2) The Red Cross units desired. (3) Material and personnel desired. (4) The place or places where the personnel and materiel shall be assembled. (5) Whether the units and personnel are to be employed under the Red Cross or are to become a part of the naval forces (art. 1470 (4), Navy Regulations). (b) Classification of agencies to be employed.—(1) The Red Cross may be called upon by the Navy Department to furnish organized units, sections, detach- ments, or individuals required in the care, transportation, and welfare of the sick and wounded. (2) Units.—The Red Cross units organized for service with the Navy or for the purpose of training personnel therefor, will be of such types and composition as the situation may require, such as: 1. Hospital units. 2. Surgical sections. S. Emergency nurse detachments and naval detachments of nurses. J+. Information sections. 5. Refreshment units. 6. Convalescent homes. 7. Welfare and recreation units. 8. Depots for Red Cross supplies. (3) Individuals.—Reserve nurses of the Navy Nurse Corps may be appointed by the Surgeon General from the roster of enrolled nurses of the American Red Cross Nursing Service. Dietitians and other specially qualified personnel may be called for in time of war. (4) To facilitate enrollment and training, Red Cross personnel will be divided into three classes: Class A.—Those willing to serve wherever needed. Only persons belonging to class A will be enrolled in Red Cross organizations intended for service in the area of operations. Class B.—Those willing to serve in home country only. Class B will be enrolled for service in hospitals and such other Medical Department activities as may be established in the home country. They may be organized into such units and receive such training as may be deemed advisable. Class C.—Those willing to serve at place of residence only. Class C will be composed of individuals of local Red Cross societies who on account of occupa- tion or experience may be expected to render efficient service with such Medical Department units as may be established in their locality. (c) Training.—Red Cross units and personnel to be used with the Navy shall be trained, so far as practicable, as prescribed by training instructions and manuals for similar organizations and personnel of the Navy. (d) Titles and uniform.—To facilitate the discharge of their authorized func- tions, duly qualified Red Cross personnel will be recognized by titles prescribed by 21 APPENDIX C. CONVENTIONS the Red Cross. Such personnel are authorized to wear the prescribed Red Cross uniform while serving with the Navy. Red Cross insignia will be supplied by the American National Red Cross. (e) Inspection.—No unit, section, or detachment of the Red Cross will be accepted for service by the Navy Department unless previously inspected and investigated by a medical officer of the Navy and found qualified for service, and no individual will be appointed or enlisted in the Naval Reserve until found physically and professionally qualified in accordance with the laws and regulations relating to the Naval Reserve. (f) Acceptance of supplies and equipment.—Medical and surgical supplies and equipment may be accepted from Red Cross representatives when authorized by the Bureau of Medicine and Surgery or in advance of such authority when an emergency exists. As a rule, no supplies shall be accepted from the Red Cross which can be obtained through regular Navy procedure. Ambulance service may be accepted when occasion arises. (g) Neutrality.—Under the Geneva Convention of 1906 the personnel charged exclusively with the removal, transportation, and treatment of the sick and wounded, as well as with the administration of sanitary formations and establish- ments, and the chaplains attached to the armies, are entitled to protection in a neutral status under the distinctive Red Cross emblem. In the theater of opera- tions the Red Cross emblem can be displayed only over sanitary formations and establishments thus entitled to protection, and only such classes of persons here mentioned shall wear the Red Cross brassard. 22 Appendix D MANUAL OF THE MEDICAL DEPARTMENT Bureau Circular Letters A Assistant Chief of Bureau TABLE OF CONTENTS Subject Date in effect Use of Medical Department Blank Forms for Prescription July 1, 1939 Appendix D Manual of the Medical Department Bureau Circular Letter A Subject: Use of Medical Department Blank Forms for Prescription. Reference: Article 101, Navy Regulations, 1920. (a) At various times in the past this Bureau has received complaints that medical officers refracting the eyes of naval personnel and their dependents use prescription forms supplied by certain optical companies and refer patients to or recommend that the prescription be filled by such companies. (b) In support of these statements there has been submitted a number of pre- scriptions for eyeglasses written on the forms of various optical companies, which in some instances are enclosed in printed envelopes addressed to the optical company. These prescriptions are signed in each instance by a naval medical officer. A number of medical officers and several Medical Department activities are involved. (c) The Bureau considers that this practice is contrary to the established policy of the Navy Department, and may be construed as a violation of reference, in that the use of a proprietary form, or the display of commercial advertising material, or instruction to the patient to patronize any particular commercial firm places the medical officer in the position of acting as agent for that firm. (d) It is specifically directed, therefore, that officers of the Medical Depart- ment shall use Navy Medical Department prescription forms for all purposes and in all instances, and that commercial prescription forms shall not be used for any official purpose. (e) The above is not to be construed as prohibiting an officer of the Medical Department, on request, from furnishing the patient with available information as to where a prescription may be filled reliably and accurately and at a reasonable cost. Appendix D MANUAL OF THE MEDICAL DEPARTMENT Bureau Circular Letters B Publications Division Subject TABLE OF CONTENTS Date in effect Changes for the Bureau Manual ..July 1, 1939 The United States Naval Medical Bulletin July 1, 1939 Appendix D, Manual of the Medical Department Bureau Circular Letter B Subject: Changes for the Bureau Manual. The appendix has been provided to contain material that is of an informatory nature or matter that is subject to change to facilitate keeping it revised without resorting to manual changes. Changes to be made in appendix A will be pub- lished as a Circular Letter Y. Changes to be made in appendix B will be pub- lished as a Circular Letter F, and changes in appendix C will be published as a Circular Letter B. Each division of the Bureau will revise and reissue annually the title sheet of its circular letters in appendix D, and on the reverse of this sheet direct changes to be made in attached letters. The Bureau would appreciate suggestions for improvement of the manual for use in future revision. Subject: The United States Naval Medical Bulletin. The Bureau publishes the Bulletin for the instruction of the Medical Depart- ment personnel. Material for publication is chosen according to the following preferential as to subject matter—(1) research (2) military medicine (3) preven- tive and industrial medicine (4) review of personal clinical experience (5) interest- ing case reports (6) reviews of clinical literature. Articles will be published according to priority of receipt, other factors being equal. An endeavor is being made to plan each issue with a primary objective and suitable material will have priority for that issue. Needless to say quality of article is a major factor in choice of material for publication. Historical articles, unless they present military medicine matter that is of cur- rent value, cannot be published. The funds provided for publication of the Bulletin are so limited and the rela- tive cost of reprints is so high that reprints are not being furnished authors. It is necessary to limit the use of illustrations and line cuts for the same reason. Authors are reminded that only exceptionally are lengthy introductory, his- torical, and bibliographic discussions justified. The busy physician commonly limits his reading of clinical articles to the summary. The quantity of material being received by the Bureau exceeds the amount it can publish. Other medical journals face the same problem. However, the Bureau solicits material because the preparation of an article benefits the author, its submission to the Bureau is a matter of official record and it may assist the editor in presenting the service material of value. 1 Appendix D MANUAL OF THE MEDICAL DEPARTMENT Bureau Circular Letters c Chief Clerk TABLE OF CONTENTS Subject Date in effect Instructions Governing Civil Employees Under the Medical Depart- ment July 1, 1939 Injured Civil Employees July 1, 1939 Funeral Expenses of Deceased Personnel of the Navy and Marine Corps July 1, 1941 Funeral Expenses of Deceased Civilian Employees of the Navy Department and Naval Establishment July 31, 1941 Appendix D Manual of the Medical Department Bureau Circular Letter C Subject: Instructions Governing Civil Employees Under the Medical Department. Table of Contents Subject: Paragraph Instructions — 1 Authority for Employment of Civilians 2 Hospital Service; Excepted Groups 3 Laborers and Mechanics 4 Classified Civil-Service Employees 5 Supervision of Employees 6 Correspondence Regarding Employees 7 Limitations of Employment 8 Medical Attendance 9 Pay 10 Pay Rolls for Civilian Employees 11 When Paid 12 Labor Roll Summary 13 Computation of Pay for Service 14 Quarters, Heat, Light, Household Equipment, Subsistence and Laundry Service — 15 1. Instructions.—Instructions concerning civil employees are contained in Chapter 42, Navy Regulations, General Order 13; United States Civil Service Form 2009 “Regulations Governing the Employment of Civil Personnel in the Field Service of the Navy Department and Marine Corps”; and in the Schedule of Wages for civil employees in the Field Service of the Navy Department and the Marine Corps issued by the Navy Department. 2. Authority for Employment of Civilians.—The employment of civilians under the Medical Department is governed by the Executive order of July 9, 1920, and the annual appropriations for the Bureau. The number of employees and the ratings allowed at any naval hospital or other Medical Department activity are fixed by the Bureau annually when allotments of funds are made for the ensuing fiscal year. Employees in excess of the number so prescribed may not be employed without the prior approval of the Bureau. Vacancies occurring within the authorized complements may be filled as required without reference to the Bureau. 3. Hospital Service; Excepted Group.—Cooks, bakers, meat cutters, mess attendants, pantrymen, housekeepers, maids, and launderers are employed directly by the commanding officer under such arrangements as he may prescribe without reference to the Labor Board. These employees are excepted from the provisions of the Civil Service Rules and the Regulations Governing the Em- ployment of Civil Personnel under the Naval Service and do not come within the provisions of the Civil Service Retirement Act. 4. laborers and Mechanics.—Positions in the laborer and mechanical ratings, classified under groups I, II, and III of the Schedule of Wages; positions in 1 5-11 CIRCULAR LETTER C group IV (a), supervisory mechanical service; and positions under group IV (6), clerical, administrative, and fiscal service, are filled through the Labor Board ..procedure. Additional positions in the supervisory mechanical service, or in the clerical, administrative, and fiscal service may not be created without the specific prior approval of the Bureau and of the Assistant Secretary of the Navy. 5. Classified Civil-Service Employees.—Employees in the classified civil service (groups II, III, and IV) and unclassified employees of group I are subject to the civil-service retirement act which provides that there shall be deducted and withheld each month from the basic salary, pay, or compensation of each employee to whom the act applies the percentage of such basic salary prescribed in the act. Temporary employees and employees excepted from civil-service rules are not subject to the retirement act. 6. Supervision of Employees.—Civil employees, except those in the culinary force, who will be under the commissary officer, shall be under the maintenance officer and under the general supervision of the executive officer and he shall require the chief mechanic and other employees charged with responsibility for the different lines of work to report daily, at a designated hour, to give an account of any work under way, receive orders for work to be done, and report any ab- sence, tardiness, or inefficiency of employees under their direction. 7. Correspondence Regarding Employees.—All correspondence with the Navy Department relating to civil employees, their employment, pay, ratings, pro- motion, discharge, leave, etc., shall be sent to or via the Bureau. 8. Limitations of Employment.—Only such mechanics and laborers as are required for routine upkeep and repair work will be carried on hospital pay rolls. Larger jobs of repair, extensive overhauling, or extensive carpentry and painting will be handled either by contract or through transfer of navy-yard labor. Civil employees shall be assigned only to essential and strictly Government work. 9. Medical Attendance.—Civil employees are entitled to compensation and reasonable medical, surgical, and hospital services and supplies under the United States Employees’ Compensation Act, as specified in article 1575, Navy Regu- lations. See accompanying circular letter on injured civil employees. 10. Pay.—The pay of civilian positions is fixed by the Secretary of the Navy and promulgated in the Schedule of Wages for civil employees in the Field Service of the Navy Department and Marine Corps. No deviation from the ratings and rates of pay of the schedule is allowed. 11. Pay Rolls for Civil Employees.—(a) If practicable, the names of the em- ployees shall be arranged on the pay roll in the order in which the various ratingB appear on the schedule of wages, which will bring together those exempt from retirement deductions, as follows: Hospital service. Laborer, helper, and mechanical service: Group I. Group II. Group III. Group IV (a). Clerical service: Group IV (6) (clerical force). (b) This arrangement can most readily be put in effect by assigning a block of pay-roll numbers to each group, to cover changes in the numbers incident to the "turnover” in personnel. Thus, the hospital service may be assigned pay numbers 1 to 99; group I, 100 to 149; group II, 150 to 199; group III, 200 to 299; and so on (the size of the block assigned depending on the number of employees in the group). 2 CIVIL EMPLOYEES 12-15 (c) A carbon or other copy of the pay roll for each period shall be transmitted to the Bureau promptly. 12. When Paid.—All hospital employees will be paid semimonthly; the first pay period will be from the first to the fifteenth day of the month, and the second pay period from the sixteenth to the last day of the month, making two equal pay installments. 13. Labor Roll Summary.—The total expenditure for employees in group IV(i>) will be shown separately. This is necessary because of appropriational limitation on the pay of these employees. 14. Computation of Pay for Service.—(a) The act of Congress approved June 30, 1903 (34 Stat. 763) provides in part as follows: Sec. 6. Hereafter, where the compensation of any person in the service of the United States is annual or monthly, the following rules for division of time and computation of pay for services rendered are hereby established: Annual compensation shall be divided into 12 installments, one of which shall be the pay for each calendar month; and in making payments for a fractional part of a month one-thirtieth of one of such installments, or of a monthly compensation, shall be the daily rate of pay. For the purpose of computing such compensation and for computing time for services rendered during a fractional part of a month in connection with annual or monthly compensation, each and every month shall be held to consist of 30 days, without regard to the actual number of days in any calendar month, thus excluding the thirty-first of any calendar month from the computation and treating February as if it actually had 30 days. Any person entering the service of the United States during a 31-day month and serving until the end thereof shall be entitled to pay for that month from the date of entry to the thirtieth day of said month, both days inclusive; and any person entering said service during the month of February and serving until the end thereof shall be entitled to 1 month’s pay, less as many thirtieths thereof as there were days elapsed prior to date of entry: Provided. That for 1 day’s unauthorized absence on the thirty-first day of any calendar month 1 day’s pay shall be forfeited. (b) This act is construed as requiring that— (1) Each calendar month shall consist of 30 days, and the computation of salary shall be by each month separately, one-twelfth of an annual salary con- stituting the compensation for each month. (2) One-thirtieth of a monthly installment of salary is to be allowed for each day of service from the 1st to the 30th, inclusive. The last day of February counts as 3 days’ service for pay purposes (2 days in leap years). (3) The thirty-first day of a month enters into the computation of salary only where there is 1 day’s absence in a nonpay status on that day—that is, absence in a nonpay status did not occur also on the 30th. For such absence on the 31st 1 day’s pay is forfeited (Department Circular No. 35, Office of the Comptroller of the Treasury Department, August 18, 1914). 15. Quarters, Heat, Light, Household Equipment, Subsistence and Laundry Service.—(a) Under the provisions of the Schedule of Wages certain employees are allowed subsistence and quarters (either or both) as a part of their regular compensation or on account of extra duty assigned—separate and apart from the regular daily work—for fire, police, or emergency protection. For all other employees the orders of the Secretary of the Navy require that the appraised reasonable value of the items furnished shall be paid for in cash by the employee concerned. (b) The furnishing of quarters, heat, light, etc., to employees not entitled thereto as part compensation or in connection with the special duty service is discretionary with the commanding officer. For charges to be made in connection with these items refer to the Schedule of Wages and to paragraphs 3106 and 3107, M. M. D.; Bu. S. & A. Manual, paragraph 2121 (3); and Navy Department Circular Letter SONYD-7-Qn, May 31, 1927. The charge for quarters shall be determined as provided in the Schedule of Wages. 3 Appendix D Manual of the Medical Department Bureau Circular Letter C Subject: Injured Civil Employees. Table op Contents Subject: Paragraph Scope of the Compensation Act 1 Conditions Due to Occupation . 2 Reporting of Injuries 3 Supplementary Reports 4 Furnishing Reports to Designated Attorneys 5 Examinations and Treatment 6 Hernias 7 Double Hernias, One Not Due to Injury _ 8 Focal Infections, Etc 9 Operations of Election 10 Doubtful Cases 11 Negative Diagnosis 12 Disabilities Not Due to Injury. 13 Report Ability to Return to Work 14 Medical and Referee Examinations 15 Employing Private Specialists 16 Car Fare 1 17 Ambulance 18 Prosthetic Appliances 19 Dental Work 20 Shoes and Braces 21 No Stock Shoes 22 1. Scope of the Compensation Act.—Section 9 of the Employees’ Compensa- tion Act as amended June 26, 1926, is quoted as follows: That for any injury sustained by an employee while in the performance of duty, whether or not dis- ability has arisen, the United States shall furnish to the employee all services, appliances, and supplies prescribed or recommended by duly qualified physicians which, in the opinion of the commission, are likely to cure or to give relief or to reduce the degree or the period of disability or to aid In lessening the amount of the monthly compensation. Such services, appliances, and supplies shall be furnished by or upon the order of United States medical officers and hospitals, but where this is not practicable they shall be fur- nished by or upon the order of private physicians and hospitals designated or approved by the commission. For the securing of such services, appliances, and supplies the employee may be furnished transportation, and may be paid all expenses incident to the securing of such services, appliances, and supplies which, in the opinion of the commission, are necessary and reasonable. All such expenses when authorized or ap- proved by the commission shall be paid from the employees’ compensation fund. In conformity with the provisions of section 9 of the compensation act, civilian employees of the Navy Department who are injured while in the performance of their official duties shall be furnished, upon application and without personal charge, necessary medical and surgical treatment, provided the applicant shall present to the medical officer in person (or by proxy if too seriously injured to do so) a “Request for treatment of injury under the United States Employees’ Compensation Act” (USECC Form CA-16), or a letter reciting (1) that the applicant is an employee of the United States, giving the place of employment 1 2-3 CIRCULAR LETTER C and the name of the Government office or establishment; (2) that he was injured in the performance of his official duties, giving the date and nature of the injury; and (3) that treatment is requested as a result of the injury, under authority of section 9 of the compensation act, the form or letter to be signed by the official superior of the applicant. If it has been impracticable for an employee to obtain a request for treatment the medical officer may furnish temporary or emergency treatment upon the statement of the injured employee giving the facts. In such instances a proper request for treatment will be obtained within 48 hours thereafter from the em- ployee’s official superior. Beneficiaries of the compensation act may also be treated upon the direct re- quest of the commission. 2. Conditions Due to Occupation.—By an amendment to the Employees’ Com- pensation Act, approved by the President June 5,1924, it is provided that compensa- tion shall be paid for occupational diseases, or, in the language of the amendment “any disease proximately caused by the employment.” It should be clearly understood that the law does not permit the payment of money compensation or the furnishing of medical care for any disease unless the result of an accident or unless its direct causal relationship to the employment is shown. The mere fact that disease develops after the employee enters Government service can not be accepted as sufficient basis for an award of compensation. The common diseases, such as colds, pneumonia, tuberculosis, typhoid fever, rheumatism, flat feet, varicose veins, and the like, which may be, and usually are, due to causes entirely outside the employment, can very rarely, and only under most unusual conditions, be the basis of an award under the compensation law. 3. Reporting of Injuries.—A medical report must be forwarded to the com- pensation commission (1) whenever a civilian employee loses time from work as the result of an injury beyond a period of 3 days, or (2) when hospitalization is required, or (3) any expense for medical treatment is incurred. Reports should also be forwarded in all hernia cases and any case such as back strain, head injuries, etc., which in the opinion of the examining officer may lead to subse- quent disability. It should be emphasized, however, that dispensary or hospital records must be carefully kept of every case treated, no matter how trivial, as claims for sub- sequent disability, which are not infrequently filed months or years after such slight injuries, would be without record and entirely forgotten. Records in the cases of civilian employees who are treated in the dispensary or hospital must be accurate, definite, and concise, and must be made with great care, as this information is the basis of all compensation claims. Medical statements on the following compensation commission forms will be filled in by medical officers for reporting to the commission injuries to civil em- ployees of the Government: C. A. 2. Official superior’s report of injury. C. A. 4. Claim for compensation or medical expenses on account of injury. C. A. 5. Claim for compensation on account of death. C. A. 8. Claim for continuance of compensation on account of total disability. C. A. 32. Report on hernia. The medical certificates appearing upon these forms will be carefully completed by medical officers when the blanks are presented to them. The disposition of the forms will be in accordance with the directions given at the top of each blank. C. A. 16. Request for treatment of injury.—To be presented by the injured employee and forwarded to the commission with Form C. A. 20. 2 4-6 CIVIL EMPLOYEES C. A. 17. Request for treatment of injury when cause of injury is in doubt.—To be presented by the injured employee when the cause of injury is in doubt, and forwarded to the commission with Form C. A. 20. (See par. 11.) C. A. 20. Medical report of injury.—This report, accompanied by Form C. A. 16 or 17, shall be for- warded to the commission as soon as a case comes under treatment. C. A. 21. Discharge report of injury case.—This report shell be forwarded to the commission when an injured employee is transferred or discharged from treatment, or the case is otherwise terminated. C. A. 78. Report of surgical operation.—To be forwarded promptly to the commission, reporting all operations of sufficient importance to require the administration of a local or general anesthetic. The commission’s forms above referred to will be supplied upon request by the United States Employees’ Compensation Commission, Washington, D. C. The foregoing reports serve their purpose only when forwarded promptly to the commission. If the forwarding of a report is delayed for any cause, it should be accompanied by a letter of transmittal explaining the cause of the delay. 4. Supplementary Reports.—(a) Supplementary case reports in the form of a letter should be made of the following cases to the commission: (1) All compensation cases treated in hospitals. (2) All cases of serious injury. (3) All cases in which there will be a disability for work for one month or more. (4) All cases sent to the medical officer for examination under the provisions of sections 21 and 22 of the compensation act. (See par. 15 on “Medical examinations.”) (b) These supplementary reports should be made when the case has been under observation for a sufficient time to determine satisfactorily the nature and extent of the injury. The reports should include— (1) Date when case was admitted for examination or treatment. If admitted to hospital, this should be noted. (2) The patient’s complaint, including his account of the injury. (3) The names of the physicians or officers (and specialists, if any) examining the case. (4) The condition found on examination and the examining physician’s opinion as to the probable rela- tionship between the disability and the injury alleged. (5) Diagnosis of the injuries sustained. (6) Description of other disabilities or conditions found and not due to injury. (7) Nature and extent of disability, preferably expressed in terms of function. Note.—The phrase “in terms of function” has been used to insure a more detailed description of the degree of disability presented than such mere percentage estimates as “50 percent” or “under 10 percent.” The actual degrees of loss of active and passive motion, the amount of atrophy or deformity, any decrease in strength, or disturbanoe of sensation or nerve and muscular reactions to electric stimulus should be painstakingly recorded. The degree of disability for any particular work depends upon so many factors that it often varies considerably from the actual anatomical disability found. For this reason an additional survey and opinion regarding a claimant’s general appearance, age, previous occupation and disease history, intelligence, education, mental and emotional qualities, and general adaptability is not infrequently of extreme importance in assisting the commission to consider rating and subsequent management. (8) Whether disabled for his usual employment. (9) Prognosis. (10) Comments, recommendations, or suggestions regarding the case. 5. Furnishing Reports to Designated Attorneys.—Upon request of the United States Employees’ Compensation Commission or its duly authorized designated attorneys, such information from the clinical records of a beneficiary of the com- pensation act, because of whose injury damage suit is being prosecuted under sections 26 and 27 of the compensation act, and such professional advice and assistance in connection with such suit will be supplied by the medical officer in charge to such designated attorney in so far as practicable. 6. Examinations and Treatment.—(a) Civilian employees of the Navy Depart- ment injured in the performance of duty may be treated at a naval dispensary or admitted to a naval hospital. Injured male civilian employees of the Navy 7 CIRCULAR LETTER C Department will be sent to the naval hospital serving the activity in which em- ployed, provided the naval hospital is nearer than a hospital of the Public Health Service, and may be retained therein during such period as hospital treatment is required, subject to the following limitations: (1) At the Naval Hospital, Brooklyn, N. Y., and Mare Island, Calif., an employee may not be retained more than 30 days without the special authority of the Employees Compensation Commission. (2) At the Naval Hospitals, Chelsea, Mass.; Norfolk, Va.; and Puget Sound, Wash., an injured employee may not be retained more than 10 days without the special authority of the Employees Compensation Commission. (b) Civilian employees shall not be continued in any naval hospital beyond the period actually necessitated by the injury, but shall be discharged as soon as out-patient or dispensary treatment can be substituted for hospital care. Com- manding officers of naval hospitals will adopt such measures as will enforce this provision. (c) Employees of other Government departments than the Navy Department injured in the performance of duty may be admitted to naval hospitals for im- mediate emergency treatment and, if beds and personnel are available, may be retained for the period necessary for their treatment, subject to the above time limitations. (d) The commanding officer of the hospital or senior medical officer of the yard should be notified by the immediate superior of the person injured that he was injured in the performance of duty and therefore entitled to treatment under the compensation commission rules. This is accomplished by the issuance of Form CA-16. (e) Patients entitled to treatment under the rules of the compensation com- mission must conform at all times to the rules and regulations of the hospital. (f) None of the naval hospitals has facilities for the treatment and care of injured women employees. (g) Full information and instructions concerning the treatment of civilian employees injured while in the performance of duty are contained in the Regula- tions Concerning Duties of Employees, Official Superiors, Medical Officers, and Others Under Federal Compensation Act of September 7, 1916, Form CA-22, United States Employees’ Compensation Commission, Washington, D. C. 7. Hernias.—(a) In a large proportion of hernia cases there is considerable doubt as to whether the case is one entitled to treatment under the compensation act. Therefore, unless the relationship of the hernia to the injury is clear, and immediate treatment is necessary because of strangulation or incarceration or for other reason, operation should not be performed until a full report of the case has been submitted to the commission and it has authorized operation. Pending decision on the case, the patient should be discharged from the hospital if practicable. Should the employee be unable to continue his work pending the commission’s decision, all facts may be transmitted by telegram in order that the employee’s period of disability for work may be shortened as far as possible. The initial report to the commission should show— (1) The nature and location of the hernia. (2) Tissues involved and the probable recency and size of the hernia. (3) The cause of the hernia, particularly whether brought on or materially aggravated by Injury, as alleged by the claimant. (4) Whether patient’s general health, including condition of his heart, lungs, and kidneys, is such that it is advisable to perform operation. (5) Whether the hernia is one for which operation should be performed and the medical officer recommends operation. 4 CIVIL EMPLOYEES 8-11 (b) The following tests in hernia claims are intended to serve as an aid and can not be considered as binding in all hernia cases: (1) Predisposition to hernia shall be regarded as immaterial. (2) Any hernia, whether complete or incomplete, resulting from an injury shall entitle the injured em- ployee to operation and compensation during the resulting incapacity, but the evidence must show with reasonable clearness that— 1. The hernia was immediately preceded by some sudden severe eSort, severe strain, or the applica- tion of external force. S. The injury was accompanied or immediately followed by definite pain and discomfort. 5. The claimant had no knowledge of the existence of the hernia prior to the alleged injury. (3) Any existing hernia which has not incapacitated an employee for work, if materially aggravated as result of an injury, is compensable and shall entitle the injured employee to operation and compensation during the resulting incapacity, but the evidence must show with reasonable clearness that— 1. The alleged aggravation was immediately preceded by some sudden severe effort, severe strain, or the application of external force. t. The injury was accompanied or immediately followed by definite pain and discomfort. S. There was a really material aggravation of the hernia existing prior to the alleged injury. (4) In all cases of hernia which the commission shall find remediable by operation the claimant shall be awarded such operation as a proper and necessary part of medical, surgical, and hospital treatment. If he refuses either to accept or secure operative treatment, he shall be denied further compensation and treat- ment, unless there are particular circumstances warranting the waiving of this rule. 8. Double Hernias, One Not Due to Injury.—When a claimant presents two hernias only one of which has been allowed by the commission, operation for the other hernia, should the claimant so desire, may be offered providing (1) the claimant signs a statement that he will assume all responsibility for any unto- ward results or failure to cure the uncompensable hernia and (2) that he will bear any extra expense connected with the additional operation. 9. Focal Infections, Etc.—Not infrequently a disability due to an injury may only be relieved by treatment directed to other complicating conditions not in themselves due to any injury, but nevertheless unduly prolonging or materially aggravating the allowed disability. Thus, a luetic infection may require treat- ment in order that the disability due to injury may be relieved. Again, focal infections often prevent recovery from injury until treated. Authority for such treatment should, however, be obtained from the commission before an extended couise of treatment is undertaken. 10. Operations of Election.—Operations of election for conditions not requiring urgent emergency treatment and not any way related to the disability for which treatment is authorized should not be performed without specific authority from the commission. In requesting authority for such operations, consideration should be given as to whether such treatment would in any way decrease the employee’s disability for work end whether the period of hospitalization or disability would not be increased by such operation. Operations of election should never be performed without a statement in writing from the claimant that he will not hold the Government responsible for failure lo cure or for un- toward results. (.See par. 8 for elective herniotomy.-) 11. Doubtful Cases.—Whenever an employee applies for treatment with a request for treatment on Form C. A. 16, or a letter of request from his official superior, the employee should be furnished such treatment as may be required; but if there is reason to believe that he is not entitled to treatment or that his disability is not due to the alleged injury, the medical officer should take up the matter with the employee’s official superior. If agreement is reached by both that the employee is not entitled to relief, he should be discharged from treat- ment. Such a claimant iShould be informed, however, that bis discharge is in no way prejudicial to his filing claim for his alleged disability directly with the 5 12-15 CIRCULAR LETTER C commission. Written records should be kept and immediate report made of all such cases to the commission. Whenever an employee presents a request, C. A. 17, from his official superior, a complete examination should be performed to ascertain whether his disability may be due to an injury or to his employment, and further procedure as outlined in the paragraph above complied with. In all doubtful cases the commission will be responsible for the expenditures incurred for such treatment up to and including the date on which it is decided the employee is not entitled to medical relief under the compensation act, but no surgical operation should be performed in advance of a decision by the commission, except in emergency. 12. Negative Diagnosis.—Injured employees not infrequently present them- selves for examination and treatment, though no anatomical lesion resulting from an injury is found, The diagnosis recorded in such cases may often be no dis- ability PRESENT or TRAUMATIC NEUROSIS Or perhaps CASE OF MALINGERING. In a proportion of these cases the conclusion is the result of the limitations of diagnosis and not due to the fact that an actual injury does not exist. In many instances the commission finds that on further and more detailed examination a definite lesion is found. These cases of what amounts to negative diagnosis are among those giving the commission the greatest amount of trouble. The injured employee insists he is injured and the commission is unwilling to deny his claim until it has exhausted the powers of diagnosis. It is, therefore, necessary in cases of this kind that the negative diagnosis be supported by a very complete examina- tion, the results of which are made a matter of careful record. It is in cases of this kind that the services of attending specialists are most needed. (See par. 16.) Back injuries are among those causing more trouble in this way. The surgeon of lesser experience finds no disabling condition. The experienced orthopedic sur- geon looks for the injured sacroiliac joint or fractured vertebra in these injuries and frequently finds them. This makes necessary the services of an expert rontgenologist and expert reading of the plates. 13. Disabilities Not Due to Injury.—Whenever, in any case, an injured employee admitted to hospital is found to have or develops a disease or disability which is not related to the injury and which is liable to prolong his stay in hospital, the commission should be notified immediately. 14. Report Ability to Return to Work.—Whenever an injured employee becomes physically fit to do light work or some form of work other than his usual work without detriment to himself and without interfering with his recovery from the injury, the medical officer in charge of the case should record the fact in the clinical history and should notify the patient, the official superior, and the commission. 15. Medical and Referee Examinations.—Attention is directed to section 21 of the Federal Compensation Act, amended June 26, 1926, as folkAvs: Sec. 21. That after the injury the employee shall, as frequently and at such times and places as may be reasonably required, submit himself to examination by a medical officer of the United States or by a duly qualified physician designated or approved by the commission. The employee may have a duly qualified physician designated and paid by him present to participate in such examination. If the employee refuses to submit himself for, or in any way obstructs any examination, his right to claim compensation under the act shall be suspended until such refusal or obstruction ceases. No compensation shall be payable while such refusal or obstruction continues, and the period of such refusal or obstruction shall be deducted from the period for which compensation is payable to him. In accordance with the provisions of the foregoing section 21, and at the request of the commission, medical officers are requested to act as examining physicians in compensation cases. Examinations will be made only at the 6 CIVIL EMPLOYEES 16-18 request of the injured employee’s official superior or the commission. All evidence submitted must be given careful attention by the examining physician and an impartial decision rendered only after the most thorough consideration of all the facts. In doubtful cases the injured employee may be admitted to the hospital for observation and treatment until such time as a complete survey has been obtained and a definite decision can be reached. Attention is also directed to section 22 of the Employee’s Compensation Act of September 7, 1916, as follows: That in case of any disagreement between the physician making an examination on the part of the United States and the employee’s physician, the commission shall appoint a third physician, duly qualified, who shall make an examination. In accordance with the provisions of the foregoing section 22, medical officers may be requested to act as referees in compensation cases. Such referee exami- nations will be made only upon request of the commission, and every possible precaution should be taken to assure the most comprehensive and impartial medical survey. In all such cases the commission desires every possible medical facility available to be extended in order that a final decision may be reached. 16. Employing Private Specialists.—Where available, eye injuries will be treated by ophthalmologists; bone and joint injuries by trained orthopedic surgeons or by surgeons having ample experience. The senior medical officer of a dis- pensary or commanding officer of a hospital has authority to employ such or other specialists or consultants to treat or examine beneficiaries of the commission as may in his best judgment be indicated. Fees for consultations and special treatment by private specialists are chargeable to the commission. Such charges should be taken up on employee’s compensa- tion Form S-69. On such vouchers inclusive dates of examination or treatment and the character of services rendered must be given, together with an itemiza- tion of each charge therefor, showing number and cost of such services. A ruling of the Comptroller General compels the certification of the injured employee on all vouchers that services were rendered or supplies furnished as charged. Should such certification be unobtainable for any particular reason, a statement must be submitted with the voucher explaining the circumstances in full. 17. Car Fare.—The commission will reimburse patients’ vouchers (Standard Form 1012) for car fare or other transportation, if shown to be necessary in reporting to and from the relief station for treatment, when such vouchers have been certified by the attending officer as complying with the records at the station. 18. Ambulance.—In cases where the injury requires such action, an ambulance (one owned by a naval hospital or navy yard) should be called and the employee sent to the hospital. When an injured employee is to be transferred to a Public Health Service hospital, request may be made for the use of the Public Health Service hospital ambulance. In any naval establishment employing any con- siderable number of civilians and where the Government maintains no ambulance services, arrangements should be made with the official superior in charge whereby there will be adequate private ambulance service if needed on account of injury cases entitled to the benefits of the compensation act. Bills on account of nec- essary expenditures incurred by said arrangement will be allowed by the com- mission when presented on voucher, Form S-69, for direct payment. Where ambulance or transportation charges have already been paid by the injured employee, reimbursement may be effected by submitting charges on Standard Form 1012. 19-22 CIRCULAR LETTER C 19. Prosthetic Appliances.—When an employee has lost a member or part of a member as a result of an injury for which he is entitled to the benefits of the compensation act, all necessary artificial arms or legs may be supplied, kept in repair, and replaced if worn out as a result of proper use. (A temporary leg will be furnished if needed for a time, and a Dorance hook or similar appliance, in addition to an artificial arm, will be supplied if requested.) When such an em- ployee has lost an eye, two properly fitting and matched artificial eyes may be furnished, one to be kept for use in case of accidental loss or breakage of the other. Under the same conditions applying to artificial limbs and eyes, other necessary prosthetic appliances may be furnished. All such appliances will be of approved manufacture and before acceptance by the commission must, where practicable, be pronounced satisfactory in workmanship and fit by a competent specialist. When such prosthetic appliance is desired, authority for its purchase should be requested from the commission. When necessary, the telegraph may be used to expedite such requisitions. 20. Dental Work.—Injured employees are entitled to repairs to fixed false teeth or to natural teeth only in so far as such repairs are due to the injury or, upon approval by the commission, where the dental condition constitutes a focus of infection aggravating or prolonging a disability due to injury. An estimate of the cost of dental work should be approved in advance as reasonable by a medical officer, who should also certify on the bill that all the work was needed as a direct result of the injury sustained. Bills for repairs or replacement of removable plates or bridges are not payable from the compensation fund. 21. Shoes and Braces.—Braces, trusses, orthopedic shoes, and other orthopedic appliances will be furnished by the commission under the same conditions and in the same way as are prosthetic appliances. In most instances the matter of time will make it advisable for the attending medical officer to secure immediately, without further authority, the orthopedic appliance indicated in a given case. When this is done, the bill therefor should be forwarded to the commission for payment, with a notation thereon that the article was necessary because of the injury, that it was satisfactory, and that the price was reasonable. 22. No Stock Shoes.—Custom-made shoes, constructed under the supervision of the orthopedist in charge, to correct the particular deformity found in the claimant, or alterations or repairs to stock shoes with a view to the same end, are expenses properly referable to the commission. However, any shoes, ortho- pedic or otherwise, which are kept in stock and for sale at shoe stores must be purchased at the expense of the claimant. This decision is necessary to prevent the unwarranted purchase of ordinary or stock orthopedic shoes and charging the cost against the commission, as the claimant should have no more difficulty in paying for these than he would for shoes worn theretofore. 8 Appendix D Manual of the Medical Department Bureau Circular Letter C July 1, 1941. Subject: Funeral expenses of deceased personnel of the Navy and Marine Corps 1. The Naval Appropriation Acts provide for care of the dead of Navy and Marine Corps personnel in accordance with the terms of the act of April 20, 1940, as followrs: PUBLIC, NO. 465-54, STAT. 144 April 20, 1940 AN ACT Authorizing appropriations to be made for the disposition of the remains of personnel of the Navy and Marine Corps and certain civilian employees of the Navy, and for other purposes Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That funds to be expended under such regula- tions as the Secretary of the Navy may prescribe are hereby authorized to be appropriated as may be necessary from time to time for the funeral expenses of deceased persons hereinafter specified. Sec. 2. The words “funeral expenses” as used in this Act, and in subsequent Acts appropriating funds as herein authorized, shall be construed to include the expenses of, and incident to, the recovery of bodies; cremation, but only on request of the relatives of the deceased; preparation for burial; transportation to the home of the deceased or to a national or other cemetery designated by proper authority; and interment. Sec. 3. Funeral expenses shall be allowed for— (a) Officers and enlisted men of the Navy and Marine Corps, including those on the retired lists who die while on active duty; (b) Members of the Nurse Corps (female) of the Navy, including those on the retired list who die while on active duty; (c) Members of the Naval Reserve or Marine Corps Reserve who die while on active duty or training duty, or while performing authorized travel to or from such duty; (d) Accepted applicants for enlistment; (e) Civilian employees of the Navy Department or the Naval Establishment who have been ordered away from their homes in the United States to duty outside the continental limits of the United States and who die while on such duty or while performing authorized travel to or from such duty; (J) Former enlisted men of the Navy and Marine Corps who were discharged while patients in hospitals and who remain as patients in such hospitals to the day of their death; and (g) Pensioners and destitute patients wrho die in naval hospitals: Provided, That only the expenses of preparation for burial and interment shall be allowed in disposing of the remains of such pensioners and destitute patients. Sec 4. The provisions of this Act shall apply in the case of personnel tempo- rarily absent with or without leave w hen death occurred. 1 CIRCULAR LETTER C Sec. 5. In any case where funeral expenses authorized by this Act are incurred prior to receipt of official authority, reimbursement may be made in the amount allowed by the Navy Department for such services. Sec. 6. Funds to be expended under such regulations as the Secretary of the Navy may prescribe are hereby authorized to be appropriated as may be necessary from time to time for the purchase and care of cemetery lots; for the care of graves of deceased personnel of the Navy and Marine Corps outside the continental limits of the United States, with which shall be included those in sites not owned by the United States; and for the removal of remains from abandoned cemeteries to naval or national cemeteries or to the homes of the persons deceased, with which shall be included remains interred in isolated graves in the United States and abroad and remains temporarily interred. 2 Appendix D Manual of the Medical Department Bureau Circular Letter C July 31, 1941. Subject: Funeral expenses of deceased civilian employees of the Navy Depart- ment and Naval Establishment. 1. The Naval Appropriation Acts provide for care of the remains of civilian employees of the Navy Department in accordance with the terms of the act approved July 8, 1940, as follows: [PUBLIC—NO. 729—76TH CONGRESS] [Chapter 551—3d Session] [S. 3899] AN ACT To defray the cost of returning to the United States the remains, families, and effects of officers and employees dying abroad, and for other purposes Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That in case any civilian officer or employee of the United States dies (1) while in a travel status away from his official station in the United States or (2) while performing official duties in a Territory or possession of the United States or in a foreign country or in transit thereto or therefrom, the head of the department, independent establishment, agency, or federally owned or controlled corporation, hereinafter called department, in the service of which such officer or employee was engaged, is hereby authorized, under regulations to be prescribed by the President and except as otherwise provided by law, to pay from the appropriation available for the activity in which he was engaged— (a) In case of the death of the officer or employee in such travel status in the United States, or in the case of the death of the officer or employee while perform- ing official duties in a Territory or possession of the United States or in a foreign country or in transit thereto or therefrom, the expenses of preparing and trans- porting the remains of such officer or employee to his home or official station or such other place as the head of the department concerned shall determine to be the appropriate place of interment. (b) In case of the death of the officer or employee while performing official duties in a Territory or possession of the United States or in a foreign country or in transit thereto or therefrom, the transportation expenses of his dependents, including expenses incurred in packing, crating, drayage, and transportation of household effects and other personal property to his former home or such other place as the head of the department shall determine. Sec. 2. The benefits ol section 1 of this Act shall not be denied in any case on the ground that the deceased was temporarily absent from duty when death occurred. Sec. 3. This Act shall become effective sixty days after its enactment. Approved, July 8, 1940. 1 CIRCULAR LETTER C 2. In accordance with the above Act, the following instructions will govern the care, preparation, encasement, transportation and burial of the remains of deceased civilian officers and employees of the Navy Department who die: (а) While on duty outside the continental limits of the United States or while performing authorized travel to or from such duty; (б) While in a travel status away from their official stations in the United States. 3. Civilian officers and employees who die while on duty outside the continental limits of the United States or while performing authorized travel to or from such duty. (a) In general and to the extent applicable, the instructions contained in the Manual of the Medical Department, Chapter 19, will apply as follows: Sec. I, Par. 2901, 2902, 2904. Par. 2908, except that appropriation chargeable is “Care of the Dead.” Sec. II. Sec. Ill, Par. 2922, 2924. Sec. IV. Sec. V, Par. 2951, 2952. Par. 2953. A corpse escort is not authorized. However, as the basic Act provides for return home of dependents, instructions regard- ing method of handling body when accompanied by a dependent are applicable. (See subparagraph (d)). Par. 2954, 2955, 2956, 2957. Par. 2958 (a). Excess weight chargeable to the appropriation “Main- tenance, Bureau of Supplies and Accounts.” Sec. VI. Not applicable. Sec. VII. Not applicable, except Par. 2990. Sec. VIII. Not applicable. (b) All necessary expenses incident to the care, preparation, embalming, cloth- ing and encasement, or of cremation of the remains of civilian employees who die while on duty outside the continental limits of the United States, and of trans- portation to the place of interment and/or local burial are chargeable to the ap- propriation ‘‘Care of the Dead.” The $50 allowance for funeral expenses at the home or other place to which the remains have been shipped also is payable from this appropriation. (c) At stations where annual contracts for care of the dead are in effect, remains shall be cared for under the terms of such contract. In the absence of available annual contract, necessary services and supplies shall be obtained from a local undertaking establishment, and covered by emergency requisition in accordance with Article 1607 (5), Navy Regulations. Expenses of preparation and encase- ment shall not exceed $200.00. If to be buried locally, this $200 shall be inclusive also of burial expenses. Expenses of transportation to another locality for burial are payable in addition to the cost of preparation and encasement. (d) The return passage of dependents may be coordinated with return of remains. Transportation of dependents is payable against the appropriation “Miscellaneous Expenses,” Office of the Secretary. 4. Civilian officers and employees who die while in a travel status away from their official station in the United States: (a) If death occurs at or in the vicinity of a naval activity, such activity will assume charge of the remains for care and disposition. The Secretary of the Navy, the official station of the employee, and the next of kin (if known) shall be 2 CIVILIAN EMPLOYEES notified by dispatch. The form of dispatch shall be an adaptation of the standard Navy form. The dispatch to the Secretary of the Navy shall include a definite statement as to whether the activity has taken custody of the remains. The dis- patch to the official station of the deceased shall state whether the next of kin has or has not been notified, and if not notified, shall request that notice be sent. In all cases, the next of kin shall be directed to telegraph the Bureau of Medicine and Surgery collect instructions for disposition of the remains. (6) Expenses for preparation and encasement of remains are limited to $100.00. This amount includes embalming, cremation, necessary clothing and casket. In addition, the following expenses are authorized: (1) Removal from place of death to an undertaking establishment; (2) Procurement of burial or shipping permits; (3) Outside case for shipment; (4) Removal from undertaking establishment to railroad station or other common carrier; (5) Cost of transporting remains to home or official station of the deceased, or such other place as may be designated by the Bureau of Medicine and Surgery; (6) One removal from common carrier at destination. (c) An escort to accompany the remains is not authorized, nor is there any allowance for funeral expenses at place of interment except one removal from common carrier as noted above. (e) As the above limitation of $100 may render use of annual Navy contracts for the care of the dead impossible, the services of any local undertaker may be obtained and properly certified and itemized bills, in duplicate, forwarded to this Bureau for payment, accompanied by copy of the official death certificate. The undertaker’s bill may include, over and above the items making up the $100 allow- ance, cost of items (1) to (4) inclusive, noted in sub-paragraph (c). 3 Appendix D MANUAL OF THE MEDICAL DEPARTMENT Bureau Circular Letters D Dental Division Subject Date in effect Postgraduate Instruction, Officers, Dental Corps July 1, 1939 Dental Technicians; Ratio, Promotion, and Training of July 1, 1939 Dental Treatment, Inactive Fleet Reservists Aug. 28, 1939 TABLE OF CONTENTS Appendix D Manual of the Medical Department Bureau Circular Letter D Subject: Postgraduate Instruction, Officers, Dental Corps. (a) Dental officers entering the Navy may be ordered, if circumstances permit, to a basic course at the Naval Dental School, and upon completion of this course they will be transferred to sea or foreign duty as vacancies occur. Since the num- ber of officers entering the corps may exceed the number which can be accommo- dated at the school, it follows that officers, representing the excess, will be denied opportunity to attend the basic course. Hence lack of a school certificate will not reflect adversely on an officer’s record or impair his eligibility for instruction in a specialty. (b) Refresher courses will be given from time to time at the Naval Dental School for the older officers in order that they may acquaint themselves with ad- vances in dentistry. (c) Those officers who wish to specialize are encouraged to attend postgraduate instruction where opportunity presents and in every way to avail themselves of service opportunities to acquire knowledge of the specialty they wish to study. Subject: Dental Technicians; Ratio, Promotion, and Training of. Reference: Bureau of Navigation Manual, article 5244, paragraphs 5 and 0. (a) In order to meet the growing need for dental technicians, it is proposed to increase the ratio of dental technicians to one and one-half for each dental officer for the service as a whole. It is felt that this allowance will provide sufficient dental technicians to assist dental officers in operating rooms, extend the oral prophylaxis service, and increase facilities for rendering dental prosthesis. In addition to the examination prescribed for hospital corpsmen, dental techni- cians will be given an examination in their specialty and marks assigned for the purpose of arriving at the professional average. (b) To provide for the training of additional hospital corpsmen as dental technicians (general) classes to receive approximately 4 months’ instruction will be organized twice a year, in February and September, at the Naval Dental School, Washington, D. C. (c) It is requested that all activities canvass their hospital corpsmen for can- didates for these classes and have them submit requests to this Bureau, via official channels. (d) The following conditions will be brought to the attention of prospective candidates: (1) Any hospital corpsman from the ratings of chief pharmacist’s mate to and including hospital apprentice, first class, is eligible. His request for instruction should have the indorsement of a dental officer as to his aptitude or qualifications for this training. 1 CIRCULAR LETTER D (2) It is the intention of this Bureau to have the following number of Hospital Corps ratings designated as “dental technicians”: Chief pharmacist’s mates 32 Pharmacist’s mates, first class 59 Pharmacist’s mates, second class. 61 Pharmacist’s mates, third class 61 Hospital apprentice, first class 183 (3) Prospective candidates should have 30 months’ obligated service or agree to extend their enlistments. (e) Dental technicians (general) who desire to qualify as dental technicians (prosthetic) should make application to this Bureau and, if approved, they will be recommended for transfer to a naval dental prosthetic laboratory for instruc- tion in this specialty, and upon successfully completing this training will be designated dental technicians (prosthetic). (f) Attention of senior medical officers is called to the fact that there is an in- sufficient number of trained dental technicians to meet the needs of the service, and it is desired that those who have been trained be assigned duty with dental officers. (g) Hospital corpsmen who were formerly designated dental technicians and who are desirous of resuming this specialty, may make application to this Bureau to be redesignated dental technicians. 2 Appendix D Manual of the Medical Department Bureau Circular Letter D August 28, 1039. Subject: Dental Treatment, inactive Fleet Reservists. Reference: Letter from the Secretary of the Navy to Commandant, Sixteenth Naval District, dated March 3, 1939—QR4/P5-1(380114). (a) The following is quoted from reference for information and guidance: “1. Careful consideration has been given to the questions raised by reference (letter of Commandant, Sixteenth Naval District) in connection with (1) the legality and (2) the practicability of extending unlimited dental care to members of the Fleet Reserve and Fleet Marine Corps Reserve (transferred thereto after 16 or-more years of naval service) in an inactive status. “2. At present, Article 1178, Navy Regulations, 1920, definitely limits the professional services of dental officers to officers and enlisted men on the active and retired lists of the Navy and Marine Corps. “3. While the Department has determined that there is no prohibition in the law to preclude the extension of dental service to these transferred members of the Fleet Reserve, nevertheless, the practical limitations imposed by the law which fixes the number of dental officers in direct proportion to the numerical strength of the active list, and the fact that appropriations for dental equip- ment, instruments, and supplies are on the basis of the active list only, render such extension impossible of accomplishment until such time as additional personnel, equipment, and material may be provided for this purpose. “4. Article 1178, U. S. Navy Regulations, 1920, is governing, and dental treatment may not be provided for inactive 16- and 20-year reservists except as an incident to hospitalization.” (b) Insert this change in Appendix D as the last sheet under Bureau Circular Letters D. MANUAL OF THE MEDICAL DEPARTMENT Appendix D Bureau Circular Letters F Finance Division TABLE OF CONTENTS Subject Date in eflect Report of Allotment Expenditures, Form B July 1, 1939 Inventory of Material, Forms D and Da_ July 1, 1939 Statement of Receipts and Expenditures of Medical Department Property, Form E July 1, 1939 Remains, Report of Disposition, and Instructions July 1, 1939 Supernumerary Patients July 1, 1939 Quarterly Ration Return, Form 36_ Jan. 1, 1941 Register No. 3 July 1, 1939 Civilian Conservation Corps July 1, 1939 Medical Stores Requisition and Invoice July 1, 1941 F-9. Quarterly Return of Medical Stores, Form V (3432) July 1, 1941 F-10. Medical Stores, Shortages and Overages in Shipments Be- tween Medical Supply Depots, Accounting Procedure July 1, 1940 F-ll. Emergency Relief Workers, Reports of Hospitals July 1, 1940 F-12. Emergency Relief Worker Injured; Reports of Out-Patient Medical Services Rendered July 1, 1940 F-13. CCC Enrollees, laundering of Washable Clothing-.. July 1, 1940 Appendix D Manual of the Medical Department Bureau Circular Letter F Subject: Report of Allotment Expenditures, Form B. (3023, 3412.) (a) This form shall be submitted, as of the last day of the quarter, and upon decommissioning, by all Medical Department activities that have been granted one or more allotments by this Bureau or have, in cases of emergency, incurred appropriational charges in the absence of an allotment. The Naval Medical Supply Depot, Brooklyn, shall continue to submit the form, monthly, for the medical stores allotment. (b) Each allotment should be closed at the end of the fiscal year, if possible. In the event it is impossible to close an allotment at the end of the fiscal year for which it was granted, every effort shall be made to liquidate such outstanding obligations at the earliest practicable date. (c) A monthly supplementary report, covering all obligations reported as out- standing against any allotment at the end of a fiscal year, shall be submitted at the end of each month thereafter until all obligations are disposed of either by (1) final liquidation, (2) cancelation, or (3) transfer of the obligations to the cor- responding allotment for the current fiscal year. When all obligations chargeable to an individual allotment have been disposed of by one or more of these three pro- cedures the word “Final” shall be inserted on line 8 of the appropriate column of table 1 on the report for the month in which the final transaction occurs. In the event final disposition is accomplished by cancelation or transfer of any part of such obligations, the facts regarding each cancelation and transfer for each allotment shall be stated under remarks. Only the amount reported as out- standing at the end of a fiscal year shall be shown as the amount available on the supplementary From B submitted on July 31. Succeeding monthly supple- mentary reports shall indicate the amount available as the amount of the obliga- tion reported outstanding at the close of the preceding month. Only the amount expended during the month for which the supplementary report is submitted shall be analyzed in tables 2, 3 (a), 4, and 5 of each supplementary Form B. (d) NMS— Form B shall be prepared in accordance with the following instructions: Heading 1. On the line headed quarter ended, insert the date of the last day of the quarter for which the report is submitted. On supplementary reports the date of the last day in the month for which the report is submitted shall be inserted on this line and the word “Supplementary” shall be typed above the heading of the form. The words “Final supplementary” shall be typed above the heading of the form on the last supplementary report for each fiscal year. 2. On the line headed from, the name of the activity shall be inserted. 3. On the line headed date, insert the date on which the report is prepared. Table 1 Status of allotments Line 1.—Insert in columns 1 to 4, inclusive, the correct allotment number as indicated on the respective allotment cards issued by the Bureau. (The allotment number of each allotment changes with each fiscal year.) 1 CIRCULAR LETTER F Line 2.—Insert in column 4 the net amount of the supply depot allotment; the original allocation plus increases and minus decreases, if any. Line 3.—Insert in column 4 the total of all amounts previously reported on line 7 of column 4 during the current fiscal year. Line 4-—Insert in columns 1, 2, and 3 the net amounts of the respective ap- portionments; the original apportionments for the quarter, plus increases and minus decreases, if any. Line 5.—Insert in columns 1, 2, and 3 the respective amounts reported on line 8 of the report for the previous quarter of the current fiscal year. Line 6.—Insert in columns 1, 2, and 3 the total of lines 4 and 5 of the respec- tive columns. Insert in column 4 the difference between lines 2 and 3. Line 7.—Insert in columns 1, 2, 3, and 4, the total expenditures charged to the respective allotments during the quarter concerned. The totals of columns 1, 2, and 3 of this line must agree with the applicable totals of line 10 of table 2 and the respective totals of table 4. The amount reported in column 4 of this line must agree with the total of table 3 (a) and with the total of table 5 (d). Line 8.—Insert in columns 1, 2, 3, and 4, the respective totals of unliquidated obligations as defined in paragraph 3023 (a), Manual of the Medical Department. Line 9.—Insert in columns 1, 2, 3, and 4, the amount obtained by subtracting the sum of lines 7 and 8 from the amount reported on line 6. Line 10.—Insert in columns 1, 2, 3, and 4, the respective sums of lines 7, 8, and 9, which must agree with the amount reported on line 6 Table 2 Analysis of completed transactions Line 1.—NS A Material.—Insert in columns 1, 3, and 4, the sum obtained by adding the totals of the three monthly summaries of Naval Supply Account stub requisitions charged to each of the respective allotments. (At shore activities the amounts reported must agree with S. & A. Forms 126 and 280 submitted to this Bureau during the same quarter.) Line 2.—Work requests.—Insert on this line, only the amounts reported by supply officers on S. & A. Forms 280 for the same quarter. In columns 1, 3, and 4 insert the applicable amounts covering work requests being undertaken by a navy yard, or by a nonindustrial naval activity, such as a naval air station or a naval training station, etc. Do not include on this line the amounts liquidated by public vouchers drawn by a public-works officer. The total reported on this line must agree with the charges made by the supply officer for NS A material, labor, and indeterminate charges (under title Z—manufacturing—at industrial yards) as reported on the three monthly S. & A. Forms 280 for the quarter. Lines S, 4, 5, 6, and 7.—Annual requisitions.—Insert on a separate line the number of each annual requisition, the inclusive numbers of the public vouchers, dated within the quarter, drawn under each annual requisition, and the amounts in the appropriate columns opposite each requisition. On board ships and at stations where public vouchers are prepared by the supply officer, the annual requisition number and the disbursing officer’s voucher number, or other identi- fying number, of each voucher shall also be indicated. Naval hospitals procuring provisions under a naval hospital fund annual requisition shall, in numbering such public vouchers, use a separate and distinct series, preceded by the letter “P.” Insert in column 2 the value of provisions obtained in the above manner. At naval hospitals, public vouchers dated within the quarter, drawn in payment for yeast purchased under an annual contract chargeable to a Bureau M. & S. requi" 2 FORM B sition and not to the naval hospital fund annual requisition of the individual activity, shall be numbered in a separate and distinct series, preceded by the letter “Y” when chargeable to subhead 06 (medicines), and by the letters *‘YP” when chargeable to subhead 13 (provisions). The total amount of all public vouchers on which the numbers are preceded by the letter “Y” shall be reported in column 3; those on which the numbers are preceded by the letters “YP” shall be reported in column 2. Line 8.—NSA Provision contracts (naval hospitals only).—Indicate the in- clusive voucher numbers (dated within the quarter) and insert the amount in column 2. Line 9.—Other charges (list separately).—Under this title, miscellaneous appropriational charges not specified on lines 1 to 8 next above, shall be reported in summary on lines 9 (1) to 9 (JO) inclusive, and classified as indicated here- under. All pertinent data shall be disclosed on a single line (or adjacent lines) when practicable. In the event of inadequate space, subsidiary schedules dis- closing the required data shall be attached. The charges occurring most fre- quently and which are to be reported separately on the lines under this heading are: (1) Pay roll (indicate as such).—Insert the amount in column 1. The sum reported opposite this heading must agree with all semimonthly standard Forms 1034 and 1034 (a), submitted during the same quarter. Medical supply depots shall report pay rolls on an accrual basis. (2) Work request charges liquidated by public voucher (indicate as such).—Insert in columns 1, 3, and 4 the amounts applicable and, if necessary, support the amounts so reported by a subsidiary schedule containing the following information: 1. M. & S. work request number. 2. NOy contract number. 8. Number of each public voucher (dated within the quarter) drawn by a public works officer. 4. The amount of each voucher drawn. (3) Provisions from supply department (indicate as such).—Insert in column 2 the total value of provisions received from the supply officer and, if necessary, support the amount so reported by a subsidiary schedule containing the following information: 1. The invoice number of each S. & A. Form No. 71. 2. The date the provisions covered by each invoice were received. 8. The amount of each invoice. (4) Provisions and maintenance items from commissary stores (indicate as such).— Insert in columns 1, 2, and 3 the respective amounts and, if necessary, support by a subsidiary schedule as in (3) above. (5) Coffee from naval clothing depot (indicate as such).—Insert the amount received in column 2 supported, if necessary, by a subsidiary schedule as in (3) above. (6) Specific requisitions (indicate as such).—Insert the amounts applicable in columns 1, 3, and 4, supported, if necessary, by a subsidiary schedule containing the following information: 1. The number of each specific requisition under which public vouchers have been drawn during the quarter. 2. The number of each public voucher dated within the quarter drawn under each specific requisition. 8. The amount of each voucher. CIRCULAR LETTER F (7) Estimated transportation, care of the dead (indicate as such).—Insert in column 4 the total amount of such estimated charges, supported, if necessary, by a subsidiary schedule containing the following information: 1. Transportation request numbers and express bill of lading numbers. 2. Name, initials, and rank or rate of each deceased transported. 8. Estimated amount of each transportation request or express bill of lad- ing. (8) Marine Corps quartermaster invoices (indicate as such).—Insert in columns 1, 2, 3, and 4, the amounts applicable to each, and submit a subsidiary schedule, if necessary, containing the following information: 1. Invoice number. 2. Date received. 8. Amount of each invoice. (9) Transportation charges on equipment (indicate as such).'—Insert in columns 1, 3, and 4, the amounts applicable to each and submit a subsidiary schedule, if necessary, containing the following information: 1. The month the supply officer made the charge on S. & A. Form 126. 2. The number of the requisition under which the item was purchased. 8. The amount applicable to each requisition. The total charges reported must agree with the total charges for transportation of material as reported by the supply officer on S. & A. Forms 126 during the same quarter. (10) Other expenditures.—Identify each, and insert in columns 1, 2, 3, and 4, the amount applicable to each. (For example, ice and laundry services at certain naval hospitals are procured under an annual or monthly naval supply account requisition and are liquidated by public vouchers charged directly to the naval hospital fund. In such instances the words “ice,” “laundry services,” etc., shall be inserted on the appropriate line; the number of the NSA requisition and the inclusive or other identifying numbers of public vouchers shall be indicated on the report or on a suppoiting schedule.) Line 10.—Insert the totals in the respective columns. The totals of columns 1 and 4 must agree with the amounts reported in columns 1 and 3, respectively, line 7 of table 1, and columns 2 and 4, respectively, of table 4. The sum of columns 2 and 3 must agree with the amount reported on line 7, column 2 of table 1 and the total of column 3 of table 4. Table 3 (1) Section (a)—Supply depot requisitions received during quarter.—Insert: In column 1 (in numerical sequence) the requisition number of each priced invoice (NMS—Form 4) covering material received during the quarter; in column 2, the date the material covered by each invoice was received; and in column 3, the money value of each invoice. The total of column 3 must agree with the amount re- ported on line 7, column 4 of table 1, and with the total receipts reported in section (d) of table 5. (2) Section (b)—Supply depot requisitions submitted (material not received).— Insert: In column 1 (in numerical sequence) the number of each supply depot requisition outstanding at the close of the quarter; in column 2, the date of each outstanding requisition; and in column 3 the estimated cost of each outstanding requisition. The total of column 3 must agree with the amount reported on line 8, column 4 of table 1. Analysis of supply depot requisitions 4 FORM B In the event that the material (supplies or equipment) covered by a requisition reported as outstanding has been received, but the priced invoices (NMS— Form 4) have not been received, such requisition shall be indicated by an asterisk. In the above case the following notation shall be typed on the invoices (NMS— Form 4) prior to distribution of the copies: Material received Date Priced invoices received Date Table 4 Analysis of appropriational allotment expenditures insert the respective allotment numbers and the fiscal year in columns 2, 3, and 4. Insert in column 1 (in strict numerical sequence) only those object and subhead numbers under which expenditures have been made during the quarter. In columns 2, 3, and 4, insert the respective amounts applicable to the object and subhead numbers indicated in column 1. The totals of columns 2, 3, and 4 shall be indicated and must agree with the amounts reported on line 7, columns 1, 2, and 3, respectively, of table 1. The totals of columns 2 and 4 must agree with the totals on line 10, columns 1 and 4, respectively, of table 2. The total reported in column 3 must agree with the sum of the amounts reported in columns 2 and 3, line 10, of table 2. Insert opposite supplies in the applicable columns of the recapitulation the sum of all expenditures reported under subheads 01 to 59, inclusive. Insert opposite equipment in the applicable columns of the recapitulation the sum of all expenditures reported under subheads 60 to 79, inclusive. Insert opposite land and buildings in the applicable columns of the recapitu- lation the sum of all expenditures reported under subheads 80 to 83, inclusive. No expenditures shall be charged to subheads 80 to 83, inclusive, without prior authority of the Bureau. The total of each column of the recapitulation must agree with the total of the respective column of the detailed analysis of expenditures by objects and sub- heads. Table 5 Analysis of supply depot allotment expenditures Insert, in the indicated space, the allotment number as shown on the supply- depot allotment card. Distribute the amount reported on line 7, column 4 of table 1, by classes and subheads as indicated in the table. This information should be available in the supply depot allotment control record of each activity. Insert opposite supplies in section (d), the total reported in section (a). Insert opposite equipment in section (d), the total reported in section (b). Insert opposite mortuary supplies and equipment in section (d), the total reported in section (c). The total receipts reported in this table must agree with the amount reported on line 7, column 4 of table 1 and with the total amount reported in section (a) of table 3. (e) Ships and stations which have not been granted an allotment under the appropriation, Medical Department, the naval hospital fund, or the appro- 5 CIRCULAR LETTER F priation, cake of the dead, but which have incurred expenses or obligated funds under the authority of an annual or a specific requisition approved by this Bureau, or by the senior officer present in cases of emergency, shall report such expenditures and obligations in the following manner: Table 1.—Columns 1, 2, and 3, as applicable. Line 5.—Insert the amount of any obligation incurred which had not been liquidated at the close of the previous quarter. Line 7.—Insert the amount expended during the quarter. This amount shall be appropriately reflected in tables 2 and 4> in accordance with instructions here- inbefore contained. Line 8.—Insert the amount of any obligations incurred which have not been liquidated as at the last day of the current quarter. No other lines under columns 1, 2, and 3 of table 1 shall be used by ships and stations which have not been granted an allotment under either the appropriation, Medical Department, the naval hospital fund, or the appropriation, care of the dead. (f) In order that expenditures reported on NMS—Form B shall include all appropriational charges, hospitals and shore stations required to submit monthly report of expenditures (S. & A. Form 280) shall submit with NMS—Form B, a schedule of APA material received, in which column 7 of the S. & A. Forms 280 for the quarter shall be analyzed to show the amount applicable to the naval hos- pital fund and each appropriation under the cognizance of this Bureau. The amounts applicable to the naval hospital fund and each appropriation shall be further analyzed to indicate the following: (1) The amount charged to the allotment of the activity during a previous quarter. (2) The amount charged to the allotment of the activity during the current quarter. (3) The amount which has not been charged and should not be charged to the allotment of the activity. The schedule of APA material shall be prepared in the form outlined in the following example: (a) Naval Hospital Fund (1) Reported in column 7, S. & A. Forms 280: July $200.00 August 50. 00 September 20. 00 Total, first quarter, fiscal year 1940 $270. 00 (2) Charged to allotment previously: Work request No. 10-39 (Form B, June 1939) $100. 00 Subtotal $100.00 (S) Charged to allotment this quarter: Work request No. 1-40 (part of line 2, table 2) $90. 00 Requisition No. 6-40, public voucher No. 6-1 (part of total line 9 (F), table 2) 10. 00 Transportation charges on equipment (line 9 (0), table 2) 40.00 Subtotal $140.00 6 FORM B (4) No allotment charge: APA material; work request No. 10-39__ $30. 00 Grand total $270. 00 (6) Medical Department (1) Reported in column 7, S. & A. Forms 280: July None August None September $10. 00 Total, first quarter, fiscal year 1940 $10. 00 (£) Charged to allotment previously: Requisition No. 6-39 (Form B, June 1939) $10. 00 When APA material has been received by shore stations which do not prepare S. & A. Form 280, a tabulation similar to the one outlined above shall be sub- mitted, indicating thereon the name of the supply department activity from which the APA material was received, i. e., “these amounts appear on S. & A. Form 280 submitted by the supply officer (accounting office) U. S Name of station and location 7 Appendix D Manual of the Medical Department Bureau Circular Letter F Subject: Inventory of Material, Forms D and Da. (3413). (a) An itemized inventory of all equipment on hand as of June 30 shall be forwarded to the Bureau annually. This inventory shall be typewritten on Form Da and faced with an accomplished Form D. The items on the inventory shall be arranged alphabetically by classes; on ships and stations other than hospitals, to conform to the arrangement in the supply table, and at hospitals, to coincide with the equipment ledger arrangement indicated in paragraph 3100. (b) The annual inventory must show an itemized list of all equipment on hand and the value of each item; also the value of supplies on hand, classified in ac- cordance with paragraph 3101 (c). (c) The value of supplies and equipment at ships and stations as shown by the annual inventory must agree with that reported on the Form E, and at hospitals with the recapitulation, submitted under date of June 30. (d) When the medical department material of a ship or station is transferred from the charge of one medical officer to that of another, the preparation of an itemized inventory is not required, but the receiving officer shall satisfy himself that the articles on hand correspond with the last itemized inventory on file and any subsequent receipts and expenditures. (e) If there be insufficient time to make a complete transfer before departure of the officer from whom the material is received, he shall report that fact to the commanding officer before his departure from the ship (art. 1392, N. R.). The officer receiving the material shall complete the inventory at the earliest prac- ticable opportunity and report any shortage in equipment or supplies to the commanding officer and request a property survey at once, in order to be relieved of responsibility for such articles. (f) Form D shall be made out in quadruplicate for the transfers noted in (d) and (e) and shall be signed by both medical officers concerned. The medical officer to whom the material is transferred may enter the words “subject to verification” on the forms before signing them, when there has not been sufficient time to make a complete transfer. He shall then proceed as indicated in sub- paragraph (e). One copy of the completed Form D shall be sent to the Bureau, one copy shall be retained by each medical officer concerned, and the fourth copy shall be kept on the files of the ship or station. (g) Except when clearly indicated on the form, medical officers shall forward to the Bureau, with the inventory, a statement as to the authority and the reasons for expenditure and disposition of all equipment items. (h) Officers will not be released from responsibility for the custody of equip- ment or supplies unless the expenditure shall have been authorized by the Bureau. (i) The property returns from ships in a fleet shall be forwarded through official channels. 1 Appendix D Manual of the Medical Department Bureau Circular Letter F Subject: Statement of Receipts and Expenditures of Medical Department Prop- erty, Form E. (3414). (a) This form accompanied by report of allotment expenditures—(Form B) and receipted copies of each transfer voucher issued—(TVI) accomplished during the quarter shall be prepared and submitted to the Bureau not later than the tenth day of the month following the end of the quarter, and upon decom- missioning, by every activity, except hospitals, charged with accountability for Medical Department property. (b) The value of all receipts and expenditures of Medical Department equip- ment and supplies shall be included. The value of equipment and supplies, the cost of which is chargeable to the appropriations of other bureaus, furnished for the use of the Medical Department, shall not be included except that the value of appropriation purchase account (APA) material items which would otherwise have been a charge to Medical Department allotments, but which are issued at no appropriational charge, shall be included at the invoice value, but will not be reported as a charge against the activity’s allotments (art. 1865 (3) N. R.). (c) The following instructions shall be observed in the preparation of Form E. Line numbers refer to numbered lines on the face of Form E. Insert name of activity and date covered by report. (1) Equipment (nonexpendable).— Line 1.—Enter sum reported on line 16 of last report. Newly commissioned, activities will indicate none. Line 2.—Enter value of all equipment received on SD. requisitions during quarter (column 2, R. and E. Journal). Must-agree with sum reported, including mortuary equipment, on Form B, and with analysis (1) on reverse of Form E. Line S.—Enter value of all equipment received on stub requisitions, including material procured Under NSA requisitions, or other invoice from the supply officer or marine quartermaster (column 3, R. and E. Journal). Must agree with analysis (2) on reverse of Form E. Line 4-—Enter value of all equipment paid for on public vouchers drawn against M. & S. requisitions (column 4, R. and E. Journal). Do not include equipment purchased under NSA requisitions. Must agree with analysis (3) on reverse of Form E. Line 5.—Enter total line 3 plus line 4. Must agree with total of equipment subhead charges reported on Form B. Line 6.—Enter value of equipment received from supplies and from other Medical Department activities by transfer vouchers received TVR during quarter (column 5, R. and E. Journal). Must agree with analysis (4) on reverse of Form E. Line 7.—Enter value of APA equipment received from supply officer at no appropriational charge (column 6, R. and E. Journal). Must agree with analysis (5) on reverse. Include only equipment otherwise properly chargeable to the Medical Department, and do not include equipment furnished by other depart- ments or bureaus on custody receipt. Consultation with the supply officer is often advisable to determine proper accounting procedure. Line 8.—Enter total of lines 6 and 7. Line 9.—Enter total of lines 2, 5, and 8. Line 10.—Enter total of lines 1 and 9. 1 CIRCULAR LETTER F Line 11.—Enter value of equipment expended by approved survey, total value of equipment surveyed, less appraised value transferred to supply officer for sale, or to medical supply depot, and value of any item found fit for use (column 9, R. and E. Journal). Must agree with analysis (6) on reverse of Form E. Line 12.—Enter value of equipment transferred (TVI) to supply officer for sale, as per approved survey or by other competent authority (column 10, R. and E. Journal). Must agree with analysis (7) on reverse of Form E. A signed, re- ceipted copy of each TVI will be forwarded with Form E. Line IS.—Enter value of equipment transferred (TVI) to supplies and to other Medical Department activities, including appraised value of surveyed equipment to medical supply depots (column 11, R. and E. Journal). Must agree with analysis (7) on reverse of Form E. Transfer of equipment must be authorized by survey or other competent authority. (See Navy Regulations.) A signed, re- ceipted copy of each TVI will be forwarded with Form E. Line 14.—Enter total of lines 12 and 13. Line 15.—Enter total of lines 11 and 14. Line 16.—Enter balance, line 10 minus line 15. This amount must equal the total value of equipment carried in the equipment ledger, as at the last day of the quarter. (2) Supplies (expendable).— Line 17.—Enter sum reported on line 45 of last report. Newly commissioned activities will indicate none. Line 18.—Enter value of all supplies, including mortuary supplies, received on S. D. requisitions during quarter (column 2, R. and E. Journal). Must agree with sum reported (including mortuary supplies), on Form B, and with analysis (1) on reverse of Form E. Line 19.—Enter value of all supplies received on stub requisitions, including material procured under Naval Supply Account (NSA) requisitions, as evidenced by summary of NSA stub requisition S. & A. Form 178, expenditure invoices S. & A. Form 71 (when an appropriational charge), transportation requests or other invoice from the supply officer or marine quartermaster. Include cost of work performed under job orders, except such portion as represents the value of APA material used in connection with job order (column 3, R. and E. Journal). Must agree with analysis (2) on reverse of Form E. Line 20.—Enter value of all supplies paid for on public vouchers drawn against M. & S. requisitions (column 4, R. and E. Journal). Do not include supplies purchased under NSA requisitions. Must agree with analysis (3) on reverse of Form E. Line 21.—Enter total amount of salaries and wages, including retirement fund deductions, of civil employees which has been earned (accrued) during the period, even though not actually received by employees (column 5, R. and E. Journal). Must agree with second column of analysis (8) on reverse of Form E. Will not necessarily agree with expenditures reported on Form B, particularly where pay rolls are prepared weekly. Line 22.—Enter total of lines 19, 20, and 21. This sum will not necessarily agree with expenditures reported on Form B, due to inclusion of salaries and wages on an accrued rather than an expenditure basis. Line 23.—Enter value of supplies or services received from equipment or from other Medical Department activities by transfer vouchers received (TVR) during quarter (column 6, R. and E. Journal). Must agree with analysis (4) on reverse of Form E. 2 FORM E Line 24-—Enter value of APA material received from supply officer, including APA material value charged to job orders, at no appropriational charge (column 7, R. and E. Journal). Must agree with analysis (5) on reverse. Include only sup- plies otherwise properly chargeable to the Medical Department, and do not include supplies furnished by other departments or bureaus. Consultation with the sup- ply officer is often advisable to determine proper accounting procedure. Line 25.—Enter total of lines 23 and 24. Line 26.—Enter total of lines 18, 22, and 25. Line 27.—Enter total of lines 17 and 26. (8) Expenditures during quarter.— Line 28.—Enter total value of all supply table and supplementary supply table supplies, except dental (ST classes 23, 25, 25A, and 27) and mortuary (ST class 20) supplies issued from the storeroom during the quarter (column 10, R. and E. Journal). From priced Form R covering this class of supplies. Line 29.—Enter total value of supply table dental supplies (classes 23, 25, 25A, and 27) issued from storeroom during quarter (column 11, R. and E. Journal). From priced Form R covering this class of supplies. Line 80.—Enter value of items of special diet expended during the quarter, exclusive of supply table items, which should be included on line 28 (column 12, R. and E. Journal). Line 81.—Enter value of laundry supplies or services expended during the quarter. Include cost of laundry supplies issued to ship or station laundry, laundry services performed by civilian concerns, and invoiced value of services performed by hospitals for stations (column 13, R. and E. Journal). Line 82.—Enter value of all motor vehicle supplies and services, including repairs, gasoline, oil, tires and tubes, automobile cleaning supplies, etc., expended during the quarter. Only supplies and services required for maintenance and operation of Medical Department motor vehicles and properly chargeable to Medical Department allotments, will be included, except certain motor vehicles furnished by other bureaus, and then only when authorized by the Bureau (column 14, R. and E. Journal). Line 38.—Enter value of all nonsupply table dental supplies and services expended during the quarter. Include repair of dental equipment, artificial teeth, and other dental supplies and services consumed by the dental office, except supply table items (column 15, R. and E. Journal). Line 84■—Enter value of Medical Department supplies and services, other than those classified on lines 28 to 42, inclusive, expended during the quarter (column 16, R. and E. Journal). Do not include value of supplies and services not chargeable to Medical Department allotments, such as cleaning gear, electric lamps, etc., furnished by other ship or station activities. Line 85.—Enter value of salaries, including retirement fund deductions of group IV-b civil employees on the Medical Department pay roll, which have been earned (accrued) during the quarter, even though not actually paid to employees (column 17, R. and E Journal). Line 36.—Enter value of wages, including retirement fund deductions of all civil employees other than group IV-b, on Medical Department pay roll, which have been earned (accrued) during the quarter, even though not actually paid to employees (column 18, R. and E. Journal). Line 87.—Enter total of lines 35 and 36. Line 88.—Enter value of supply table mortuary supplies (class 20), and all other supplies and services properly chargeable to the appropriation care of the dead, expended during the quarter. Must equal amount reported as expended 3 CIRCULAR LETTER F by Form B, plus value of issue (Form R) of supply table class 20 items (column 19, R. and E. Journal). Line 39.—Enter total of lines 30, 31, 32, 33, 34, 37, and 38. Line 40.—Enter total value of supplies expended by approved survey (column 20, R. and E. Journal). Must agree with analysis (6) on reverse of Form E. Line 41 •—Enter total invoice value of supplies transferred to the supply officer. Such transfers must be approved by the Bureau or other competent authority (column 21, R, and E. Journal). A signed, receipted copy of each TVI will be forwarded with Form E. Line 4ft-—Enter total invoice value of medical supplies or services transferred to other Medical Department activities. Such transfers must be approved by the Bureau or other competent authority (column 22, R. and E. Journal). A signed, receipted copy of each TVI will be forwarded with Form E. Line 48.—Enter total of lines 41 and 42. Line 44•—Enter total of lines 28, 29, 39, 40, and 43. Line Jfi.—Enter balance, line 27 minus line 44. This amount must exactly equal the total value of supplies carried in the supplies ledger as at the last day of the quarter. (4) Operating expense.— Line 46.—Enter total of lines 15 and 44. Line 47.—Enter total of lines 14, 38, and 43. Line 48.—Enter remainder, line 46 minus line 47. (5) Complement (including all units).— Line 49.—Enter average number of active duty service personnel, officers, and enlisted men, Navy and Marine Corps, at all units served by the Medical Depart- ment of the reporting activity. This information should be obtained from the personnel officer, and is determined by dividing the total muster days by the number of days in the quarter. Line 50.—Enter daily average number of civil employees of the Navy. Do not include any other civilians. Other civilians should be noted under remarks on reverse of Form E. Line 51.—Enter total of lines 49 and 50. (6) Medical services rendered civilians.— Line 52.—Enter under respective headings, the number of individual civil em- ployees of the United States (Navy or other department) for whom medical services were rendered, numbering each separate injury or condition as one. Thus, medical services may be rendered one individual for two different injuries, in which case two would be included under the heading Number of individuals. Include only injuries or occupational diseases incurred in connection with work, and for which employee is entitled to treatment under the provision of the United States Employees Compensation Act. Include under the heading Number of treatments the total number of treatments for all injures or occupational diseases as defined above. Line 53.—Enter under respective headings, as for civil employees (except that restriction as to type of injury, etc., does not apply) required data as to dependents of naval personnel. Line 54.—Enter under respective headings, as for civil employees (except that restrictions as to type of injury, etc., does not apply) required data as to all medical services rendered civilians, other than dependents and civil employees, 4 FORM E as a humanitarian act. Include such services rendered employees for conditions not included on line 52. Line 55.—Enter total of lines 52, 53, and 54. (d) Reverse of Form E.— (1) Analysis of supply depot requisitions received during quarter.—Tabulate data indicated on Form E, dividing each requisition as to equipment and supplies. Include any mortuary equipment or supplies under appropriate heading. Enter totals as indicated, which must agree with amount reported on lines 2 and 18, face of Form E, and reverse of Form B. (2) Analysis of stub requisitions and expenditures invoices (priced) received during quarter.—Tabulate by each month of the quarter, value of NS A material re- ceived from supply officer on stub requisitions or other invoice, indicating re- spective values of equipment, supplies, and total for each month. Enter totals of respective columns, as indicated, which must agree with amount reported on lines 3 and 19, face of Form E and be included in expenditures reported on Form B which should further agree by months with amounts reported by supply officer on S. & A. Forms 126 and 280. (3) Summary of public vouchers drawn against M. & S. requisitions.—Tabulate value of equipment and supplies and total purchased under each annual requi- sition separately. Include similar data for all other M. & S. purchase requisitions on the line other than annual requisition. Enter totals, which must agree with amounts reported on lines 4 and 20, face of Form E, and be included in ex- penditures reported on Form B. Public vouchers prepared and forwarded to a disbursing officer (or the Bureau of Supplies and Accounts, when required) for payment, will be considered as paid for the purpose of this report. Only public vouchers dated within the quarter will be reported. List the following informa- tion on separate sheet if space is not sufficient for each requisition: Req. No. PV No. Equipment Supplies Total (4) Analysis of transfer vouchers received from other Medical Department activities during quarter.—Transfer vouchers received shall be assigned numbers by receiving activities, serially by fiscal years, in the order received, and should indicate the fiscal year thus: “TVR-1-39,” “TVR-2-39,” “TVR-3-39,” etc. List all transfer vouchers received during the quarter, including required data as indicated. Enter totals, which must agree with amounts reported on lines 6 and 23, face of Form E, but is not included as a charge to any allotment. (5) Analysis of APA material received from supply officer during quarter.— Tabulate by each month of the quarter, value of APA material received from supply officer on stub requisition or other invoice, indicating respective values of equipment, supplies, and total for each month. Enter totals of respective columns, as indicated, which must agree with amounts reported on lines 7 and 24, face of Form E but are not included as a charge to any allotment. Each activity reporting the receipt of APA material in this analysis, and on line 7 or 24, for which no allotment charge should be made, shall list each item received and its money value under the heading remarks or on an additional sheet securely attached to NMS—Form E. (6) Analysis of approved surveys during quarter.—List each approved survey, indicating required data. Do not include value of items canceled from survey or recommended to be retained as fit for use. Value expended by survey plus VALUE TO S. O. FOR SALE plus VALUE (APPRAISED) TO MEDICAL SUPPLY DEPOT equals total value of survey. Indicate surveys containing items of supplies by an asterisk. Enter column totals as indicated. 5 CIRCULAR LETTER F (7) Analysis of transfer vouchers issued during quarter.—Transfer vouchers issued should be assigned numbers by issuing activity, serially by fiscal years, in the order of issue, and should indicate the fiscal year. Thus: “TVI-1-39,” “TVI-2-39,” “TVI-3-39,” etc. List each TVI indicating required data. Enter column totals, which must agree with amount reported on lines 12, IS, 1+1, and 1+2 on face of Form E. Transfer vouchers issued are not a credit to any allotment. Transfer of supplies must be authorized by the Bureau or other competent authority. TVI’s shall not be charged off until a receipted invoice is received (art. 1390 N. R.). (8) Analysis of pay rolls.—Tabulate data required by months. Enter totals of second and third columns only. Total of the column headed Accrued current month must equal amount earned and reported on lines 21 and 37, respectively, face of Form E. The total of the column headed paid during month must equal the sum reported on Form B covering salaries and wages. The sum in- dicated as accrued and unpaid from previous month, opposite the first month of the quarter will be the amount of unliquidated obligations reported on Form B except for first quarter each fiscal year, and the sum indicated as accrued and unpaid at end of month opposite the last month of the quarter must equal the amount reported on Form B as an outstanding obligation. (e) General instructions.—Care and accuracy are necessary in the prepar- ation of Form E, and other financial reports and records. After preparation, the report should be carefully checked before submission. The forego- ing instructions include several methods of comparing the several items to guard against errors, but none of the methods stated will reveal items completely omitted from all reports. This may be avoided by other internal checks, includ- ing consultation with supply, disbursing, and accounting officers, when indicated, as to charges and credits made and reported by them. The submission of a supplementary NMS.—Form E is never required. Liqui- dations of outstanding obligations (on board ships and at stations) are considered to be current receipts and are properly taken up in the journal of receipts and expenditures as at the date of liquidation and are reported on NMS.—Form E for the quarter in which the obligations were actually liquidated. 6 Appendix D Manual of the Medical Department Bureau Circular Letter F Subject: Remains, Report of Disposition, and Instructions. Form of Report 1. U. S. Naval Date 2. Name of deceased (Surname first, Christian names in full) Rank or rating Service number 3. Station to which attached on date of death 4. Place of death Date of death 5. Disposition— (а) To local interment: Lot No. Cemetery (б) To home addressed to (Name, relationship, and address of person to whom remains were sent) (c) To national cemetery for interment: Name of cemetery (d) To other naval activity which is furnished copy of this report: Name of activity (e) Via (Transportation facility used in transporting remains) (f) Remains not recovered (State latitude and longitude, or other description) 6. Remarks EXPENSES INCURRED AGAINST BUREAU OF MEDICINE AND SURGERY FUNDS 7. Appropriation (care of the dead) charges incurred at this activity: (o) Burial expense (subhead 2250) $ P. V. Nos. Burial expense (subhead 2250) $ C&SS Exp. Inv. No. (b) Transportation of remains (subhead 2251). $ B/L No. Transportation of remains (subhead 2251). $ Trans. Request No. (One first-class ticket.) (c) Casket and mortuary supplies (subhead 2252) $ PV. No. 8. Above charges reported on Medical Department financial reports for the quarter. 9. Other charges (not allotment charges): Navy standard casket when furnished $ (Specify any other expense.) , (Signature) U. S. Navy. I CIRCULAR LETTER F 1. Official name of activity submitting report and date report is rendered. 2. Full name of deceased, surname first, followed by full Christian names. Rank or rating and the service number, in case of enlisted Navy personnel. 3. Station to which attached on date of death. If enroute to new station, so indicate. If on leave, station to which deceased would have reported upon expirtation of leave. 4. Indicate city, county, and State if not naval reservation. If on naval reserva- tion, state name of station. If aboard ship, state ship and port. State the date death actually occurred. 5. The Bureau desires a chronological set of reports on each deceased person so that when all reports on any individual are assembled the record will be complete from date of death to date of burial. Any activity, including transports, receiving remains for any purpose shall submit the report even though no expenses are incurred. When transportation of any character is used, other than local, state the name of the transportation facility. When line 5 (b), 5 (c), or 5 (d) applies, the transportation facility must be stated on line 5 (e). When line 5 (a) applies, the name of the transportation facility is disregarded if local transportation is paid under local authority, except payments made on the Asiatic station. 6. State any data which is necessary to complete the report, including name, rank or rate, or relationship, of escort. 7. Appropriational charges incurred shall be stated in each case. Where no charges are incurred, state “none” on each line. Transportation of remains and transportation for escort, of deceased members of the Marine Corps, is chargeable to General expenses, Marine Corps; transportation of escorts of deceased Navy personnel is chargeable to Pat, subsistance, and trans- portation, and such expenses are not to be reported on this report. 8. Indicate the quarter in which the expenditure will be reported on the financial reports from the activity. 9. In case a Navy standard casket is used, indicate the book value and also indi- cate any other charges incurred, except transportation for escorts or de- ceased members of the Marine Corps. Instructions for Preparation of Report 2 Appendix D Manual of the Medical Department Bureau Circular Letter F Subject: Supernumerary Patients. (1678 and 3508.) Table of Contents Subject: Paragraph Persons Considered Supernumeraries 1 Charges for Hospitalization of Supernumeraries 2 Naval Reserves Except Fleet Reserves 3 Retired Officers, Nurses, and Enlisted Men 4 Naval Reserve Retired Officers 5 Enlisted Men, Fleet Reserves, Classes F3, F4, F5, and M. C. 2 6 Naval Pensioners 7 Ex-Naval Personnel, Discharged, Retained in Hospital 8 Ex-Naval Personnel, Honorably Discharged 9 Naval Reserve Officers Training Corps 10 United States Army, Active List 11 United States Army, Retired Officers, Nurses and Enlisted Men 12 Reserve Officers Training Corps (Army) 13 Civilian Military Training Corps (Army) 14 United States Coast Guard 15 United States Coast and Geodetic Survey - 16 Civilian Conservation Corps 17 Veterans’ Administration Patients 18 Employees' Compensation Commission 19 Federal Civil Employees, Disability Examinations 20 State Department 21 Officers and Enlisted Men, Foreign Navies 22 Civil Employees, Not E. C. C. Patients 23 Civilian Population 24 Dependents, Navy and Marine Corps Personnel 25 Emergency Officers Retired List 26 Quarterly Report of Hospitalization, Letter Form 27 1. Persons Considered Supernumeraries,—(a) All persons not on the active list of the Navy and Marine Corps are to be considered supernumeraries when admitted to a naval hospital for treatment. (b) Specifically, the following are to be classed as supernumeraries. The authority for and method of admission, together with the procedure for obtaining reimbursement of hospital costs, are indicated in the following table: 1 1 CIRCULAR LETTER F Class Authority for admission How authority is presented Method of reimbursement 1. Naval Reserves, except Naval Reserve Act of Patient in hospital. Ac- Report in column 6—ra- Fleet Reserves. 1938. tive duty period ex- pired. tion return. 2. Retired officers and Title 24, sec. 3, U. s. By application of the in- Ration notice (S. & A. nurses. Code. dividual and suitable Form 35-M). (See identification. par. 4 this letter.) 3. Naval Reserve retired do Ration notice (S. & A. Form 35-M). (See officers. par. 5 this letter.) 4. Enlisted men, Fleet Naval Reserve Act of do Report in column 6—ra- tion return. Reserves, classes F3, F4, F5, and M. C. 2. 1938. 5. Title 24, sec. 6, U. Code. s. By application of the in- dividual and presen- Letter report of admis- sion to Veterans’ Ad- tation of pension cer- tificate or other suita- ble identification. ministration, Washing- ton, D. C. (Report of discharze independent- ly.) None. 6. Ex-naval and Marine Art. 1190 (4), Navy Reg- Direction of command- Corps personnel, dis- charged, retained in hospital. ulations. ing officer. 7. Ex-naval personnel, Art. 1412, Navy Regu- Request of commanding None. honorably dis- charged. lations. officer, receiving ship. 8. Naval Reserve Officers Title 34, sec. 821, U. s. Request of commanding Bill prepared by Bureau. Training Corps. Code. officer. (Form Q.) (See par. 3508.) RETIRED, RESERVE, AND EX-NAVAL PERSONNEL PATIENTS OF OTHER FEDERAL SERVICES 9. United States Army Art. 1204, N. R Request of Army com- Bill prepared by Bureau. active list. manding officer, or in absence of command- ing officer, of the indi- vidual concerned. (See par. 3508.) 10. United States Army, Art. 1204, Navy Regula- By application of the in- Collection from individ- retired officers, tions. dividual and suitable ual. (See par. 12, this nurses, and enlisted identification. letter.) men. 11. Reserve Officers Train- Title 10, sec. 441, U. S. Request of commanding Bill prepared by Bureau. ing Corps (Army). Code. officer. (See par. 3508.) 12. Citizens Military Training Corps Title 10, sec. 442, U. S. Code. do Do. (Army). 13. United States Coast Executive order, June Request of Coast Guard Do. Guard. 21, 1937. commanding officer. 14. United States Coast and Geodetic Sur- vey. do Request of Coast Sur- vey commanding offi- cer. Do. 15. Civilian Conservation Act of Mar. 31, 1933 (48 Written request of camp Do. Corps. Stat., 22) title 16, sec. 585, U. S. Code. commander or medi- cal officer. 16. Veterans’ Administra- Act of Mar. 20, 1933 (48 Veterans’ Administra- Bill prepared by Bureau. tion patients. Stat., 8) title 38, sec. tion hospital admis- (See also par. 18, this 706, U. S. Code and supp. I, II, III. sion form. letter.) 17. Employees’ Compen- Title 5, ch. 15, U. S. Form C. A. 16, 17, or letter from official superior. Bill prepared by Bureau. sation Commission. Code. Acts Sept. 7, 1916 (39 Stat., 742) and Feb. 28, 1925 (43 Stat. 1080). Title 34, sec. 762, U. S. Code. (See par. 3508.) 18. Federal civil employ- M. & S. letter P3-5/LL Request of Civil Service Do. ees, disability exam- inations. (043), Aug. 1, 1935. Commission or au- thorized representa- tive. 19. State Department Executive order, June 21, 1937. Letter from M. & S Do. 2 SUPERNUMERARY PATIENTS 2-3 CIVILIAN, EMERGENCY, AND HUMANITARIAN CASES Class Authority for admission How authority is presented Method of reimbursement 20. Officers and enlisted men, foreign navies. 21. Civil employees, not E. C. C. patients. 22. Civilian population International courtesy.. Humanitarian Request of commanding officer or consular representative. Request of superior offi- cer; admission discre- tionary with com- manding officer of hospital. Patient brought to hos- pital; admission dis- cretionary with com- manding officer of hos- pital. Request of medical offi- cer in charge of case. None. Collection from individ- do ual; rate $3.75 per day. (See par. 23, this let- ter.) Collection from individ- 23. Dependents, Navy and Marine Corps personnel. 24. Emergency Officers Retired List. (See par. 26.) C. M. 0. 10—1935 (13)... ual; rate $3.75 per day. (See par. 24, this let- ter.) Collection from individ- ual; rate $3.75 per day. (See par. 25, this let- ter.) 2. Charges for Hospitalization of Supernumeraries.—Where specified in the above table and in subsequent paragraphs, the charges for hospitalization will be collected directly from the patient and deposited with the disbursing officer for credit to the naval hospital fund. (a) The commanding officer shall designate a depositary, who shall be an officer of the hospital staff. (b) Patients who are required to pay the expenses of their hospitalization shall deposit at the time of their admission, sufficient funds to cover hospitalization charges for such advance period as the commanding officer may determine as reasonable, and shall thereafter be required to maintain sufficient funds in the hands of the depository to cover hospitalization charges for such additional advance periods as the commanding officer shall determine as reasonable. (c) As often as the commanding officer may direct during a month, and on the last business day of each month, earned funds in the hands of the depositary shall be delivered to a disbursing officer for credit to the naval hospital fund, with the exception that of any funds earned on account of hospitalization of dependents of the Navy and Marine Corps personnel, 75 cents shall be deposited to the credit of the naval hospital fund and $3 shall be deposited to the credit of the ship’s service store fund. No advance deposits, as distinguished from earned funds shall be deposited to the credit of the naval hospital fund. (d) Supernumeraries from whom hospital charges are collected, as above, shall be reported on the ration return, as directed by paragraph 3472 of this manual. Sick days, except E. C. C. sick days, and subsistence days shall be computed in the same manner as for regular Navy patients. (e) No allowance shall be made for unconsumed meals. (f) If any patient from whom charges are to be collected locally is unable to pay for the hospitalization, or pays only in part, the report required by paragraph 3508 shall show what action was taken toward collection, and the opinion of the commanding officer regarding the ability of the patient to meet the obligation. 3. Naval Reserves Except Fleet Reserves.—(a) Members of the Naval Reserve, except classes F3, F4, F5, and Marine Corps Reserve, class 2, may be retained in naval hospitals, in those cases where the period of active duty expires while a patient is in the hospital for treatment of a disease. 3 4-7 CIRCULAR LETTER F (b) Members of the Naval Reserve, except classes F3, F4, F5, and Marine Corps Reserve, class 2, may be retained in naval hospitals, as Employees’ Com- pensation Commission patients, in those cases where the period of active duty expires while a patient in the hospital, for treatment of an injury or occupational disease incurred in line of duty. No charges for subsistence or treatment shall be collected by the hospital. Submit quarterly report, as Employees’ Compensation Commission patient, as required by paragraph 3508. (c) Members of the Naval Reserve of any class hospitalized for disease or injury, during the period of active duty, are to be handled as regular Navy and Marine Corps patients and not classed as supernumeraries, in which case no special reports are necessary. 4. Retired Officers, Nurses and Enlisted Men.—(a) Retired officers, nurses, and enlisted men not on active duty may be admitted to any naval hospital upon the application of the individual and presentation of suitable identification. Submission of Ration Notice (S. & A. Form 35M) is required in case of retired officers and nurses only. No charges for subsistence or treatment shall be col- lected by the hospital. No report of hospitalization is required. (6) The provisions of this article do not apply to retired officers on the Emer- gency Officers Retired List. 5. Naval Reserve Retired Officers.—Naval Reserve officers retired with pay under acts of July 1, 1918, June 4, 1920, or June 12, 1921, may be admitted to any naval hospital upon the application of the individual and presentation of suitable identification. Submission of Ration Notice (S. & A. Form 35M) is required in each case. No charges for subsistence or treatment shall be collected by the hospital. No report of hospitalization is required. 6. Enlisted Men, Fleet Reserves, Classes F3, F4, F5, and M. C. 2.—Members of the Fleet Reserve transferred thereto after 16 or more years’ naval service may be hospitalized in naval hospitals upon application of the individual and presentation of suitable identification. Submission of Ration Notice (S. & A. Form 35M) is not required. No charges for subsistence or treatment shall be collected by the hospital. No report of hospitalization is required. 7. Naval Pensioners.—(a) Section 4813, Revised Statutes, provides that when- ever any officer, seaman, or marine entitled to a pension is admitted to a naval hospital his pension, while he remains there, shall be deducted from his account and paid to the Secretary of the Navy for the benefit of the fund from which such hospital is maintained (naval hospital fund). (b) On the admission of a naval pensioner under the above law, immediate letter report will be made to the Director of Finance, Veterans’ Administration, Washington, D. C., direct, giving the pensioner’s name, pension number, home address, and date of admission, and requesting information as to the rate of pen- sion payable to the hospital. Discharge from hospital will be similarly reported. Section 4813 R. S. applies not only to pensioners under the general pension laws, but to those who have been awarded pension by the Secretary of the Navy pursuant to sections 4756 and 4757, Revised Statutes. (c) Pension checks, drawn to the order of the commanding officer, will be forwarded by the Veterans’ Administration to cover the period of hospitalization of each pensioner. Such checks usually are mailed following the completion of each calendar month. If not received within a reasonable time, direct request for same will be made on the Veterans’ Administration. When received, and before being endorsed to the disbursing officer for deposit to the credit of the naval hospital fund, the hospital will determine if the rate of pension and period covered 4 SUPERNUMERARY PATIENTS 8-15 by the check are correct. If not, the check will be returned to the Director of Finance, Veterans’ Administration, for adjustment. 8. Ex-naval Personnel, Discharged, Retained in Hospital.—Regular Navy and Marine Corps enlisted men retained in naval hospitals after expiration of enlist- ment are entitled to hospitalization therein at Government expense. No charges for subsistence or treatment shall be collected by the hospital. Detailed report of hospitalization is not required. 9. Ex-naval Personnel, Honorably Discharged.—Ex-naval personnel who have been honorably discharged from the naval service and elect homes on receiving ships for a period of not more than 3 months may be admitted to any naval hospital upon the request of the commanding officer of the receiving ship any time during the 3 months’ period. No charges for subsistence or treatment shall be collected by the hospital. Detailed report of hospitalization is not required. 10. Naval Reserve Officers’ Training Corps.—Members of the N. R. O. T. C. requiring treatment w'hile on active duty or requiring treatment for disease or injury incurred while on active duty, may be admitted to any naval hospital upon the request of the officer’s commanding officer. No charges for subsistence or treatment shall be collected by the hospital. Submit quarterly report as required by paragraph 3508. 11. United States Army Active List.—Officers, nurses, and enlisted men on the active list of the Army may be admitted to any naval hospital upon the written request of the individual’s commanding officer or in the case of detached personnel, on their own request. No charges for subsistence or treatment shall be collected by the hospital. Submit quarterly report as required by paragraph 3508. 12. United States Army, Retired Officers, Nurses, and Enlisted Men.—Retired officers, nurses, and enlisted men of the United States Army may be hospitalized in naval hospitals upon the application of the individual and presentation of suitable identification. The hospital shall collect subsistence charges as follows: Retired officers, $1 per diem. Retired nurses and enlisted men at the rate of subsistence checkage applica- ble to Navy personnel as specified in the Annual Naval Appropriation Act. Submit quarterly report as required by paragraph 3508. 13. Reserve Officers’ Training Corps (Army).—Members of the Reserve Officers’ Training Corps may be admitted to any naval hospital upon the request of the individual’s commanding officer or other competent authority. No charges for subsistence or treatment shall be collected by the hospital. Submit quarterly report required by paragraph 3508. 14. Civilian Military Training Corps (Army).—Members of the Civilian Military Training Corps may be admitted to any naval hospital upon the request of the individual’s commanding officer or other competent authority. No charges for subsistence or treatment shall be collected by the hospital. Submit quarterly report required by paragraph 3508. 15. United States Coast Guard.—(a) Officers, enlisted men, and general court- martial prisoners of the Coast Guard may be admitted to any naval hospital upon the request of the individual’s commanding officer, or in the case of detached personnel, on their own request. No charges for subsistence or treatment shall be collected by the hospital. Submit quarterly report as required by paragraph 3508. 5 16-18 CIRCULAR LETTER F (b) Retired personnel of the Coast Guard are not entitled to hospitalization and may be admitted only in emergency and for humanitarian reasons. Col lections shall be made from the individual concerned at the rate of $3.75 per diem. Submit monthly report required by paragraph 3508. 16. United States Coast and Geodetic Survey.—Officers and men on the active list may be hospitalized upon the request of the individual’s commanding officer or the Coast and Geodetic Survey Department of the Commerce Department. No charges for subsistence or treatment shall be collected by the hospital. Sub- mit quarterly report required by paragraph 3508. 17. Civilian Conservation Corps.—(a) Personnel of the Civilian Conservation Corps or personnel on duty therewith are classified for Bureau purposes as follows: Class A—Regular Enrollees. Class B—Officers and enlisted men of any militarv service on duty with C. C. C. (b) Personnel of class A and B may be admitted to any naval hospital upon the written request of the camp commander or camp medical officer. No charges for subsistence or treatment shall be collected by the hospital. Submit monthly letter report required by paragraph 3507 and the quarterly report required by paragraph 3508. 18. Veterans’ Administration Patients.—(a) While Veterans’ Administration beneficiaries shall be officially classed as supernumeraries, they shall, in other than official reports and correspondence, be designated “veterans” and not “supernumeraries.” In reporting United States Veterans’ Administration pa- tients on statistical returns the abbreviation “VAP” shall be used. (b) Under the agreement between the Navy Department and the Veterans’ Administration for the hospitalization of ex-service men, the prior individual authorization of the Veterans’ Administration office having local jurisdiction is required in each case. The Veterans’ Administration will validate and reimburse the Navy Department only for those cases in which this procedure has been fol- lowed. In general, only medical and surgical cases requiring hospital treatment are to be admitted. In addition, neurological and certain psychoneuroses cases without frank mental symptoms and not requiring restraint, may be admitted for diagnosis. Cases of suspected tuberculosis also may be admitted for diagnosis. When diagnosed, cases of psychoneurosis and tuberculosis should be reported to the local Veterans’ Administration authorities, with request for prompt removal to an appropriate Veterans’ Administration facility. (c) Veterans under treatment shall be required to conform to the regulations governing the internal administration of the hospital. Restrictive or punitive measures applied to this class of patients shall conform as nearly as possib’e to the instructions issued by the Administrator of Veterans’ Affairs. (d) All matters pertaining to admission, medical or other records, and discharge of veterans and correspondence regarding them shall be directed between the commanding officer and the regional manager of the Veterans’ Administration. Correspondence involving questions of policy and administration,^if addressed to the Veterans’ Administration, should be forwarded via the Bureau. On ad- mission to the hospital, each patient of the Veterans’ Administration 6hall be assigned a case number from the Register of Patients, M. & S. Form 39. This number shall appear on all records of the patient during the period of hospitaliza- tion. (e) Assignment of Veterans’ Administration patients to working details should be in accordance with instructions from the Veterans’ Administration or its local 6 SUPERNUMERARY PATIENTS 19-25 representatives. It is assumed, however, that such patients will be available for such work as they may be able to do for the order and cleanliness of the part of the hospital they occupy. No charges for subsistence or treatment shall be col- lected by the hospital. The data necessary for reimbursement is obtained from NMS-Form 36 and the report set forth in paragraph 3508 need not be submitted. 19. Employees’ Compensation Commission.—See Circular Letter C—Injured Civil Employees for regulations and instructions relative to treatment of civil employees. 20. Federal Civil Employees—Disability Examinations.—Federal civil employ- ees may be admitted to any naval hospital upon the request of Civil Service Commission or authorized representative thereof, for the purpose of completing a physical disability examination. Expenses of such hospitalization will be borne by the Civil Service Commission only when proper authorization for hospitalization is obtained. No charges for subsistence or treatment shall be collected by the hospital. Submit quarterly report required by paragraph 3508. 21. State Department.—Foreign Service officers may be admitted to any naval hospital only upon specific authorization from the Bureau. No charges for subsistence or treatment shall be collected by the hospital. Submit individual report covering each case as required by paragraph 3508. 22. Officers and Enlisted Men, Foreign Navies.—Members of foreign navies requiring hospitalization and treatment may be admitted to any naval hospital upon the request of the individual’s commanding officer. No charges for sub- sistence or treatment shall be collected by the hospital. Submit quarterly report required by paragraph 3508. 23. Civil employees, not E. C. C. patients.—Civil employees of the naval establishment may be admitted for humanitarian reasons to any naval hospital upon the request of the employee’s official superior and within the discretion of the commanding officer of the hospital. The hospital shall collect from the individual the expense of hospitalization at the rate of $3.75 per diem. Submit quarterly report required by paragraph 3508. 24. Civilian population.—Members of the civil population may be admitted for humanitarian reasons, to any naval hospital, within the discretion of the commanding officer of the hospital. The hospital shall collect from the individual the expense of hospitalization at the rate of $3.75 per diem. Submit quarterly report required by paragraph 3508. 25. Dependents, Navy and Marine Corps Personnel.—(a) Dependents of Navy and Marine Corps personnel may be admitted to any naval hospital, suitable accommodations being available, in the following order of preference: (1) Dependents of naval personnel on active list. (2) Dependents of retired personnel on active list. (3) Dependents of reserve personnel (including transferred and retired) performing active duty other than training duty. (4) Dependents of retired naval personnel not on active duty. (5) Dependents of enlisted personnel transferred to the Fleet Reserve after 16 or 20 years naval service not on active duty. (See C. M. O. 3-1938(7).) (b) The privilege of hospitalization is not extended to the dependents of Naval Reserve or Marine Corps Reserve (other than transferred members of the Fleet Reserve or Fleet Marine Corps Reserve) who are called to active duty for short periods of training duty. 7 25 CIRCULAR LETTER F (c) The term “dependent” shall include a lawful wife and unmarried dependent children, and the mother of the officer, nurse, or enlisted man, provided she is in fact dependent upon him (or her) for her chief support. (d) With the approval of the Secretary of the Navy, the Surgeon General designates the naval hospitals to which dependents may be admitted, or withdraw such designations. (e) The commanding officer of the hospital concerned shall determine the availability of suitable accommodations and the need for hospitalization. Avail- ability shall be understood to mean suitable accommodations and facilities in excess of present or prospective current needs for naval personnel and other patients whose hospitalization is authorized by law. (f) Dependents shall be admitted only for acute medical and surgical condi- tions. Chronic cases, mental cases, or those requiring domiciliary care only shall not be admitted. (g) No dental treatment except to alleviate suffering shall be administered. (h) All expenses incurred in connection with the admission and treatment of dependents, including the employment of nurses, maids and culinary employees, shall be paid from ships’ service store funds, as follows: For each dependent admitted and for each day in hospital, the officer, nurse, or enlisted man concerned shall pay to the commanding officer of the hospital the sum of $3.75. Of this amount, 75 cents per diem for subsistence shall be deposited with the disbursing officer for credit to the naval hospital fund. The remaining amount of $3 per diem shall be deposited to the credit of the ship’s, service store, accounted for separately from all other monies, and expended by direction of the commanding officer to defray those costs of hospitalization not provided by law. (i) The hospitalization costs of dependents which may be borne by naval funds and the 75 cents per day per patient paid into the naval hospital fund include: Subsistence. Medicines, dressing, x-ray films or other regularly stocked supply table or SUPPLEMENTARY SUPPLY TABLE items. Standard surgical instruments and equipment. Beds, bedding, linen, ward furniture, mess gear, etc. Laundering of hospital linen. Professional care by naval medical officers, members of the Nurse Corps and members of the Hospital Corps to the extent possible within the hospital complement. Prosthetic orthopedic and other appliances will not be furnished. (j) The hospitalization costs of dependents to be borne from sums deposited with the ship’s service officer include: Additional employees required for care of dependents, such as civilian nurses, maids and culinary employees, and the cost of their subsistence and laundry services. The services of civilian specialists. Medicines, drugs, etc., not carried on the supply table, or supple- mentary supply table of the medical department, or regularly stocked by the naval hospital. Blood transfusions. (k) Payment for subsistence furnished by the hospital to persons employed to care for dependents shall be made at the rate of the average cost of the ration 8 SUPERNUMERARY PATIENTS 26-27 for the most recently completed quarter, for each day subsisted; an amount covering payment for subsistence furnished during each month shall be deposited with the disbursing officer for credit to the naval hospital fund on the last working day of each month. (l) Under the authority of article 1185, N. R., the policy to be observed in the expenditure of medical material as an incident to the hospitalization of de- pendents is as follows: (1) Only items on the supply table or supplementary supply table of the medical department shall be issued or dispensed. No pur- chases of other drugs or supplies (except as authorized in subparagraph (j) above) shall be made for such issue except by authority of the Bureau. (2) Issues shall be made only on the prescription of a naval medical officer or dental officer for use or administration under his supervision. (3) No medical stores shall be issued on the prescription of civilian practitioners or for self administration. (m) Submit quarterly report required by paragraph.,3508. 26. Emergency Officers Retired List.—By the act of May 24, 1928, emergency officers transferred to the retired list under the act are held by the Comptroller General “to be entitled to all hospitalization privileges and medical treatment as are now or may hereafter be authorized by the United States Veterans’ Adminis- tration.” The Secretary of the Navy has decided, therefore, that the Medical Department of the Navy is obligated to furnish treatment to those coming within the purview of that act only upon the request and at the charge of the Veterans’ Administration. Except in emergency cases, therefore, when delay would cause great suffering or endanger life, these officers are to be treated only at the specific request of the Veterans’ Administration. This same principle applies also to dispensary service. 27. Quarterly Report of Hospitalization, letter Form.—(a) In compliance with paragraph 3508 of the Manual of the Medical Department the following letter form will be used in reporting hospitalization of certain supernumerary patients. United States Naval Hospital (Place) (Date) From: The Commanding Officer. To: The Chief of the Bureau of Medicine and Surgery. Subject: Hospitalization, certain supernumerary patients, quarterly summary re- port of. Reference: (a) Paragraph 3508, Manual of the Medical Department. Inclosure: (A) (Number) detailed reports of hospitalization, in quadruplicate. 1. The following tabulation indicates the data required by reference (a): 9 27 CIRCULAR LETTER F Class of patient Total sick days dur- ing quarter Detailed report in- closed (yes or no) United States Coast Guard (detailed report monthly) United States Coast and Geodetic Survey Civilian Conservation Corps enrollees United States Employees’ Compensation Commission Federal civil employees (disability exams.) Naval Reserve "Officers’ Training Corps - _ Reserve Officers’ Training Corps " Civil employees, not E. C.C. patients _ American citizen employees, 16th N. D. (Cahacao only) Total- (Signature) (b) The summary report shall be accompanied by detail reports, in quad- ruplicate, for each class of patients listed on the summary report, which were hospitalized during the quarter. (c) The detail reports shall be prepared on 8- by 13-inch paper, and, when reimbursement is to be obtained by the Bureau, contain the following information in columnar form: Name; rank or rate; organization; diagnosis; date admitted; date discharged; sick days during the quarter. "When reimbursement is obtained locally by cash collections the report shall contain the following information in columnar form: Name; rank or grade; diagnosis; date admitted; date discharged; sick days during quarter; charge per day; amount of charge during quarter; amount deposited with disbursing officer. The latter report shall contain a statement that the sum, indicated as deposited with the disbursing officer, has been delivered to the disbursing officer, United States Naval , for credit to the naval hospital fund, and his receipt obtained prior to the close of business on the last day of the quarter. (d) The detail report required by the above shall be modified in the case of Civilian Conservation Corps patients so as to indicate in columnar form the following: Name; serial number or rank; organization; company number; camp number or designation; diagnosis; date admitted; date discharged; sick days during quarter. Separate reports shall be submitted covering “Enrollees, C. C. C.” and “Officers and enlisted men on duty with the C. C. C.” Each report shall be prepared and forwarded to the Bureau in quintuplicate. The name, rank, and title, of the officer signing the report, shall be typed or stamped on the original and all copies. The original signed request for treatment for each patient to be attached to the report on which appears the patient's name for the first time. (e) In the case of Army personnel hospitalized, the original signed request for treatment for each patient shall be submitted with the first quarterly report which contains the name of the patient. 10 Appendix D, Manual of the Medical Department Bureau Circular Letter F-6 Subject: Quarterly Ration Return, Form 36. (3472.) (a) This return shall be forwarded to the Bureau from all hospitals and hos- pital ships. The columns are numbered 1, 2, 3, 4, 5, 6, and 7. The data to be entered in each column are as follows: (1) Column 1.—Enter total muster days for each class of patients and staff personnel admitted or attached to the hospital. Muster days for all personnel shall be computed by the formula for computing sick days for naval personnel; i. e., exclude the day of admission or reporting and include the day of discharge, transfer, or detachment. (See art. 1827 (2), N. R.). Fractional days shall not be included in this column. The data required for column 1 is taken from NMSH—Form 36a, fourth column, total number attached under total for quarter to date, for the last day of the quarter. Totals of columns 2 and 3 must equal total of column 1. (2) Column 2.—Enter number of patient days or staff days not subsisted. Fractional days, expressed in thirds, may be necessary under staff personnel to adjust for meals furnished (sold) staff personnel not otherwise entitled thereto; i. e., duty officers, enlisted personnel drawing commuted rations, nurses’ guests, Red Cross representatives, civil employees (special depositors), civilian nurses, etc. (3) Column 3.—Enter number of days subsisted. Column 1 minus column 2. Fractional days may be necessary under staff personnel to adjust, as stated under column 2 above. (4) Column 4-—Enter rates of reimbursement for each class of patients, as in- dicated under instructions for each line. The abbreviations used to designate the rates of reimbursement in these instructions are defined as follows: ACR—Average cost of ration for the quarter reported. NAA—Commuted value of ration stopped on account of sick in hos- pital as established in the Naval Appropriation Act, under pay, SUBSISTENCE, AND TRANSPORTATION. When extension of number of subsistence days (column 3) is made to columns 5, 6, and 7, at more than one rate of reimbursement, an analysis of the line will be made on the reverse of Form 36. Such analysis shall indicate data for all columns and rate, i. e., line 47 as shown on face of report: (1) (2) (3) (4) (5) (6) (7) 4,000 100% 3, 899% 0. 70 94. 25 2,520. 70 94. 49 Indicate line number and analysis on reverse of report as illustrated in the follow- ing example of analysis of line 47: LINE 47 January 1, 1941. Analysis (l) 3,701 126 173 (2) 100 Vi (3) 3,601 125% 173 (4) 0.70 .75 AC R.5462 (5) (6) 2, 520. 70 (7) 94.25 94. 49 Total 4,000 ioo 3,899% 94. 25 2, 520. 70 94.49 1 CIRCULAR LETTER F-6 (5) Column 5.—Enter amount checked against individual pay accounts by ration notice or letter checkage and amount of checkage against advance deposit (the sums of column 3, times respective rates indicated in column 4). (6) Column 6.—Enter value of rations for which reimbursement is to be ob- tained by the Bureau (the sums of column 3, times respective rates indicated in column 4). (7) Column 7.—Enter value of rations for which no reimbursement is obtain- able (the sums of column 3, times respective rates indicated in column 4). (b) The lines are numbered 1 to 53, inclusive. The data to be entered in each line are as follows: PATIENTS, NAVAL, ACTIVE DUTY Column 4 rate Money value ex- tended to column— NAA NAA NAA NAA NAA NAA NAA NAA 5 5 5 5 6 6 6 0 Report all Navy officer patients, including retired and Naval Reserve officers, who are on active duty. Officers of the Naval Reserve, admitted for an injury falling within Employees’ Compensation Commission definition of like of duty incurred while on active duty, shall be reported on this line during period of active duty, after which transfer to line 26. Naval Reserve officers retained in the hos- pital after period of active duty has expired, for treatment of disease incurred while on active duty, shall be transferred to line 20 on the day following the day the period of active duty expires. Report all Marine Corps officer patients, including retired and Marine Corps Reserve officers who are on active duty. Employees’ Compensation Commission injury cases same as officer, Navy, above. Marine Corps Reserve officers re- tained in the hospital after period of active duty has expired, for treatment of disease incurred while on active duty, shall be transferred to line 21 on the day following the day the period of active duty expires. S. Lines.—Midshipmen, active. .......... _ 4. Line 4-—Cadet, aviation, Naval Reserve and Marine Corps Reserve . . Naval Reserve nurses retained in hospital for treatment after period of active duty has expired shall be handled and reported in accordance with the instruc- tions governing other Naval Reserve personnel. Report all Navy enlisted patients, including retired and Naval Reserve per- sonnel on active duty. Members of the Naval Reserve, admitted for an injury, falling within the Employees’ Compensation Commission definition of line of duty, incurred while on active, duty, shall be reported on this line during period of active duty, after which transfer to line 26. Members of the Naval Reserve admitted for an injury, not falling within the Employees’ Compensation Com- mission definition of line of duty or for any disease which was incurred while on active duty, shall be reported on this line during the period of active duty, after which transfer to line 20. 7. Line 7.—Enlisted Marine Corps, active . .......... Report all Marine Corps enlisted patients, including retired and Marine Corps Reserve personnel on active duty. Marine Corps Reserve injury cases shall be handled and reported as under line 6 above. Marine Corps Reserve disease cases shall be handled and reported as under line 6 above, except that after ex- piration of active duty period they shall be transferred to line 21. 8. Line 8.—General courts-martial prisoners serving sentence. __ Report only general courts-martial prisoners admitted from naval prisons or other places specifically designated for confinement of general courts-martial prisoners. Do not include prisoners awaiting trial by general courts-martial, or awaiting sentence; these cases shall be included on lines 1 to 7 as indicated. 9. Line 9 —Reserved 10. Line 10.—Reserved. .. .. . ... . 11. Line //.—Subtotals, patients, naval, active duty Enter totals of lines 1 to 10, inclusive, in columns 1, 2, 3, 4, 5, 6, and 7. 2 QUARTERLY RATION RETURN PATIENTS, NAVAL, INACTIVE (See Bureau Circular Letter F-5) Column 4 rate Money value ex- tended to column— 1. Line It.—Officer, Navy, retired, inactive (see line 15) NAA 5 t. Line IS.—Officer, Marine Corps, retired, inactive (see line 16) NAA 5 S. Line 14-—Nurse, retired, inactive ... NAA 5 4. Line 15.—Enlisted, Navy, retired and Fleet Reserve, classes F-3-4-5, inactive NAA 6 Analyze columns 1, 2, 3,4, and 6 on reverse of the form to indicate Fleet Reserv- ists and retired personnel separately. Include enlisted personnel retired with officer rank in accordance with act of May 7,1932. (See current Navy Register under heading “Retired Act of May 7, 1932.”) 6. Line 16.—Enlisted, Marine Corps retired and Marine Corps Reserve, class 2, inactive. (Instructions for line 15 apply) NAA 6 6. Line 17.—Ex-naval personnel, discharged, retained in hospital ACR 7 Report all midshipmen, enlisted Navy and Marine Corps patients discharged from the service while a patient in hospital, and retained after discharge. In- clude also honorably discharged enlisted men admitted to hospital while electing homes on receiving ships (art. 1412 N. R.). 7. Line 18.—Beneficiary, Naval Home ACR 7 8. Line 19.—Pensioner... ..... .... .... ... ... 5 Report all Navy pensioners hospitalized during the quarter. Do not include pensioners hospitalized as Veterans’ Administration beneficiaries. Column 4 shall be left blank and the sum total of pension checks received and deposited to the credit of the naval hospital fund shall be entered in column 5. On admission, and on discharge, a letter report shall be made to the Veterans’ Administration, direct, giving pensioner’s name, pension number, etc. (See Bureau Circular Let- ter F-5.) List each pensioner’s name and total of all checks received during quar- ter in space provided at right on this form. 9. Line SO.—Navy Reservists retained after expiration of active duty period for disease (see lines 1, 5, and 6, and Bureau Circular Letter F-5) t NAA 6 10. Line if .—Marine Corps Reservists retained after expiration of active duty period for disease (see lines 2 and 7, and Bureau Circular Letter F-5)...-.. NAA 6 11. Line SS.—Subtotal, patients, naval, inactive. __ . Enter totals of lines 12 to 21, inclusive, in columns 1, 2, 3, 4, 5, 6, and 7. 1. Line 2S.— Army, Regular and Reserve, active - Include officers, nurses and enlisted personnel. Total number indicated in col- umn 1 must agree with total sick days reported on quarterly summary and de- tailed reports. (See Bureau Circular Letter F-5.) No charges shall be collected by hospital. NAA 6 2. Line 24.—Coast Guard, active Include both officers and enlisted personnel. Total number indicated in col- umn 1 must agree with total sick days reported on the 3 monthly reports for the quarter. (See Bureau Circular Xetter F-5.) Retired Coast Guard personnel are not entitled to hospitalization at Government expense except by special authority from Public Health Service headquarters. In case collection locally is directed, report such cases on line 31. Retired Coast Guard personnel shall not be considered as indigent. 5. Line 25—Veterans’ Administration beneficiaries Include only those patients whose admission and treatment have been properly authorized by a responsible Veterans’ Administration representative in writing. Telephone authorization must be confirmed in writing. NAA 6 NAA 6 4. Line 26.—Employees’ Compensation Commission beneficiaries Report civil employees of the United States admitted for treatment of injuries or occupational diseases incurred while in the performance of their official duties as defined in pt. 2, pp. 11 to 16 inclusive, Employees’ Compensation Com- mission Regulations. Also, include members of the Naval and Marine Corps Reserve, who are retained for treatment after expiration of active duty period, when original admission was for treatment of an injury incurred in line of duty. (See Court-Martial Order No. 11, 1935, pp. 9 and 10; and title 34, sec. 762, U. S. C. as to jurisdiction determining injuries and occupational diseases sustained while in the performance of official duties.) The number of sick days reported on the quarterly report of Employees’ Compensation Commission patients will not necessarily agree with the number of sick days indicated by column 1, due to different method of computing sick days reported on the quarterly report of Employees’ Compensation Commission patients. (See Bureau Circular Letter F-5.) 5. Line 27.—Civilian Conservation Corps Report both enrollees and officers and enlisted personnel of the naval and mili- tary services who are assigned to duty with the Civilian Conservation Corps. Written authorization for admission or written confirmation of telephone authori- zation is required. Total of column must agree with quarterly summary and detail reports. (See Bureau Circular Letter F-5.) NAA 6 NAA 6 PATIENTS, SUPERNUMERARY 3 CIRCULAR LETTER F-6 PATIENTS, SUPERNUMERARY—Continued (See Bureau Circular Letter F-5) Column 4 rate Money value ex- tended to column— $1.00 NAA NAA NAA ACR ACR NAA NAA NAA 5 5 5 7 7 6 6 6 (See art. 1204 N. R. and Bureau Circular Letter F-5.) Total of column 1 must agree with quarterly summary and detail reports. (See art. 1204 N. R. and Bureau Circular Letter F-5.) Total of column 1 must agree with quarterly summary and detail reports. Total of column 1 ‘must agree with quarterly summary and detail reports. (See Bureau Circular Letter F-5.) Report patients admitted under authority of Bureau Circular Letter F-5, from whom reimbursement for the cost of hospitalization is collected by the hospital at the uniform reciprocal rate of $3.75 per diem. Column 1 must agree with the quarterly summary and detail reports. (See Bureau Circular Letter F-5.) Report patients admitted under authority of Bureau Circular Letter F-5 from whom reimbursement for the cost of hospitalization cannot be collected. Column 1 must agree with the quarterly summary and detail reports. (See Bureau Circu- lar Letter F-5.) Report all patients admitted under authority of par. 22 of Bureau Circular Letter F-5. No collections, local or otherwise, shall be made for this class of supernumeraries. Report all Emergency Relief Workers hospitalized in accordance with the rules and regulations of the Employees’ Compensation Commission for traumatic injuries sustained in the performance of duty. (Refer to Bureau Circular Letters F-5 and F—11.) Analyze this line on reverse to indicate security workers and administrative workers separately. The total sick days indicated by column 1 will not necessarily agree with the total sick days reported in the detailed reports of hospitalization because of the difference in method of computing sick days for purposes of reimbursement. Column 1 must agree with the total sick days reported on the individual de- tailed reports submitted during the quarter. (See Bureau Circular Letter F-5.) Column 1 must agree with the total sick days reported in the quarterly summary and detailed reports. (See Bureau Circular Letter F-5.) 15. Line 37.—Miscellaneous (if only 1 class indicate, if more than 1 analyze on report'i.. Report all patients of other Government departments not otherwise specifically listed herein, admitted in accordance with existing or specific authority and for whom reimbursement for cost of hospitalization will be requested by the Bureau. Includes U. S. Coast and Geodetic Survey personnel; civil employees admitted for disability examinations when authorized by the Civil Service Commission; Reserve Officers’ Training Corps (Army); etc. Each class of patients must be reported in the summary and detail reports. (See Bureau Circular Letter F-5.) When patients of more than one class are included on this line, analysis shall be made on the reverse of this form showing data pertaining to columns 1, 2, 3, 4, and 6 for each class. 16. Line 38.—Subtotal, patients, supernumerary __ _ Enter total of lines 23 to 37, inclusive, columns 1, 2, 3, 4. 5, 6, and 7. Enter total of lines 11, 22, and 38 in columns 1, 2, 3, 5, 6, and 7. STAFF PERSONNEL $0.75 5 Report all officers attached, except officer patients. Officers guest meals will be counted as officer meals. When meals furnished Red Cross representatives arc checked against an officer’s account, such meals will be included on this line as officers’ guest meals. S. Lineal.—Nurse, Navy NAA 6 Report all nurses attached, except nurse patients. Include nurses performing duty at other activities but assigned quarters and messing facilities at hospital nurses’ quarters. At hospital where occasional meals are furnished nurses’ guests, the amount checked against their pay accounts at the rate of $0.75 per ration will be entered in column 5. An analysis indicating data included on line 41 for nurses’ guests shall be made on reverse of this form. (See par. (a) (4), this letter.) 4 QUARTERLY RATION RETURN STAFF PERSONNEL—Continued (See Bureau Circular Letter F-5) Column 4 rate Money value ex- tended to column— s. NAA 6 4- R Hospital corpsmen detailed to Hospital Corps school for duty under instruction shall not be included in line 42. At hospitals where meals are furnished hospital corpsmen drawing commuted rations, the amount checked against their pay accounts at the rate of $0.75 per ration shall be entered in column 5. An anlaysis indicating the data included on line 42 for rations sold shall be made on the reverse of this form. (See par. (a) (4), this letter.) NAA 6 Report all hospital corpsmen and other Navy enlisted personnel detailed to Hospital Corps school for duty. Instructions for reporting occasional meals under line 42 apply to line 43. NAA 6 Report all Navy hospital corpsmen and other Navy enlisted personnel under instruction at Hospital Corps schools. Report Coast Guard personnel under instruction on line 51. Instruction relative to reporting occasional meals under line 42 apply to line 44. NAA 6 7. Report all naval duty personnel, except those otherwise classified (lines 42, 43, and 44). Instructions relative to reporting occasional meals under line 42 apply to line 45. NAA 6 8. Line 47.—Civil employee, classified. This line shall be analyzed on the reverse of the form to indicate separately the data applicable to each of the three groups mentioned below. (See par. (a) (4) of this letter.) Rations sold special depositors of this group shall be reported in column 4 at $0.75 5 Rations furnished commissary employees and maids of this group shall be reported in column 4 at $0.70, and the total charge, not to exceed the amount of NAA 6 Rations furnished employees of the special duty service of this group shall be reported in column 4 at the average cost of ration and money value extended to column 7 .. __ _ __ ACR 9. Rations furnished commissary employees and maids of this group shall be reported in column 4 at $0.70, and the total charge, not to exceed the amount of NAA 6 Rations furnished employees of the special duty service of this group shall be reported in column 4 at the average cost of ration and money value extended to ACR 7 10. $0. 75 5 It. See par. 3109 of this manual for proper method of handling financial transactions for meals furnished Red Cross representatives. Rations furnished Red Cross representatives shall be reported on this line only when the value thereof has been checked against an advance deposit maintained by the individuals concerned. When cost of rations furnished is checked against the account of an officer they shall be included on line 40. $0.75 5 It. Include all employees of dependents ward who were furnished meals by the hospital and all special nurses employed by naval personnel to care for their dependents. 18. Coast Guard personnel under instruction at Hospital Corps schools shall be reported on line 51, the NAA rate will be used in column 4 and the amount extended to column 6. Hospitals authorized to furnish meals to Veterans’ Administration out-patients, report meals furnished, expressed in rations (3 meals equal to 1 ration) in columns 1, 2, and 3, indicate $0.75 rate in column 4 and extend to column 6. 14. Enter total of lines 40 to 51, inclusive, in columns 1, 2, 3, 4, 5, 6, and 7. Enter total of lines 39 and 52 in columns 1, 2, 3, 5, 6, and 7. (c) The data to be recorded at the right side of this form are adequately indi- cated on the form. Note.—This letter is a revision of and shall be substituted for the current circular letter on this subject in Appendix D of the manual. 5 Appendix D Manual of the Medical Department Bureau Circular Letter F Subject: Register No. 3. (3498.) (a) Register no. 3 shall be prepared quarterly and when decommissioned, and forwarded to the Bureau, accompanied by the quarterly ration return, report of allotment expenditures and other financial data, not later than the fifteenth day after the close of the quarter or date of decommissioning. Financial reports shall be forwarded by ordinary mail. This statement is prepared as of the last day of each quarter. Insert designation and location of hospital and date of the last day of the quarter or period covered by the statement. (b) Instructions for preparation of obverse of form.— (1) Statement of general ledger accounts.—Insert in the columns headed begin- ning of quarter, opposite the respective accounts, in summary, all debits and credits recorded in the general ledger during the fiscal year, prior to the beginning of the quarter covered by the statement. For the first quarter of each fiscal year, insert only the net balance appearing in the real accounts at the close of the preceding fiscal year. Total columns at bottom of statement. Insert in columns headed transactions during quarter, opposite the respec- tive accounts, in summary, all the debits and credits recorded in the general ledger during the quarter covered by the statement. Total columns at bottom of statement. Insert in the columns headed end of quarter, opposite the respective accounts, in summary, all the debits and credits recorded in the general ledger during the current fiscal year, which sums shall equal the total of the columns beginning OF QUARTER plus TRANSACTIONS DURING QUARTER. Total Columns at bottom of statement. The balances opposite each account shall agree with debits and credits in each of the respective general ledger accounts. (2) Under (2) Analysis of transfer vouchers issued, insert the debit and credit effect of each transfer voucher issued. Similar transactions covered by two or more transfer vouchers issued may be grouped. (3) Under (3) Analysis of transfer vouchers received, insert the debit and credit effect of each transfer voucher received. Similar transactions covered by two or more transfer vouchers received may be grouped. (4) Under (8) Patient data, insert the latest authorized bed capacity for the hospital. The bed capacity for each hospital as set by the Bureau may not be changed without Bureau authority. Insert number of patients beginning of quarter, which number shall be the same as the last quarter’s report under Remain- ing, end of quarter; add the number of patients actually admitted during the period and subtract the number of patients actually discharged; the resultant figure should be the number of patients remaining in the hospital at the end of the period. Insert the daily average of patients for the period, which figure is obtained by dividing the number of sick days for the period by the number of days in the period. Insert the percentage of bed, capacity which figure is obtained by dividing the daily average of patients by the authorized bed capacity. The percentage figure shall be computed to two decimal places. 1 CIRCULAR LETTER F (5) Under (9) Subsistence data, insert total number of subsistence days, total value of provisions expended and average daily cost of ration, as calculated on NMS Form 36. (c) Instructions for preparation of reverse of form.— (1) Under (4) Statement of expenses analysis register accounts, insert the total expenditures opposite each account and for each class of material or services expended during the period. Each account is analyzed and the expenditures to be recorded under each account are set forth in paragraph 3103 of this manual. Indicate total expenditures opposite each account. Insert the per diem rate opposite each account, calculated by dividing the expenditures applicable to each account by the number of sick days in the period covered by the statement. Insert the percentage of total expenditures applicable to each account which percentage is obtained by dividing the total expenditures opposite each account by total expenditures for all accounts. (2) Under (5) Analysis of property surveys, insert the debit and credit effect of each survey which has been approved by the Bureau during the period. (3) Under (6) Analysis of job order charges, insert the debit and credit effect of the charges incurred on account of job orders as stated on the S. & A. Form 280, for each month, covered by the period. (4) Under (7) Analysis of adjustment vouchers, insert the debit and credit effect of each voucher prepared to adjust accounts (pars. 3107, 3108, and 3109, this manual.) Subject: Civilian Conservation Corps. (3507.) (a) The Civilian Conservation Corps administration requires that separate vouchers be prepared for each classification, as follows: Classification sick days (A) Enrollee, C. C. C (B) Officers and enlisted men (of any service) on duty with c. c. c (b) Each naval hospital within the continental limits of the United States shal report monthly the number of C. C. C. sick days during the month. Sick days shall be computed as for Navy patients. This report shall be made by letter to the Bureau, on the first working day following the end of the month, and shall be made whether or not C. C. C. patients have been hospitalized. This report shall indicate the number of sick days for each classification. Appendix D, Manual of the Medical Department Bureau Circular Letter F May 26, 1941. (To become effective simultaneously with the new Supply Catalog) Subject: Medical stores requisitions and invoice. NMS-Form 4, preparation and submission of. (a) Requisitions for medical stores listed in the Supply Catalog, or such nonlisted material as may be authorized for procurement through a medical supply depot, shall be prepared on NMS-Form 4 and submitted to the Bureau of Medicine and Surgery, except as follows: (1) In an emergency, due to unanticipated ship movements, or when the urgency will not permit delay incident to transmission to the Bureau, requisitions may be submitted directly to the nearest medical supply depot designated as carrying the material required. The reason for the urgency shall be stated on the face of such requisitions and an extra copy immediately forwarded to the Bureau. (2) Ships and stations within the command of the commander in chief, Asiatic Fleet, may submit requisitions for medical stores designated as obtainable from the Naval Medical Supply Depot, Canacao, P. I., directly to that depot. Rou- tine quarterly replenishment requisitions of the naval hospitals, Canacao and Guam, shall be submitted to the Bureau. (3) When an emergency of sufficient urgency warrants, material may be requested by despatch to the nearest naval medical supply depot designated as carrying the material required. In such cases, a copy of the despatch shall be mailed to the Bureau. Material issued in response to despatch requests shall be invoiced by the issuing medical supply depot. No confirming Form 4 is required. (b) Separate requisitions (Form 4) shall be prepared for the following groups of items: (1) Items listed in part I, Supply Catalog. (2) Precious metals for dental use (pt. of class 11). (3) Field supplies and equipment (all of classes 13 and 14). (4) Items designated as not obtainable from the nearest medical supply depot from which stores will be issued, subject to prospective ship movements or other considerations. (Including either pt. I or pt. II items.) (5) Items listed in pt. Ill Supply Catalog, which are designated as “T” and “X” items (including books and blank forms, formerly requiring separate requi- sition) . (6) Items listed in pt. Ill Supply Catalog, which are designated as “N. S.-l,” “N. S.-2,” or “N. S.-3” (not stocked) items. (7) Biological products. (8) Nonlisted items, other than books. (9) Nonlisted books (for procurement during August or February only). 1 CIRCULAR LETTER F (c) The number of copies of NMS-Form 4 requisitions required to reach the Bureau and the issuing medical supply depot, is as follows: (1) Regular Navy and Marine Corps activities, 4. (2) Naval and Marine Corps Reserve activities, 6. (3) Other Government agencies, 6. An additional file copy, plus other copies as may be required by the naval district commandant or other authority, should be prepared and specifically designated. J (d) Requisitions shall be prepared in accordance with the following instructions The data required by subparagraphs (1) to (12) inclusive shall be entered on each sheet of the requisition when more than one sheet is required. (1) U. S. Enter the official name of the requisitioning activity as listed in the Naval Directory and the mail address. (2) Date. . Enter the date prepared. (3) Requisition No.: Requisitions shall be numbered consecutively in a separate series for each fiscal year, preceded by the letters “S. D-” and followed by the last two digits of the fiscal year. Thus: S D -1-40 S D -2-40 S. D.-3-40, etc. ' ’ ’ ’ (4) Allotment No.: Enter the S. D. allotment number as indicated by the allotment card issued by the Bureau. If no allotment has been received or in the case of recruiting and other small activities which are chargeable to an allotment maintained by the Bureau, leave blank. (5) Total allotment: Enter total amount of the S. D. allotment if known, otherwise, leave blank. (6) Previously obligated: Enter actual value of material received plus estimated cost of outstanding requisitions of the same fiscal year series. (7) Estimated cost this requisition: Enter estimated cost of material requested, based on approximate values indicated by the Supply Catalog. (8) Available balance: Enter amount of Total allotment less sums Previously obligated and Estimated cost, this requisition. If no allotment has been received, or in the case of recruiting and other small activities which are chargeable to an allotment maintained by the Bureau, leave blank. (9) Average complement: Enter average number of Naval and Marine Corps personnel attached or furnished medical services. Shore activities shall also enter in parenthesis the average number of civil employees. (10) Account No.: .... Enter the accounting number assigned the Shli), °u ®tatlon ln the “List of Accounting Numbers of Ships and Stations” published by the Bureau of Supplies and Accounts. This number may be obtained rom the supply officer. If unobtainable, leave blank; the issuing medical supply depot will supply the correct number for use on subsequent requisitions (11) Reserve for N. M. S. D. Brooklyn: Leave blank. Brooklyn06 f°r logistic data compiled by the Medical Supply Depot, • (12? ° Enter code number as indicated on requisitions issued by the Medical Supply Depot, Brooklyn. If unknown, leave blank. ... . ,. °* Leave blank. The issuing medical supply depot wi !ndlcate ln this space on the third and fourth copies of requisitions, the box number in w hich each item is packed. (14) Item No.: Each item of the entire requisition shall be num- bered consecutively, beginning with 1. FACE 2 NMS—FORM 4 (15) Stock No.: The stock number of each item, as indicated by the Supply Catalog shall be entered in this column on the same line on which the name of the item begins. Items and stock numbers shall be arranged in the exact order in which they appear in the Supply Catalog. The stock class number and name shall be typed at the head of each class of items requested. Two blank spaces shall be left between each class of items. When nonlisted items are re- quested, the appropriate class shall be entered in this column as “NL-3,” “NL-5,” “NL-12,” etc. (16) Item: List each item requested, beginning on the same line with the stock number, exactly as listed in the Supply Catalog, except that infor- mation contained in parenthesis may be omitted. Indicate the electric current on which electrical apparatus will be required to operate, stating the voltage and type of current (A. C. or D. C.). If alternating current, state also cycles and phase. (Example: 110-v., D. C.; 220-v., D. C.; 110-v., 60-cy., 1-ph.) When replacement parts, or accessories, for X-ray, electrically operated, or other equip- ment is required, an adequate description of the part, and of the equipment item for which the part is required, or with which the accessories are to be used, shall be stated, including the make, model, serial number, part number, or such descrip- tion as may be available, including electric current data, when indicated, in order to enable the procuring medical supply depot to accurately identify the material required. Requisition for nonlisted books shall state the exact title, the author, the edition, the publisher’s name, and the list price of each book. Incomplete description of nonlisted material necessitates considerable needless correspondence and procurement delays. As a general rule, in the case of nonlisted material, several makes of an item are available in the market, where competitive bidding is required, therefore catalog references must be construed as descriptive but not restrictive, unless sufficient justification is furnished for proprietary purchase. (17) Unit: Enter on the same line with the stock number and the first line of the item description, the “unit of quantity” as stated in the Supply Catalog. “One,” “Pair,” “Dozen,” “Pkg.,” “100-gm. bot.,” etc. (18) Minimum stock: Enter the minimum stock quantity required to be carried in store by the activity, determined as required by paragraph 3069, M. M. D. Leave blank in the case of perishables and items of which minimum stock quantities are not required. (19) On hand: Enter the quantity of the item on hand as indicated by the stock ledger and verified by recent inventory. Material expended from the stock ledger, such as part bottles, etc., in the pharmacy is not included. (20) Required: Enter the quantity required. In the event the quantity on hand considerably exceeds the maximum stock quantity, as may be necessary for some specific purpose, an explanatory note should be made on the reverse of the form to justify the apparent excess quantity required. Care shall be observed to avoid requesting excessive quantities of biologicals, X-ray films, and other similar items which deteriorate within comparatively short periods. When practicable, items shall be requested in packages or case multiples to eliminate unnecessary repacking and handling and to reduce time and cost of issues. (21) Value: The value of each item shall be entered on the original and fourth copy of each requisition by the issuing medical supply depot. The receiving activity shall copy the values on the second, third, and other required copies from the original. (22) Paging: When the listing of items required exceeds one page each page shall be serially numbered near the bottom. 3 CIRCULAR LETTER F (23) Signature: Requisitions shall be signed by the medical officer or the accounting officer (hospitals) and approved by the commanding officer. (24) Copies designation of: The requisitioning activity shall desig- nate the respective copies as follows: Ribbon copy “original.” Duplicate “second.” Triplicate “third.” Quadruplicate “fourth.” Quintuplicate “file copy.” Other required copies “Commandant, N. D.” Hdqtrs., U. S. M. C., etc Designating the office for which intended. reverse (25) Prospective movements. (Ships and mobile organizations only): Enter name of port or place at which ship or organization will be located, so far as is known, as indicated by the Form, except when military considerations prohibit such statements. (26) Explanatory remarks: Enter reference to property survey when requesting replacement of equipment items. Explain need for apparently large quantities of supplies, or additional items of equipment. Explain the need for nonlisted items, and any other information that appears pertinent. In the event space provided is inadequate, the face of the requisition, after the last item or a separate letter may be utilized. (27) Value of material invoiced by stock classes: The issuing medical supply depot shall enter the value data indicated on the original and fourth copy of each requisition. The receiving activity shall copy the values on the second, third, and other required copies from the original. (28) Receipt endorsement: The receiving activity shall enter the date the material or the priced original of the invoice was received, whichever is the later date, any exceptions noted (art. 1164 (b) N. R.), and receipt the original, second, and third copies of the invoice. (29) Disposition of copies: The receiving activity shall mail the receipted original to the medical supply depot from which the material was received, the second copy to the Bureau, and shall retain (par. 3094 N. M. D.) the third copy in the files, destroying the “file copy” (fifth) if no longer required. (30) Shipping information: The issuing medical supply depot shall indicate on the third copy (packing list), which is mailed direct to the requisition- ing activity at the time stores are shipped, sufficient data to inform the activity as to the manner and means by which the material was forwarded. Reference to the shipping data furnished on the third copy will inform activities when delivery may be expected, and the (supply) officer to which consigned, to whom inquiries, in cases of delay, should be addressed, rather than to the issuing medical supply depot. (e) Naval and marine corps reserve activities.— Requisitions for medical stores for Naval Reserve and Marine Corps Reserve activities shall be prepared in accordance with the foregoing instructions, with the following exceptions: (1) Except in an emergency, all requisitions shall be submitted to the com- mandant of the naval district within which the activity is located, for verification as to correct preparation, approval and forwarding to the Bureau. 4 NMS—FORM 4 (2) When shipment to an address other than the mail address is desired, the shipment address shall be stated on the face of the requisition, in the item space at the top of the list of items, thus— Ship to— (Name of officer or individual), (Address). (3) The issuing medical supply depot shall enter the value on all copies of the requisitions received, except the third (packing list), and shall forward the fifth copy direct to the Bureau marked “Advance Priced Copy.” (4) Immediately upon receipt of the material, or the priced invoices, which- ever is the later date, the proper officer shall copy the values on the third copy, execute the receipt endorsement (all copies), and forward all copies, except the third, which shall be retained on file, to the naval district commandant, for dis- position as follows: Original.—To medical supply depot issuing stores. Second.—To the Bureau. Sixth.—Naval District files. (f) CORRECTION OF APPARENT ERRORS. If any apparent shortage, over-delivery or other error is found in comparing the medical stores received with the invoice, the medical supply depot issuing the stores shall be informed by letter, and requested to ascertain if the discrepancy can be corrected. If the discrepancy cannot be verified as occurring at the issuing depot, and corrected, the stores shall be taken up as invoiced, and adjusted on the books of the receiving activity. A notation indicating the nature of the discrepancy shall be included in the receipt endorsed. The receiving activity shall make no change or alteration in an invoice except when requested to do so by the issuing medical supply depot. Medical stores lost in transit shall be taken up by the activity to which invoiced and a property survey prepared to cover material lost or missing (art. 1164 N. R.) (art. 1600 N. T.). 5 Appendix D, Manual of the Medical Department Bureau Circular Letter F-9 July 1, 1940. Subject: Quarterly Return of Medical Stores, Form V. (3432.) The following detailed instructions relative to the preparation of this form shall be observed. (a) Receipts during quarter.— (1) Allotment charges.— Line 1. Balance beginning of quarter.—From line 45 of previous report. Line 2. Purchase contracts.—Total value of stores received during a quarter under purchase contracts, payment for which was authorized by public vouchers drawn against Bureau funds (appropriations or allotments of appropriations). Total value must agree with totals indicated under (1) Summary of public vouchers. Line 3. From supply department.—Total value of stores received during quarter from the supply department on expenditure invoices or other vouchers which are charged to Bureau funds. Total value must agree with totals under (2) Sum- mary OF EXPENDITURE INVOICES FROM SUPPLY DEPARTMENT. Line 4■ From U. S. M. C.—Total value of stores received during a quarter from Marine Corps on invoices (NMC-Form-24-Qm.) or other vouchers which are charged to Bureau funds. Total value must agree with totals under (3) Sum- mary OF QUARTERMASTER INVOICES FROM URMC. Line 5.—(Blank.) Line 6. Subtotal, lines 2 to 5 inclusive.—(Self-explanatory.) (2) Transfer vouchers received.— Line 7. From supply department.—Total value of stores received during a quarter from the supply department on expenditure invoices or other vouchers which have not been, and shall not be, charged to Bureau funds. (APA material as defined by art. 1865 (3) N. R.) Total value must agree with totals under (4) Summary OF EXPENDITURE INVOICES (APA) FROM SUPPLY DEPARTMENT. Line 8. Material returned to store.—Total value of all material received during a quarter from field activities, including material other than unissued stores received from other supply depots on S. & A. Form 71. Total value must agree with total value under (5) Analysis of material returned. Line 9. From other medical supply depots.—Total value of unissued stores received during a quarter from other medical supply depots on Form 4 invoices or other vouchers. Total value must agree with total value indicated under (6) Summary of stores received from other medical supply depots. Line 10.-—(Blank.) Line 11. Subtotal, lines 7 to 10, inclusive.—(Self-explanatory.) (3) Adjustment receipts.— Line 12.—(Blank.) Line 13. Gain by inventory.—Total increases in inventory value during the quarter, as a result of differences between physical inventory quantities and stock ledger quantities. 1 CIRCULAR LETTER F-9 Line 14- Gain by unit price adjustment.—Total increase in inventory value dur- ing the quarter as a result of unit price adjustments incident to receipt of new stock and adjustments incident to transfer of items of returned stores from Stores Returned account to the appropriate stock ledger sheet. Line 15. Gain by reappraisal.—Total increase in inventory value during a quarter, resulting from revaluation of stores to comply with Bureau instructions, or gain resulting from the difference between the book value of items returned to store and their exchange credit when applied to the purchase of similar items. Line 16.—(Blank.) Line 17. Subtotal, lines 12 to 16, inclusive.—(Self-explanatory.) Line 18. Total receipts during quarter.—(Self-explanatory.) Line 19. Total.—(Self-explanatory.) (b) Expenditures during quarter.— (1) Expenditures to use.— Line 20. To ships, including hospital ships.—Total value of stores issued to ships, except Naval Reserve ships, during a quarter. Line 21. To shore stations, except hospitals.—Total value of medical stores issued during a quarter to shore stations, except Naval Reserve activities and hospitals. Include the value of vaccines issued to Naval Reserve Officers Train- ing Corps units. The value of stores consumed during a quarter in testing and for depot maintenance, shall be covered by a Form 4 requisition charged to the depot maintenance allotment. Line 22. To naval hospital.—Total value of stores issued to hospitals during the quarter. Line 23.—(Blank.) Line 24. Subtotal, lines 20 to 23, inclusive.—(Self-explanatory.) (2) Transfer vouchers issued (reimbursed)— Line 25. To Naval Reserve units, except aviation units.—Total value of stores issued during a quarter to Naval Reserve activities, except aviation units. Total value must agree with statement accompanying Form V. Line 26. To Naval and Marine Corps Reserve aviation units.—Total value of stores issued during a quarter to Naval and Marine Corps Reserve aviation units. Total value must agree with statement accompanying Form V. Line 27. To Marine Corps Reserve units, except aviation units.—Total value of stores issued during a quarter to Marine Corps Reserve activities, except aviation units (identified by Marine Corps “authority number”). Total value must agree with statement accompanying Form V. Line 28. To supply department.—Total value of stores transferred to the supply department during the quarter for which credit to Bureau funds is received. Total value must agree with statement and copies of expenditure invoices accompanying Form V. Line 29. To other Government agencies.—Total value of stores transferred during a quarter to other Government agencies. Total value must agree with statement accompanying Form V. Line 30.—(Blank.) Line 31. Subtotal, lines 25 to 30, inclusive.—(Self-explanatory.) (3) Transfer vouchers issued (not reimbursed).— Line 32. To other medical supply depots.—Total value of stores transferred dur- ing a quarter to other medical supply depots on Form 4 invoices or other vouchers. Total value must agree with totals indicated under (7) Summary of stores SHIPPED TO OTHER MEDICAL SUPPLY DEPOTS. 2 FORM V Line 38. To supply department for sale (surveyed stores).—Total appraised value of medical stores, transferred during a quarter to the supply department, for sale by authority of approved survey. The amount reported must agree with the total of all receipted S&A Forms 71 covering items transferred to supply officers for sale. This amount shall be supported by a summary, listing each S&A 71, its serial number and value. Line 3J+. Material returned to store, transferred to other medical supply depots.— To include the book value of all material returned to store from field activities which is transferred to another medical supply depot for any purpose. Line 35. Subtotal, lines 32 to 34, inclusive.—(Self-explanatory.) (4) Adjustment expenditures.— Line 36.—(Blank.) Line 37. Material returned to store, resurveyed.—Total value of material returned to store expended by approved survey during the quarter. Total value must agree with total indicated under (8) Analysis of material returned, resur- veyed, column headed value expended. Line 38. Unissued stores, surveyed.—Total value of unissued stores expended by approved survey during the quarter. Total value must agree with the total indicated under (9) Analysis of unissued stores surveyed, column headed VALUE EXPENDED. Line 39. Loss on inventory.—Total decreases in inventory value during the quarter, as a result of differences between physical inventory quantities and stock ledger quantities. Line 40. Loss on unit price adjustment.—Total decrease in inventory value dur- ing the quarter as a result of unit price adjustments incident to receipt of new stock and adjustments incident to transfer of items of returned stores from Stores returned account to the respective stock ledger sheets. Line 41. Loss on reappraisal.—Total decrease in inventory value, during a quarter, resulting from revaluation of stores to comply with Bureau instructions, or resulting from the difference between the book value of items returned to store and their exchange credit when applied to the purchase of similar items. Line 48.—(Blank.) Line 43. Subtotal, lines 36 to 42, inclusive.—(Self-explanatory.) Line 44• Total expenditures during quarter.—(Self-explanatory.) Line 45- Balance, end of quarter.—(Self-explanatory.) (c) Statement of receipts and expenditures of medical stores by CLASSES. Includes data formerly reported on Form Va with the addition of a Manufac- turing account and an account for Stores returned; the report is drawn to separate supply catalog classes from the supplementary supply catalog classes. (1) Summary of public vouchers.—Vouchers authorizing payment for stores, drawn against Bureau funds, and dated within the respective months of a quarter, shall be summarized and reported as indicated by the form. (2) Summary of expenditure invoices from supply department.—Stores received during the respective months of a quarter, from supply department activities on expenditure invoices or other vouchers, as a charge to Bureau funds shall be summarized and reported as indicated by the form. (3) Summary of quartermaster invoices from USMC.—Stores received during the respective months of a quarter, from Marine Corps activities, on invoices (NMC— Form-24-Qm.) or other vouchers, as a charge to Bureau funds, shall be sum- marized and reported as indicated by the form. 3 CIRCULAR LETTER F-9 (4) Summary of expenditure invoices (APA) from supply department.—Stores received during the respective months of a quarter from supply department activities on expenditure invoices or other vouchers, which have not been and should not be charged to Bureau funds, shall be summarized and reported as indicated by the form. (5) Analysis of material returned.—Invoices of material returned to store by ships and stations, received during a quarter, shall list the following data: 1. Transfer voucher received number, assigned by receiving depot. 2. Date material was received. 3. Name of activity from which received. 4. Invoiced value of material returned to store. (6) Summary of stores received from other medical supply depots.—Invoices of unissued stores received, during the respective months of a quarter, from other medical supply depots, shall be summarized and reported as indicated by the form. (7) Summary of stores shipped to other medical supply depots.—Invoices of un- issued medical stores shipped, during the respective months of a quarter, to other medical supply depots, shall be summarized and reported as indicated by the form. (8) Analysis of material returned, resurveyed.—Approved surveys of material returned to store shall be tabulated to indicate the following data: 1. Depot survey number. 2. Total invoiced (book) value of items included in survey. 3. Net gain or loss by approved reappraisal. 4. Value of items approved for retention in stock. 5. Value of items approved for transfer to supply officer for sale. 6. Value of items approved for expenditure from books. (9) Analysis of unissued stores surveyed.—Approved surveys of unissued stores shall be tabulated as indicated under (8) Analysis of stores returned, RESURVEYED. (10) Remarks.—Insert data required by paragraph (e) on reports for the quarter ending June 30, annually. Other pertinent data may be iucluded. (d) A separate statement listing all invoices of medical stores issued by the de- pot to each of the following activities shall be prepared and forwarded with Form V, when the corresponding line indicates issues have been made: 1. Line 25.—Naval Reserve units, except aviation units. 2. Line 26.—Naval and Marine Corps Reserve aviation units. 3. Line 27.—Marine Corps Reserve units, except aviation units. 4. Line 28.—Supply department. 5. Line 29.—Other Government agencies. 6. Line S3.—Supply Department for sale. 4 FORM V 7. The statements shall be listed in columnar form as follows: Statement of Medical Stores Issued to During the quarter ended. By the medical supply depot Depot in- voice No. Shipped Name of activity to which issued Value $ Total value (List invoices and data.) (e) This return for the quarter ended June 30, annually, shall contain a state- ment under subparagraph (c) (10), Remarks, indicating the following data: Value of Reserve Stores on Hand June 30, 19 Reserve stores A $ Reserve stores B Reserve stores C Reserve stores D — Total, reserve stores $__ 5 Appendix D, Manual of the Medical Department Bureau Circular Letter F-10 Subject: Medical Stores, Shortages and Overages in Shipments Between Medical Supply Depots, Accounting Procedure. July 1, 1940. References: (a) Article 1600 (1), IJ. S. Navy Regulations, 1920. (b) Article 1601, U. S. Navy Regulations, 1920. (c) Article 1120 (3), BuS&A Manual. (d) Article 1125 (6), BuS&A Manual. (e) Article 1131 (4), BuS&A Manual. (f) Article 1903, BuS&A Manual. (g) BuM&S letter to Naval Medical Supply Depots, Brooklyn, N. Y. and Mare Island, Calif., dated May 27, 1939. (h) C. 0., N. M. S. D., Brooklyn, letter NT4-2/EN10 dated June 6, 1939. (i) C. O., N. M. S. D., Mare Island, letter NT4-6/JJ57/L7-2 dated June 3, 1939. The following instructions shall be observed in all cases of shortages and overages in shipments of medical stores between depots: SHORTAGES IN SHIPMENTS (a) The receiving depot shall, in each case of shortage in shipments of medical stores received from other depots, advise the shipping depot of the facts and re- quest comment and verification appertaining to the shortage. (b) The shipping depot shall then inform the receiving depot whether or not the items were actually shipped. (c) (1) If the records of the shipping depot indicate that the items were actually shipped, the receiving depot shall be so informed and shall take up the gross amount of the invoice as stores received from other medical supply depots and a survey covering the items not received shall be held immediately. (2) Upon receipt of the approved survey the items shall be expended as un- issued stores surveyed. (3) No adjustment of the records of the shipping depot will be necessary in the above case. (d) (1) If the records of the shipping depot indicate that the items were not shipped, the receiving depot shall be advised accordingly. (2) The receiving depot shall, upon receipt of the above information, take up the gross amount of the invoice as stores received from other medical supply depots, and shall transfer the invoice value of the items not received, and not shipped, back to the shipping depot on N MS-Form 4 transfer requisition, listing the items and invoice value of each in the same manner as other transfer requisitions are prepared. A notation of the pertinent facts with respect to the transaction shall be typed on the face of all copies of the transfer requisition. 1 CIRCULAR LETTER F-10 (3) The receiving depot shall expend the amount invoiced back to the shipping depot as stores shipped to other medical supply depots and shall include the amount on line 32 and in analysis (7) of N MS-Form V for the same quarter. (4) The shipping depot shall upon receipt of the transfer requisition from the receiving depot, take up the items at invoice value as stores received from other depots and shall report the amount on line 9 and in analysis (6) of N MS-Form V. (5) In the event the stores included in the invoice to the receiving depot but not actually shipped have been taken up by the shipping depot as a gain on inventory and so reported on line 13, NMS-Form V, the shipping depot shall, upon receipt of the transfer requisition from the receiving depot, take up the items at invoice value as stores received from other medical supply depots as in subparagraph (d) (4) above and shall expend the items and the invoice value thereof as a loss on inventory, reporting the amount on line 39 of NMS-Form V. (6) Immediately upon receipt of a transfer requisition from the receiving depot invoicing the items and values of shortages as required by subparagraph (d) (2) above, the shipping depot shall issue the original shortage to the receiving depot on special issue requisition. OVERAGES IN SHIPMENTS (e) The receiving depot shall, in each case of overage in shipments of medical stores, advise the shipping depot of the items received which were not included in the invoice. (f) Upon receipt of notice from the receiving depot of any overages not covered by invoice, the shipping depot shall immediately invoice the material to the re- ceiving depot on special issue requisition. (g) In the event that notice of overage is received by the shipping depot after the discrepancy has been cleared in the records by loss on inventory and so re- ported on line 39, of N MS-Form V, the shipping depot shall make the necessary adjustment by reporting a corresponding gain on inventory on line 13, of NMS- Form V for the succeeding quarter and shall expend the gain so reported as stores issued to other medical supply depots. 2 Appendix D, Manual of the Medical Department Bureau Circular Letter F-ll Subject: Emergency Relief Workers, Reports of Hospitalization. References: (a) Section 7 (b), Emergency Relief Appropriation Act of 1939. (b) U. S. Employees’ Compensation Commission Regulations Gov- erning the Administration of the United States Employees’ Compensation Act of September 7, 1916, as amended, Re- lating to Civil Employees of the United States, and as Ex- tended to Emergency Relief Employees and Others, effective June 1, 1938, as amended to June 30, 1939. (c) Bureau Circular Letter F-5, Appendix D, M. M. D. July 1, 1940. (a) Hospitalization shall be furnished Work Projects Administration person- nel only upon proper authorization duly confirmed by written order (CA-16, CA-17, Special CA-16, or Special CA-17) issued within 48 hours after admission, as required by the regulations of the Employees’ Compensation Commission. (b) Two separate reports of hospitalization furnished Work Projects Admin- istration personnel are required each quarter. One report shall cover only se- curity workers and the other shall cover only administrative employees. The word “administrative” as used here refers principally to Work Projects Admin- istration officials and employees performing clerical, administrative, or supervisory duties. “Security” workers may be identified by the form of medical authoriza- tion used in referring such workers for treatment. Security workers will present Employees’ Compensation Commission Special Form CA-16 or Special Form CA-17, whereas the administrative employees will present Standard Form CA-16 or Standard Form CA-17 regularly used in connection with the treatment of old- line beneficiaries of the Commission. (c) The quarterly report of hospitalization furnished each class of Work Proj- ects Administration personnel shall be prepared in septuplicate on 8- by 13-inch paper and shall contain the following information, in columnar form, writh respect to each Work Projects Administration patient hospitalized during the quarter: (1) Maine in full, surname first. (2) Occupation, i. e., painter, laborer, etc. (3) Month, date, and year of injury. (4) Diagnosis of the injury for which hospitalized in the terms of the Navy nomenclature. (Causative agent must be stated in each case.) (5) Inclusive dates of hospitalization. (Date of admission and date preceding the day of discharge. For example, in a case admitted on January 1 and dis- charged on January 26, the inclusive dates of hospitalization would be January 1 to January 25, both dates being included in the computation of sick days which in this case would be 25.) (6) Number of sick days during the quarter. (d) Special emphasis is placed on the importance of promptly completing and forwarding the forms required by the regulations of the Employees’ Compensation 1 CIRCULAR LETTER F-ll Commission in each case. These reports are essential to and required by the com- mission in connection with their consideration of compensation claims and vouch- ered cost incident to the hospitalization of Work Projects Administration personnel. The commanding officer of each naval hospital furnishing hospitalization to Work Projects Administration personnel should contact the local compensation officer, or other local representative of the commission, with a view to instituting such cooperative measures as will assure strict compliance with the regulations of the commission. He shall see that the information contained in the reports submitted by the hospital is covered by and in agreement with Employees’ Compensation Commission Forms CA-1, CA-2, CA-16, or CA-17, and such other reports as may have been submitted to the commission in each case. Copies of reference (b) should be requested from the Employees’ Compensation Commission direct if not now available for reference. (e) In connection with the treatment and hospitalization of beneficiaries of the Employees’ Compensation Commission the following pertinent comment con- tained in a recent letter from the Commission is quoted for information and guidance: “The Commission recognizes that the medical establishments of the Navy are not able in all instances to determine whether in a particular case the applicant is entitled to medical care at the expense of the Commission. It is expected, however, that the officer in charge of each medical establishment will exercise due diligence to see that medical care is rendered for the account of the Commission in cases which appear to be within the purview of the Compensation Law. In the case of emergency relief workers the law does not provide for medical care on account of illness or disease but is limited exclusively to cases involving traumatic injury. Except in rare cases, a medical officer after examination should be able to determine whether the condition requiring treatment is the result of trauma or disease. In the event treatment should be rendered in such cases where it is more or less obvious that such treatment is not authorized under the Compen- sation Law, the Commission would not consider such treatment a proper charge against the funds advanced to your department.” (f) In connection with the submission of reports required by the Commission, as specified in reference (b), the following pertinent comment contained in the Commission’s letter referred to above is also quoted for information and guidance: “A number of vouchers representing services rendered for the account of the Com- mission, covering hospitalization of regular beneficiaries at naval establishments, have recently been audited. The services rendered in these cases, for the most part, involve employees injured in naval establishments. It has been found that out of a total of 554 days’ hospital care disallowed by the Commission, the dis- allowance in 184 days was due to lack of any information in the files of the Com- mission concerning the injury. Hospitalization amounting to 248 days was disallowed under rulings of the Comptroller General which the Commission and the Navy Department apparently are required to observe. It is believed, how- ever, that no difficulty will be encountered in the accounts of emergency relief employees if hospitalization is provided only upon proper authorization duly con- firmed by written order issued within the 48 hours, as required by the regulations of the Commission.” (g) All Work Projects Administration personnel hospitalized shall be reported on line 34 of the quarterly ration return (NMSH—Form 36) and line 34 shall be analyzed on the reverse to indicate subsistence days for security workers and administrative employees separately. The total subsistence days reported on the quarterly ration return will not necessarily agree with the total sick days 2 REPORTS OF HOSPITALIZATION reported in the detailed reports of hospitalization for the same quarter, due to the fact that sick days must be computed by the formula prescribed by the Em- ployees’ Compensation Commission in reference (c); i. e., in computing sick days, the day of admission shall be included and the day of discharge shall be excluded. (h) Security workers and administrative employees shall be reported separately in the quarterly summary report of hospitalization of supernumerary patients. (i) It is essential that the reports be accurately prepared and that they be forwarded promptly after the close of the quarter in which the services were rendered. Only full quarterly periods shall be reported and services rendered in two different quarters must not appear on the same report. 3 Appendix D, Manual of the Medical Department Bureau Circular Letter F-12 July 1, 1940. Subject: Emergency Relief Workers, Injured; Reports of Out-Patient Medical Services Rendered. References: (a) Section 7 (b), Emergency Relief Appropriation Act of 1939. (b) U. S. Employees’ Compensation Commission Regulations governing the Administration of the United States Employees’ Compensation Act of September 7, 1916, as amended, relating to Civil Employees of the United States, and as extended to Emergency Relief Employee and Others, effective June 1, 1938, as amended to June 30, 1939. (a) The medical officer of each activity furnishing out-patient medical services to emergency relief workers shall submit to this Bureau quarterly", not later than the seventh day after the close of each quarter, a letter report, in septuplicate, stating the total number of out-patient treatments rendered emergency relief workers for conditions resulting from traumatic injuries sustained in the per- formance of duty, excluding those employed in an administrative capacity. The word “administrative” as used here refers principally to Work Projects Adminis- tration officials and employees performing clerical, administrative, or supervisory duties. Administrative employees of the Work Projects Administration are considered to be in the same category as old-line beneficiaries of the commission insofar as out-patient treatment at naval medical facilities is concerned and no charge will be made for out-patient treatments rendered this group. (b) This Bureau has been informed that Employees’ Compensation Commission Forms CA-1, C-2, CA-16, or CA-17 will not be required by the Commission in those cases in which no time is lost from work. However, each case requiring more than five treatments, hospitalization, or where disability extends beyond a period of 10 days, the reports enumerated above, together with such other reports as may be required by the regulations of the Commission, must be promptly submitted to the Commission. (c) It will not be necessary to submit a detailed report of the individuals treated. However, a permanent record of each case shall be maintained by the medical officer in order that the following information may be available in the event it is requested by the Commission at a later date: (1) Name in full of the injured worker, surname first. (2) Home address of injured worker. (3) Status, i. e., administrative or security worker. (4) Occupation, i. e., painter, carpenter, laborer, etc. (5) Month, date, and year of injury. (6) The diagnosis of the injury for which treated in the terms of the Navy no- menclature. The causative agent must be stated. If the medical officer has any reason to suspect that the causative agent was other than as reported by the in- jured employee, he should contact the employee’s immediate superior for verifi- cation of causative agent and such investigation as may be necessary. 1 CIRCULAR LETTER F-12 (7) Circumstances under which the injury occurred. (8) Date of each treatment rendered. (9) Date of discharge from treatment, or other disposition. (10) Total number of treatments for each separate and distinct injury. (11) Physical condition of injured employee upon discharge from treatment. (If fully recovered, so state; if not fully recovered record the probable extent of future disability and prognosis.) (d) The regulations of the Commission as contained in reference (6) require that treatment shall be rendered emergency relief workers for the account of the com- mission only in cases of disability resulting from traumatic injury sustained while in the performance of duty. If for humanitarian or other sufficient reasons, treatment should be rendered emergency relief workers for conditions which do not qualify the worker for treatment at the expense of the Commission, such treatments shall not be included in the quarterly report of out-patient treatments mentioned in paragraph (a) above. The following pertinent comment contained in a recent letter from the commission is quoted for information and guidance: “The Commission recognizes that the medical establishments of the Navy are not able in all instances to determine whether in a particular case the applicant is entitled to medical care at the expense of the Commission. It is expected, how- ever, that the officer in charge of each medical establishment will exercise due diligence to see that medical care is rendered for the account of the Commission only in cases which appear to be within the purview of the Compensation Law. In the case of emergency relief workers the law does not provide for medical care on account of illness or disease but is limited exclusively to cases involving traumatic injury. Except in rare cases, a medical officer after examination should be able to determine whether the condition requiring treatment is the result of trauma or disease. In the event treatment should be rendered in such cases where it is more or less obvious that such treatment is not authorized under the Compensation Law, the Commission would not consider such treatment a proper charge against the funds advanced to your department.” (e) In order that this simplified procedure may accomplish the desired result, and thus eliminate the great volume of clerical work which would otherwise be required, the full cooperation of all concerned is necessary and requested. 2 Appendix D, Manual of the Medical Department Bureau Circular Letter F-13 Subject: Civilian Conservation Corps Enrollees, Laundering of Washable Clothing. References: (a) Civilian Conservation Corps Regulations, War Department, Par. 54 (b), Change no. 37. (b) Par. 27 (d), Circular Letter F-5 on the subject of supernumerary patients, Appendix D, M. M. D. July 1, 1940. (a) Reference (a) provides for laundry service for Civilian Conservation Corps enrollees hospitalized in Government hospitals as follows: “The washable clothing of enrollees while patients in Government hospitals will be laundered at the expense of the Civilian Conservation Corps.” (b) In transmitting the above quoted change in the Civilian Conservation Corps Regulations, the War Department made the following comment with regard to laundry services to be provided by Government hospitals: “It is understood that the laundry service per this letter will be kept at a minimum. It will include the washable clothing worn by Civilian Conservation Corps enrollees when admitted to the hospital, when such clothing requires wash- ing before it can be put away for use on departure of the patient from the hospital. It will include also laundry for the relatively few Civilian Conservation Corps ambulatory cases who wear their own clothing instead of hospital clothing.” (c) Effective upon receipt of this letter Civilian Conservation Corps enrollees who are patients in naval hospitals shall be furnished laundry service to the extent authorized in paragraphs (a) and (b). (d) The following instructions shall obtain in recording and reporting the cost of laundry services furnished such enrollees: (1) An accurate record shall be kept of laundry service furnished each Civilian Conservation Corps enrollee. (2) The cost of laundry service furnished each Civilian Conservation Corps enrollee, each quarter, shall be determined either on a pro rated cost basis or on an actual cost basis, as may be most feasible at each hospital. (3) The War Department requires that vouchers covering the cost of laundry services furnished Civilian Conservation Corps enrollees be submitted with the quarterly bills for hospitalization. Therefore, a quarterly report shall be sub- mitted to this Bureau, listing, in alphabetical order, the names of all Civilian Conservation Corps enrollees furnished laundry service during the quarter, the cost of laundry service furnished enrollee, and the total cost of laundry service furnished all enrollees. The report shall be prepared in the following form and shall be submitted in quintuplicate with the quarterly report of hospitalization of Civilian Conservation Corps enrollees; U. S. Naval Hospital (Place) (Date) 1 CIRCULAR LETTER F-13 From: Medical Officer in Command. To: The Chief of the Bureau of Medicine and Surgery. Subject: Laundry service furnished enrollees of the Civilian Conservation Corps during the quarter ended (Date) References: (o) Bureau Circular Letter F-13, Appendix D, M. M. D. (b) Quarterly report of hospitalization of C. C. C. enrollees dated 1. Laundry service was furnished Civilian Conservation Corps enrollees dur- ng the quarter, fiscal year 19 , in accordance with the requirements of paragraph 54 (b), Civilian Conservation Corps Regulations as follows: Name Cost Enrollee John Jones $x. xx Enroliee Tom Brown x. xx Total $x. xx [s] (Signature, name, and rank of medical officer in command.) (e) At the close of each quarter an adjustment voucher covering the value of laundry service furnished Civilian Conservation Corps personnel, and indicating the data on which charges are calculated, shall be prepared and posted by journal entry as a debit to Account 13—Navy as a whole and as a credit to Account 10— Operating expense. Proper adjustment shall also be made in the expense analysis register accounts and the expense analysis classifications involved, which adjust- ment shall be indicated on the voucher. A copy of the adjustment voucher for each quarter shall be submitted with NMS Register No. 3 for the same quarter. 2 Appendix D MANUAL OF THE MEDICAL DEPARTMENT Bureau Circular Letters I Hospitals and Inspections Division TABLE OF CONTENTS Subject Date in effect Authorization to Convene Summary Courts Martial July 1, 1939 Possession or Sale of Alcoholic Beverages in Naval Hospitals and on Hospital Reservations July 1, 1939 Weekly Report of Patients in Naval Hospitals, Bed Capacity, Distri- bution, and Certain Classifications—Form I (3419) July 1, 1939 1-4. Case Records Required in Naval Hospitals (1612(i)(3)) Jan. 1, 1941 1-5. Ward Records and Reports (1672(c)(9)) Jan. 1, 1941 Appendix D Manual of the Medical Department Bureau Circular Letter I Subject: Authorization to Convene Summary Courts Martial. In accordance with the act of August 29, 1916 (39 Stat. 586, U. S. Code, title 34, sec. 1200) the Secretary of the Navy in Court-Martial Order No. 6 of 1933 empowered the commanding officers of the following designated naval hospitals to convene summary courts-martial: United States Naval Hospital, Annapolis, Md. United States Naval Hospital, Canacao, P. I. United States Naval Hospital, Charleston, S. C. United States Naval Hospital, Chelsea, Mass. United States Naval Hospital, Great Lakes, 111. United States Naval Hospital, Mare Island, Calif. United States Naval Hospital, New London, Conn. United States Naval Hospital, Newport, R. I. United States Naval Hospital, New York, N. Y. United States Naval Hospital, Parris Island, S. C. United States Naval Hospital, Pearl Harbor, T. H. United States Naval Hospital, Pensacola, Fla. United States Naval Hospital, Philadelphia, Pa. United States Naval Hospital, Portsmouth, N. H. United States Naval Hospital, Portsmouth, Va. United States Naval Hospital, Puget Sound, Wash. United States Naval Hospital, San Diego, Calif. United States Naval Hospital, Washington, D. C. The medical officer in charge, United States naval unit, Fitzsimons General Hospital, Denver, Colo. Subject: Possession or Sale of Alcoholic Beverages in Naval Hospitals and on Hospital Reservations. Under date of June 2, 1937, the Chief of the Bureau of Medicine and Surgery issued the following directive to commanding officers of naval hospitals. 1. The Bureau directs that, except as authorized by paragraph 1 of General Order No. 59, the introduction, possession, or use of alcoholic liquors for beverage purposes or for sale, including beers having an alcoholic content of 3.2 percent, or less, shall be prohibited in naval hospitals or on hospital reservations. 2. This order shall be effective immediately. 3. As noted in paragraph 1 hereof, and in accordance with General Order No. 59, this order will not apply to officers’ quarters, officers’ messes, and officers’ clubs. 4. In the opinion of the the authorization of the use, possession, or sale of alcoholic liquors for drinking purposes in naval hospitals or on hospital reservations neither is professionally ethical nor good administrative practice. The one possibility that alcohol thus may be more readily obtained by convales- cents or others for whom alcohol is contraindicated, is sufficient basis for its exclusion. 1 Appendix D Manual of the Medical Department Circular Letter I Subject: Weekly Report of Patients in Naval Hospitals, Bed Capacity, Distribu- tion, and Certain Classifications—Form I. (3419). Column A.—Enter number of patients subdivided as indicated on form; entries under Remaining last report must agree with those reported as remaining on report submitted for the previous week. The total remaining must represent the entire number of patients carried on the sick list and under treatment on the date of the report, and must agree with the total of beds occupied in column D. Column B.—Permanent accommodations for patients (on 8-foot centers). The number reported in this column is the bed capacity based on 8-foot centers in fire-resisting buildings, as authorized by the Bureau, and is subdivided into beds allocated to officers and to enlisted men. Column C.—Temporary accommodations for patients (on 8-foot centers). The number reported in this column is the total bed capacity of a temporary nature in frame buildings as authorized by the Bureau. Column D.—Total number of beds for patients. This column is divided into two parts—Beds occupied and beds vacant. The total figure of beds occu- pied, subdivided as officers and men, must equal the total remaining in column A. Patients who are carried on the sick list and under treatment but are at home must be included in the number of beds occupied. Beds vacant is self explanatory, being the difference between those occupied and the authorized capacity. Hospital ships will report only accommodations for patients in this column. Column E.—Beds temporarily occupied by others, not patients. In this column enter the number of beds temporarily occupied by others—not patients—as for example, relatives of patients. Such figure is not deducted from the total beds vacant in column D. Column F.—Number carried on sick list and under treatment in other institu- tions. In this column enter the number of hospital patients carried on the sick list and under treatment in civil hospitals or in other institutions. It will not include officer, enlisted men, or supernumeraries granted leave of absence from the hospital. Column G.—Classification of Veterans’ Administration patients remaining. In order to compile a special report for the Veterans’ Administration, patients who are beneficiaries under that administration will be classified as to number in this column as provided under the headings, tubercular, psychotic, other n. p., and general. Total of this grouping must equal the number reported as Veterans’ Administration, remaining in column A. (b) Instructions for numbered columns.— In columns 1 and 2. enter the names and rank of all patients who are officers (Navy and Marine) on active duty, nurses, midshipmen, aviation cadets, or Naval Reserve officers on active duty, who have been admitted or discharged during the period of the report, or whose diagnosis has been established or changed in any way. (a) Instructions for lettered columns.— 1 CIRCULAR LETTER I Column 8.—Use terms of Navy nomenclature and enter diagnosis under which patient was received as a transfer; or if established or changed, enter accordingly. Column 4-—Enter name of place from which patient was received; if established or changed, enter words change of diagnosis or established as case may be. Column 5.—Enter date, expressed in figures, taken up as a readmission, diag- nosis established, or change of diagnosis. Column 6.—Enter date of discharge expressed in figures. Column 7.—For Bureau use, express condition as follows: C=Convalescent. F=Favorable. U=Unfavorable. S=Serious. Column 8.—Enter date patient is considered as likely to be ready for duty. In case of actual discharge from the sick list or other change, indicate as D, C, DD, IS, Ran, or T. (c) Summary of communicable diseases.— There shall be entered on the last page of Form I, a summary of the number of patients (active-duty personnel) for each of the diseases included in classes VIII—IX—X—XIII, Navy nomenclature, remaining on the date of the report. (d) Maximum number of patients.— There shall be entered on the last page of Form I, after the summary of com- municable diseases, a statement of the maximum number of patients under treat- ment on any one day, as follows: Navy (active) All supernumeraries (e) Civilian Conservation Corps patients.— C. C. C. personnel under treatment in the hospital during the period of the report shall be indicated by a special grouping on the last page of the report, as follows: Admitted during the week Discharged during the week Remaining end of week (f) Officer-beds occupied.— In order to know the number of officer-beds occupied by active-duty personnel, a special entry is required on the last page of Form I, as follows: Active-duty personnel Supernumeraries The total must equal the figure reported under Officer-beds-occupied in column D. Active-duty personnel included in this count are officers (Navy and Marine Corps), nurses, midshipmen, aviation cadets, and officers (Navy and Marine Corps Reserve) on active duty. (g) Civilian dependents of naval personnel.— Personnel of this classification under treatment during the week of the report shall be reported under such heading, and in the following manner, on the last page of the report: Patients admitted Patients discharged Patients remaining 2 Appendix D, Manual of the Medical Department Bureau Circular Letter 1-4 Subject: Case Records Required in Naval Hospitals. (1612(i) (3)). (a) Register of patients, nmsh-Form 39.—This record shall be maintained by all hospitals and kept up to date. When a patient is admitted to the hospital, a new case number shall be assigned him unless he has been admitted previously at the same hospital, in which event the case number for the original admission shall be used. (b) Record jacket.—A file folder, size 11% inches by 9% inches shall be prepared for each patient. All the data pertaining to the patient as recorded in the Register of Patients shall be recorded on the face of this folder. (c) Record forms.—The following items or copies thereof, prepared or received by the hospital and pertaining to a patient, shall be permanently filed in his record jacket: (1) Admission or Discharge of Officer, NMSH-Form 1. (2) Hospital Ticket, NMS-Form G. (3) Admission Report. (4) Clinical Record, NMS-Form 59 and 59a. (5) Clinical Chart, NMS-Form Q. (6) Clinical Notes, NMS-Form 17. (7) Laboratory Examination, NMS-Form 27. (8) Request for Examination or Treatment, NMS-Form 57. (9) Operation Record, NMS-Form 58. (10) Notice of Change of Diagnosis, NMS-Form 53. (11) Discharge Report. (12) Ration Notice, S&A Form 35M. (13) All correspondence or other communications relating to the individual. (14) Misconduct Report, S&A Form 35L. (15) Report of Medical Survey, NMS-Form M. (16) Report of Death, NMS-Form N. (d) Procedure.—The custody, preparation, and disposition of the various items enumerated in this letter shall be governed by Bureau manual and hospital instructions. January 1, 1941. 1 Appendix D, Manual of the Medical Department Bureau Circular Letter 1-5 Subject: Ward Records and Reports. (1672(c) (9)). (a) Ward regulations.—Orders, regulations, and instructions governing the administration of the ward shall be published on the ward for the information of the staff and patients. (b) Admission and discharge reports.—Each naval hospital shall provide itself with these reports in a form suitable to its particular needs. It shall issue detailed instructions requiring the prompt preparation and submission of these reports. (c) Ward order book.—This record shall be in book form. Treatments ordered for patients shall be recorded in this book in ink and signed by the officer issuing the order. (d) Clinical records.— Clinical charts, NMS-Form Q, and clinical notes, NMS-Form 17, shall be kept up to date and supervised in accordance with hospital instructions. (e) Inventory of equipment.—This shall be a record of all nonexpendable property on charge and shall show all changes entailed by receipt and transfer of equipment. The form of this record and verification of this record by physical inventory shall be in accordance with hospital instructions. (f) Preparation and submission of the following items shall be governed by hospital instructions: (1) Issue Voucher, NMS-Form R. (2) Ward Report, NMSH-Form 9. (3) Request and Disposition Form, NMSH-Form 11. (4) Diet Sheet, NMSH-Form 18. (5) Liberty List, NMSH-Form 20. (6) Laundry List, NMSH-Form 21. (7) Personal Effects Tag, NMSH-Form 22. (8) Laboratory Examination, NMSH-Form 27. (9) Special Diet Order Sheet, NMSH-Form 40. (10) Request for Examination or Treatment, NMSH-Form 57. January 1, 1941. 1 Appendix D MANUAL OF THE MEDICAL DEPARTMENT Bureau Circular Letters M Personnel Division TABLE OF CONTENTS Subject Date in effect Postgraduate Education, Medical Department July 1, 1939 Hospital Corpsmen Qualified as Technical Specialists, Reporting of July 1, 1939 The Naval Reserve (Medical Corps) July 1, 1939 Membership in the Association of Military Surgeons July 1, 1939 College of Physicians and College of Surgeons July 1, 1939 M-7. Roster Report of the Hospital Corps, NMSHC-4 In .tructions Governing (637) (3511) Jan. 1, 1941 M-8. Monthly Return of Nurses July 1, 1940 M-6. Receipt, Transfer, and Disposition Card (NHSHC-Form 3) Instructions Governing (635) and (3510) Jan. 1, 1941 Appendix D Manual of the Medical Department Bureau Circular Letter M Subject: Postgraduate education, Medical Department. 1. Introduction. (a) From the date of entry into the service until retirement, opportunities are provided to all for continuous advancement in the way of postgraduate education. To be of value to the individual and the service, this continuous opportunity must be actively utilized by each one interested in his or her future in the service. The mission of the Navy requires efficient Medical Department activities on ships at sea, and all in each corps must take their full share of rotation in the perform- ance of this basic duty. (b) The Bureau is constantly seeking to find especially informed personnel to carry on special needs in hospitals, at naval stations, in special units of the service at sea, with expeditionary forces, and at foreign shore stations. In par- ticular, qualified personnel are sought for: Internal medicine, general surgery, orthopedics, urology, radiology, ophthalmology, otolaryngology, psychiatry, aviation medicine, tropical medicine, obstetrics and gynecology, clinical labora- tory, pathology, chemistry, public health, deep-sea diving and submarine duties, prosthodontia, oral surgery, chemical warfare, field service, anaesthesia, dietetics, accounting, electrocardiography, pharmacy, and embalming. Those who are preparing themselves for maximum effectiveness, capable of functioning inde- pendently afloat or ashore, should also at all times seek to develop themselves in a chosen specialty. In this the Bureau desires to assist and may be of service along the following lines: (a) The naval medical school.—(1) Officers recently commissioned will be ordered for the basic course, which includes 3 weeks in chemical warfare at Edgewood, Md., and a similar period in field service at Quantico, Va. Note.—Since the number of officers entering the corps at times will exceed the number which can be accommodated at the school, it follows that a certain number, representing the excess, will be denied opportunity to attend the basic course. Hence, lack of a school certificate will not reflect adversely on an officer’s record or impair his eligibility for instruction in a specialty. (2) There may be admitted to the basic course a certain number of senior officers desiring to review the medical and medico-military subjects embraced in the curriculum. (3) Systematic instruction is available to individuals in histopathology, clinical laboratory procedure, and other special lines either as training for a specialty or as preparation for general medicine and surgery. (b) Professional course in civilian institutions.—(1) Courses are available in various parts of the country and in practically all recognized specialties. The number of officers granted the privilege of civilian courses in any given year will depend upon conditions, such as funds at the disposal of the Bureau and current prospective requirements of the service. The basic course at the Naval Medical 2. Postgraduate Instruction, Medical Officers. 1 CIRCULAR LETTER M School is not a requisite preliminary to postgraduate instruction in a specialty. Most important, however, is that an applicant shall furnish evidence of qualifying elementrary training, shall have had experience sufficient to enable him to profit by an advanced course, and shall have clearly demonstrated specific aptitude. (2) Officers who cannot perhaps meet all of these requirements but who may give promise may be ordered to a naval hosptial for duty under instruction and observation, in order that they may have opportunity to qualify. (3) Whether an application submitted by an individual will receive approval likewise depends upon circumstances. In general the Bureau, recognizing the necessity of affording facilities for special training, is disposed to further the legitimate desires of officers. But its action in any case is influenced by various considerations; for example, an application can rarely be approved if its author is shortly due for sea. (c) Medico-military subjects.—Instruction in medico-military subjects is offered to selected officers at the Naval War College and the Army Industrial College; in field service at Quantico, Va., and Carlisle, Pa.; in chemical warfare at Edgewood, Md.; in aviation medicine at Randolph Field, Tex., and Pensacola, Fla.; in deep-sea diving and submarine duty at Washington, D. C., and New London, Conn.; and preventive medicine at Johns Hopkins. (d) Research and investigation.—Special facilities for research and investi- gation combined with relevant instruction and guidance, are available for the study of problems of naval interest in several universities and in other Govern- ment activities. Since research represents limited duty of a highly specialized character, selection of applicants will be peculiarly individual. Officers who have in mind some promising line of investigation requiring special facilities are invited to present their problems, clearly defined, to the Bureau for consideration. 3. Postgraduate Instruction, Dental Corps. (See Circular Letter D) 4. Postgraduate Instruction, Nurse Corps. Special courses outlined below may be allowed, upon application, to qualified members of the Navy Nurse Corps, providing they have served 3 years in the naval service, they have the ability and personality to cope with such peculiarities of the service as may arise, and have the approval of their chief nurse and com- manding officer. Applicants for any of these courses will use form letter as out- lined below. The courses referred to are— Physical therapy: United States Naval Hospital, Philadelphia, Pa. Length of course, 6 months. Anaesthesia: Graduate hospital, University of Pennsylvania, Philadelphia, Pa. Length of course, 4 months. Dietetics: George Washington University, Washington, D. C. Length of course, 9 months. 2 INSTRUCTION OF PERSONNEL 5. Postgraduate Instruction for Chief Warrant and Warrant Officers. Special courses as outlined below may be allowed upon application to chief pharmacists and pharmacists providing they have the ability and experience to enable them to derive benefit by a study of a specialty. The courses referred to are— Pharmacy: At Washington, D. C., and Philadelphia, Pa. Chemistry: At Washington, D. C., Philadelphia, Pa., and New York, N. Y. Commissary: At Philadelphia, Pa. Accounting: At Washington, D. C., and New York, N. Y. 6. Instruction Hospital Corps Personnel. (a) Prospective hospital corpsmen will receive a 4-month course of instruction in the basic school at Portsmouth, Ya., or San Diego, Calif. As a rule, only nonrated men of the seaman and fireman branches will be sent to these schools. Upon graduation from the basic school, hospital corpsmen will be sent to naval hospitals for 1 year. During this year training will be continued by lectures, demonstrations, etc., and also by strict enforcement of rotating system of service in order to more fully prepare hospital corpsmen for duty at sea or on foreign shore stations. (b) In order to provide adequate number of hospital corpsmen trained as technical assistants the following courses will be given from time to time as required by the demands of the service for technical specialists. Subject Rates eligible Where given Length of course Certifi- cate PhMlc, PhM2c, PhM3c. PhMlc, PhM2c, Naval air stations. 4 months... Yes. Clerical procedures, short- 6 months... Yes. hand and typewriting. PhM3c. CPhM, PhMlc, PhM2c. PhMlc, PhM2c_. Naval hospitals As neces- Yes. Deep-sea diving Naval Medical School and Navy sary. 6 weeks Yes. Dental technicians, general. All ratings. Yard, Washington, D. C. Naval Dental School, Washing- 4 months... Yes Dental technicians, pros- PhMlc, PhM2c, ton, D. C. Naval prosthetic dental activities.. 5 months... Yes. thetic. Electrocardiograph and PhM3c. PhM2c, PhM3c.. Naval Medical School, Washing- 4 months— Yes. basal metabolism. PhM2c, PhM3c~ PhMlc, PhM2c, ton, D. C. Naval Hospital, New York Varies Yes. Laboratory (medical tech- Naval Medical School, Washing- 7 months... Yes. nologist). PhM3c. All ratings ton, D. C. Marine Barracks, Quantico, Va., and San Diego, Calif. All naval hospitals 6 weeks to Yes. All ratings 3 months. Indefinite.. No. Pharmacy and chemistry.. PhMlc, PhM2c, Naval Medical School, Washing- 9 months Yes. Photomicrography PhM3c. CPhM, PhMlc, ton, D. C. Naval Medical School, Washing- 6 months... Yes. PhM2c. All ratings. .. .. ton, D. C. All naval hospitals Varies Physiological methods for CPhM, PhMlc, Naval Medical School and Navy 4 months... Yes. diving and chemical warfare research-1 Property and accounting... Roentgenology PhM2c. PhMlc, PhM2c, PhM3c. PhMlc, PhM2c, Yard, Washington, D. C., Harvard University, Cambridge, Mass. All naval hospitals... Naval Medical School, Washing- Varies 9 months... Yes. Yes. PhM3c. ton, D. C. i This course to be given to men on duty at station. * Only qualified laboratory technicians may take this course. 3 CIRCULAR LETTER M (c) In the above courses all efforts will be made to have them so arranged that graduates can, if possible, comply with the requirements for registration that have been, or may be, promulgated by the American Medical Association, the American Nurses Association, and State licensing board or other governing bodies. (d) It is desired that officers canvass hospital corpsmen in their activity who desire to take the courses given at the Naval Medical Center and submit their names and qualifications to this Bureau via official channels. 7. Application Form. (a) The following form letter will be used in submitting an application for postgraduate or special instruction: From: (Name and rank or rating.) To: Chief of Bureau of Medicine and Surgery, Navy Department, Washington, D. C. Via: Commanding officer. Subject: Request for postgraduate instruction. 1. It is requested that I be assigned to a postgraduate course of instruction in (give subject of course; also, when applicable, name of institution, duration of course, giving inclusive dates and tuition fee). 2. My experience in this or related subjects includes 3. If this request is granted I hereby agree not to resign during the course, and to serve the Navy for at least 3 years after completion of the course.1 From: Commanding officer. To: Chief of Bureau of Medicine and Surgery, Navy Department. Subject: 1. (Commanding officers shall report fully regarding the equipment and aptitude of candidates for courses requested.) (b) Applications for instruction must be received in the Bureau not later than March 1, prior to the beginning of the fiscal year in which the course is to be taken. [First endorsement] Subject: Hospital Corpsmen Qualified as Technical Specialists, Reporting of. (a) The Bureau has been informed several times that hospital corpsmen listed as specialists have been ordered to a station for the express purpose of filling a vacancy in that specialty and upon arrival at their new station it was found that they had not performed any duty for several years in the specialty for which they had been trained. (b) In order that this Bureau’s records may be kept current, it is requested that all medical department activities be directed to list on the reverse side of monthly NMS-HC-4 for the last month of each quarter, all hospital corpsmen who are technicians and have actually been performing duty in their specialty or those who in the opinion of the commanding officer or senior medical officer are still considered qualified to perform duty in their specialty. (c) It is further directed that these men be assigned a mark (based on 4.0) as to their technical ability. > Warrant officers, nurses, and hospital corpsmen will omit par. 3. 4 Appendix D Manual of the Medical Department Bureau Circular Letter M Subject: The Naval Reserve (Medical Corps). (171 and 281.) (a) Introduction.—(1) The Naval Reserve, as established by the Naval Reserve Act of 1938, is a component part of the United States Navy and consists of four classes that are discussed in the following paragraphs. (2) All information pertaining to the procurement, organization, training, pro- motion, transfer, etc., of the Naval Reserve, including that for the Medical Corps and Dental Corps, is incorporated in Part H, Bureau of Navigation Manual, from which the following information is abstracted. (3) The purpose of the Naval Reserve is to provide a force of qualified officers and enlisted men who are available for immediate mobilization in the event of a national emergency, and who together with the active and retired personnel, can effectively meet the needs of the expanding naval establishment while an adequate flow of newly trained personnel is being established. (b) Fleet reserve.—The purpose of the Fleet Reserve is to provide an avail- able reserve of ex-officers and ex-enlisted men of the Regular Navy who may be utilized without further training to fill those billets requiring experienced per- sonnel in the initial stages of mobilization. Medical officers of the Fleet Reserve are designated MC-F, dental officers of this class DC-F, and consist of ex-medical and dental officers of the Regular Navy who have been honorably discharged therefrom after not less than 4 years’ service therein, and appointed in the rank last held by them in the Regular Navy. The same requirements apply to ex- chief pharmacists and ex-pharmacists of the Regular Navy. Officers appointed under the foregoing provision wrill not, in time of peace, be ordered to active duty, except with their own consent, and shall be under no obligation to perform training or drill duty during that period, but shall be paid in advance $20 per annum. (See sec. 205, Naval Reserve Act of 1938.) (c) Organized reserve.—(1) The purpose of the Organized Reserve is to provide a trained force of officers and men which added to qualified personnel from other sources will be adequate in numbers and composition to complete the war organization of the United States Fleet. Medical officers of the Organized Reserve are designated as class MC-O, and are required to perform annual train- ing and other duties and be available for immediate mobilization, in accordance with the provisions of Part H, Bureau of Navigation Manual. (2) Medical officers of the Organized Reserve are assigned to battalions, divi- sions, or aviation squadrons or may be assigned to units of the Organized Reserve of the Marine Corps Reserve. Subject to service requirements and their own consent in lieu of being attached to a battalion, division, or squadron of the Organ- ized Reserve, they may be placed on active duty in connection with the adminis- tration and training of the Naval Reserve, or, if authorized by the Bureau, assigned appropriate duties in this connection. The Bureau of Navigation issues annually a table of organization indicating locations of authorized organizations of the Naval Reserve, the character and composition of the organization at each location, the number of officers and men allowed each organization in a pay status (operating quota) and the number of officers of the various grades and classifications, and number of men of the various rates required in the organization for mobilization purposes (mobilization quota). (d) Volunteer reserve.—The purpose of the Volunteer Reserve is to provide a force of qualified officers and men in numbers which added to the officers and 1 CIRCULAR LETTER M men in other branches of the reserve will be adequate to fulfill the purpose of the Naval Reserve. The Volunteer Reserve is composed of medical officers who are not assigned to the Fleet Reserve, or the Organized Reserve, who are qualified or partially qualified for prescribed mobilization duties. Medical and dental officers of the Volunteer Reserve are divided into three classes as follows: MC-V(G)—Medical officers, commissioned and warrant, including phar- macists, qualified and available for general detail afloat or ashore. MC-V(S) —Medical officers qualified for specialist duties. MC-M —Commissioned officers qualified for duties as medical officers afloat or similar duties ashore. DC-V(G) —Commissioned dental officers qualified and available for general detail afloat or ashore. DC-V(S) —Commissioned dental officers qualified for specialist duties. Except for medical specialist units, classes V-l and V-2 and special classes of instruction composed of officers and men in the naval districts, the Volunteer Reserve is unorganized and consists of individuals to be mobilized as such and trained either individually or in groups. (e) Medical specialist units.—Medical specialist units are intended to pro- vide groups of qualified medical units, which in time of war or national emergency, will be assigned to hospital ships, station ships, or base hospitals as staffs thereof, or to augment the Regular Navy Medical Corps staffs. Each medical specialist unit is composed of eight medical officers of the Volun- teer Reserve (Special Service), one of whom is assigned as organizer and consists of a surgeon, urologist, internist, clinical pathologist, ophthal-oto-laryngologist, psychiatrist, roentgenologist, and orthopedist and in addition, one dental officer of the Volunteer Reserve (Special Service), assigned as a prosthodontist. When the unit is called into service, six nurses of the Naval Reserve Nurse Corps are included as component parts of the unit. Subject to the recommendation of the Bureau of Medicine and Surgery, each naval district is assigned a quota of medical specialist units which are organized and maintained therein. Units in excess of this quota are not authorized. The organization and disbandment of these units is made by the district commandants in accordance with instructions issued by the Chief of the Bureau of Navigation. In issuing such instructions, due consideration will be given to the recommenda- tions of the Bureau of Medicine and Surgery. The personnel of a medical specialist unit is assigned by the district commandant on recommendation by the organizer of the unit. After due allowances are made for the complete formation of the specialist units assigned to each district, an alternate for each specialist in each unit may be assigned on recommendation by the organizer of the unit to the commandant, provided the quota of medical and dental officers (Special Service) in the district is not exceeded. These alter- nates should be younger medical and dental officers qualified in the specialties. However, the alternates will not be called for service with the units unless cir- cumstances prevent the principals from serving. In time of national emergency, and provided their services are not required with the units, these alternates may be assigned to mobilization as unassigned medical and dental specialists. (f) Medical corps—merchant marine.—For appointment in this class, can- didates must be employed on passenger vessels documented under the laws of the United States, or they must be employed in connection with the seafaring profession in a capacity directly connected with the operation of ships of the American Merchant Marine. 2 Appendix D Manual of the Medical Department Bureau Circular Letter M Subject: Membership in the Association of Military Surgeons. (a) It is desired to draw to the attention of all medical officers the advantages and desirability of membership in the Association of Military Surgeons and their eligibility for membership in it. (b) The Association of Military Surgeons was incorporated by act of Congress in 1903 for the purpose of “advancing the knowledge of military surgery, medicine, and sanitation, in the Medical Department of the Army, the Navy, and the Marine hospital service of the United States and of the militia of the different States and to increase the efficiency of the different services by mutual association and the consideration of matters pertaining to the medico-military service of the United States in peace and in war.” This association is the only organization of its kind incorporated by act of Congress and may be regarded in a sense as a Government agency. (c) Commissioned medical officers (active, reserve, retired) of the Army, Navy, and Public Health Service and physicians of the Veterans’ Administration are eligible for membership in the Association of Military Surgeons. In view of the importance of the association in promoting medical preparedness and advances in military medicine, I wish to urge all those eligible to membership to join the association and thus lend their support to its work. (d) During its more than 30 years existence the association has been a most valuable agency in providing a medium for the exchange of information on medico-military subjects between medical officers of the Regular Army, National Guard, and Organized Reserves and between the officers of the Army Medical Department, the Navy Medical Department, the United States Public Health Service, and the medical service of the Veterans’ Administration. Furthermore the association is the only agency through which our medical services maintain contact with the medical services of the armies and navies of other nations. A number of foreign delegates always attend each annual meeting of the association. The work of the association in encouraging American military men to attend meet- ings of medico-military associations in foreign countries and in its publication of the proceedings of such congresses is a most valuable contribution to medico- military preparedness. The association issues the Military Surgeon, a monthly journal devoted to general professional and military medical subjects. The prin- cipal military medical journals of the world are reviewed in it; it contains a section devoted to the history of military medicine; while current notes on matters of interest to the various Government medical services are in each number. The competition for the Wellcome Medal and prize is carried on under the auspices of the association and the winning essays are published in the Military Surgeon. The cost of this journal and of membership in the association combined is $3 a year. The positions of president and first vice president of the association are held by officers of the Government services in regular rotation. There is thus an additional responsibility on the part of all services to supply an adequate mem- bership. All medical officers of the Government services are entitled to member- ship, and it is felt that this association merits the loyal support of all officers of the Medical Corps of the Navy. 1 CIRCULAR LETTER M Subject: College of Physicians and College of Surgeons. (a) The Bureau desires that applications, case reports, or other credentials of medical officers who are candidates for admission into the American College of Physicians or the American College of Surgeons be submitted not later than July 1. (b) Application blanks may be obtained by writing to the Chief of the Bureau of Medicine and Surgery, Navy Department, Washington, D. C. 2 Appendix D, Manual of the Medical Department Bureau Circular Letter M-7 Subject: Roster report of the Hospital Corps (NMSHC-4, Instructions Governing (637). (3511.) January 1, 1941. (a) The greatest care shall be exercised in preparing this report to the end that it shall be complete and accurate in all respects. This report shall always bear the signature of the representative of the medical department responsible for making it, and shall be prepared and forwarded immediately as directed in the following instructions. (b) When prepared and forwarded.— (1) Monthly.—By all ships and stations, including Marine Corps activities and recruiting stations on the first day of the month for the preceding month. (2) Quarterly.—By all district medical officers for the Fleet Reserve and Naval Reserve on April 1, July 1, October 1, and January 1. (3) Decommissioning.—Whenever an activity is placed out of commission. (c) Period covered by reports.— (1) Monthly.—The calendar month ending at midnight on the last day thereof. (2) Quarterly.—The quarter ending at midnight, March 31, June 30, September 30, and December 31. (3) Decommissioning.—The period since forwarding last report. (d) Information contained on the face of the roster report to be filled IN WHENEVER SUBMITTED. (1) The allowance “authorized” is the allowance authorized by the Bureau of Navigation, for the fiscal year concerned. (2) The allowance “on board” shall be the number of hospital corpsmen per- manently attached to the ship or station for duty. Men ordered “under instruc- tion” by the Bureau of Navigation shall not be reported in this space. (3) “Total patients” signifies the total number of patients on board on date for which the report is submitted and shall be reported by hospitals and hospital ships only. (4) “Total persons on board” signifies all officers, nurses, hospital corpsmen, patients, and all civil employees on shore stations except hospitals; all officers and enlisted men on ships and with Marine Corps activities. (5) The “percent of hospital corpsmen” to patients in hospital or to total persons on board is found by dividing the total number of hospital corpsmen shown “on board” by the total number of patients in hospital, or by the total number of persons on board, and using the figure so obtained for the percent. (6) “Enlisted, received or transferred since last report” includes all changes of station or status of all hospital corpsmen occurring since submission of the last previous report. (7) The term “staff” applies only to hospital corpsmen who are a part of the regular ship’s or station’s allowance. It does not apply to any man temporarily attached for any reason. Temporary patient, passenger, or prisoner hospital corpsmen are not to be reported as among those “on board” unless they are regu- larly transferred to the staff. Such men will be shown on the reverse of the roster 1 CIRCULAR LETTER M-7 report under the appropriate heading, e. g., “Temporary duty,” “Patients,” “Passengers,” etc. Men ordered by the Bureau of Navigation from the staff to “Under instruction” on the same station will be shown as “transferred” to instruction and “received” for instruction. (e) The information contained on the reverse of the roster report shall be sub- mitted monthly by ships and stations, quarterly by naval districts for the Fleet Reserve and Naval Reserve and whenever an activity is placed out of commission. List the names of staff personnel by groups according to rank or rating. List nonstaff personnel after staff personnel by classes according to duty status, e. g., Patients, Passengers, etc. Group each class by rank or rating. Type above each class and group the appropriate heading and arrange the names in each group alphabetically, surname first. The following instructions apply to individual groups and classes: (1) Chief pharmacists and pharmacists.—Show duty or duties assigned and the original date of reporting. (2) Staff hospital corpsmen.— List those remaining on board at end of the month. (3) Patients.—List those remaining on board at the end of the month. Do not list staff hospital corpsmen who are patients under this heading. (4) Passengers.—List those remaining on board at the end of the month, giving ship or station to which ordered. (5) Temporary duty.—List and give date and ship or station from which received. (6) Under instruction.—List only those placed under instruction by orders of the Bureau of Navigation, giving course, dates of commencement and completion of course. (7) Technicians.—List all technicians, showing the duty they are performing, and assign a mark (based on 4.0) as to their technical ability. (8) For each column the following instructions shall apply. Column I: Names grouped by rank or rating and in alphabetical order, the surname first, then the Christian name and initials, or all names in full in case two or more have the same surname. Column II: The rank or rate indicated by abbreviations; if Fleet Reserve, or Naval Reserve abbre\ iate as FR or NR and show class. Column III: The date of expiration of enlistment, shown by figures. If a man has entered into an agreement to extend enlistment, the date of expiration of enlistment will be the date of expiration of extension. 2 Appendix D, Manual of the Medical Department Bureau Circular Letter M-8 July 1, 1940. Subject: Monthly Report of Nurses. NMSH-Form 42 will be prepared and forwarded in accordance with the following instructions: (1) This report will be prepared on the last day of each month and forwarded promptly to the Bureau. In the date of this report, the month will be spelled out, e. g., December 31, 1940. For other dates in this report, the day may be entered in figures and the month and year omitted, e. g., “25” for December 25, 1940. (2) Enter names of all nurses attached to the station \mder the appropriate headings, “Chief nurses,” “Nurses,” “Reserve,” or “Temporary additional duty.” Nurses transferred to the station for treatment will be reported under a separate heading, “Under treatment.” (3) Change in status of a nurse will be promptly reported to the Bureau on NMSH-Form 45. Appendix D, Manual of the Medical Department Bureau Circular Letter M-6 January 1, 1941. Subject: Receipt, Transfer, and Disposition Card. (NMSHC-Form 3). Instructions Governing. (635) and (3510). (a) Subject card is printed on yellow paper 5 inches by 6 inches in size and is perforated across the center so as to form two 3-inch by 5-inch cards when sepa- rated along the perforated line. The upper half or receipt card, is printed in red ink, and the lower half, or transfer and disposition card, is printed in black ink. These cards fully filled out in accordance with the following instructions, shall be forwarded to the Bureau of Medicine and Surgery, immediately upon any change of station or status of a hospital corpsman. (b) General instructions.— (1) In preparing this form the surname and the Christian name or names must be spelled correctly and written out in full, surname first. (2) All dates indicated must be filled in. (3) Upon the receipt of a hospital corpsman from any source or status, the double card should be placed in the typewriter and red ink portion shall be filled in completely. Also fill in the black ink portion down to and including the arrived and date line. (4) State on both cards (red and black) if the man is a qualified technician; also indicate if he has any special qualifications for which no technician designa- tion has been made, such as ambulance driver, auto mechanic, bookkeeper, printer, draughtsman, etc. (c) Receipt card (red ink).—Forward this card for Hospital Corps personnel upon their— (1) Enlisting or reenlisting in the Regular Navy or in the Naval Reserve. (If in Naval Reserve, state class.) (2) Reporting of fleet reservist for active duty. (3) Reporting of naval reservist for active duty. (4) Reporting from another ship, station or status, to include Hospital Corps personnel: (aa) Received for further transfer. (bb) Admitted as patient for treatment. (cc) Returning to duty from treatment. (dd) Received for temporary duty. (ee) Received from temporary duty for permanent duty. (ff) Received as straggler. (gg) Received from custody of Federal or civil authorities. (hh) Received for instruction by orders from Bureau of Navigation. (it) Received from 10 or more days’ confinement, or from “awaiting trial”. (jj) Received from 10 or more days’ leave. (kk) Reservist of any class received from other ship, station, or naval district. 1 CIRCULAR LETTER M-6 (d) Transfer and disposition card (black ink).—Forward this card for Hospital Corps personnel upon their: (1) Discharge (termination of enlistment for any cause, giving character of dis- charge); death; or desertion. (2) Extension of enlistment, stating length of extension and effective date thereof. (3) Entering into agreement to extend enlistment, stating length of extension and effective date thereof. (4) Entering into agreement to reenlist on the date following that of discharge. (5) Transfer to another ship, station, or status, to include: (aa) Man transferred for further transfer (in such case indicate “Via R. S. and/or U. S. S. ).” (bb) Patient transferred. (cc) Patient discharged to duty. (dd) Transfer of staff hospital corpsman to instruction by order of the Bureau of Navigation. (ee) Man transferred from “Under instruction” to permanent duty. (ff) Man transferred from Regular Navy to Fleet Reserve, stating class of Reserve and naval district to which transferred. (gg) Reservist transferred to other naval district. (hh) Fleet Reservist recalled to active duty; or other reservist transferred for period of active training duty. (it) Reservist transferred from one class to another. (jj) Reservist transferred to inactive status upon completion of active training duty period. (kk) Man transferred to retired list. (U) Man transferred for temporary duty. (ram) Man transferred from temporary duty to permanent duty. (rm) Advancement in (including acting appointment to permanent appoint- ment), reduction in, or change of rating, stating from to , giving date, and authority. (oo) Placing of staff hospital corpsman in confinement for 10 or more days or to await trial. (pp) Departure of staff hospital corpsman on 10 or more days’ leave. (qq) Change of date of expiration of enlistment on account of “time not served” for any cause, showing number of days to be made up. (rr) Arrest by Federal or Civil authorities. (e) On the reverse of the transfer and disposition card (black ink card) under “Personal qualifications,” indicate in space provided whether hospital corpsman is superior, above average, average, below average, or unsatisfactory in applica- tion, cooperation, dependability, energy, and personality. All spaces must be filled in and the card signed by the medical officer, or commanding officer. Column IV: Original date of reporting for duty, shown by figures. Column V: Beginning of present tour of sea or shore duty, shown by figures. In cases of men who have extended their enlistment or reenlisted under continuous service, this date will be the actual date of commencement of sea or shore duty; not the date of reenlistment or beginning of extension of enlistment. Column VI: Remarks. In this column, show present detail as “Ward,” “Clerical,” “Materiel office,” “Laboratory,” “X-ray,” “Pharmacy,” “On sick list (with diagnosis),” “On leave (with expiration date),” “Confined,” “Awaiting 2 RECEIPT AND TRANSFER CARDS transfer to (this will apply to all men whose orders have been received but who have not been transferred as of date of report),” “Temporary duty at etc. If a staff hospital corpsman has been placed under instruction in any specialty by the commanding officer and has not been ordered to such instruction by the Bureau of Navigation, show assignment followed by “Instruction” and the date of commencement of course in figures, in parentheses, e. g., Laboratory (instr.—3-31-40). Note. —The words “show by figures” mean to use figures for dates, e. g. 7-1-40 for July 1, 1940. 3 MANUAL OF THE MEDICAL DEPARTMENT Appendix D Bureau Circular Letters P Planning Division TABLE OF CONTENTS Subject Date in effect Instructions on First-aid July 1, 1939 Research Under Cognizance of the Bureau July 1, 1939 P-1. First Aid Instruction and Treatment of Casualties (836) (1201) July 1, 1940 P-2. Supplies and Equipment for Landing Forces and Field Or- ganizations (1201,1231 (b)) July 1, 1940 P-3. Individual Equipment and Clothing for Field Service (1201,1229 (a), (b)) July 1, 1940 Appendix D Manual of the Medical Department Circular Letter P Subject: Instructions on First-Aid. (836). (a) First-aid supplies.—Supplies for first aid are provided by the medical department. They are expended during drills, at instruction periods, and when needed for the care of the injured. The aircraft package and the boat box (medical) are standard naval medical supply depot outfits. The contents of first-aid boxes, gun bags, and other containers for first-aid supplies are not stand- ardized by the Bureau. First-aid boxes are placed in the ship where the com- manding officer directs. Each battle station isolated from contact with medical department personnel by the materiel condition of the ship should have its own first-aid supplies to meet the probable battle need. The medical officer should recommend the location of the first-aid supplies for drill and supervise their stow- age and custody between drills. He should be responsible for the placement of first-aid supplies prior to battle. He should maintain a list, in the sick bay, of the locations and contents of all authorized first-aid containers, and be prepared to supply the necessary material when required for drill, instruction, or other authorized use. (b) Occlusive dressings.—The first-aid packet is a standard item, provided by the naval medical supply depot. The battle or large wound dressing is pro- vided as indicated in subparagraph (d). (c) First-aid packet.—Exhibit the first-aid packet and, during the course of instruction, open it and exhibit its contents. This packet is designed to cover the wounds made by bullets from small arms. A bullet or shell fragment may produce a wound of entrance and also a wound of exit if it passes out, and both wounds should be dressed. Apply a compress to each wound. (d) Battle or large wound dressings.—The battle dressings will be fur- nished by naval medical supply depots only in an emergency. When supply depot items are not available, battle dressings may be improvised as follows, and medical officers should be familiar with the method of their construction: From the standard gauze roll (of 4 thicknesses and 8)4 to 9 inches wide) cut off a length of 30 inches. First fold from side to side to diminish the width. Then fold the free ends over so that they meet in the middle. Now fold a second time along the line where the free ends meet. The length has thus been reduced to about 7 inches, the width to 4 inches, and the thickness increased to 32 layers. Tear off a piece of unbleached muslin 5 by 50 inches. Lay the gauze compress in the center of the muslin and fasten it there by sewing along the sides toward the binders and diagonally from corner to corner. Each free end of the unbleached muslin is now torn down the middle to the pad so as to give a four-tailed bandage. Fold the dressing along the center by its short dimension so that the gauze is on the inside, the muslin binders on the outside. Now fold the upper tails on them- selves in layers the width of the exposed half of the muslin back. Do the same for the lower pair. Once more the dressing is folded, but now at right angles to previous folds, so as to bring the tails or binders in opposition to each other and inside the whole. Cover with a piece of unbleached muslin, 8 by 10 inches, wrapping like an ordinary parcel and securing with a couple of stitches. Mark 1 CIRCULAR LETTER P plainly with indelible pencil, stencil, or rubber stamp. Sterilize and dry. Wrap in oiled muslin or paper. Six to a dozen of these dressings may be wrapped together in canvas and kept at each gun station in a metal box secured by padlock or seal. It will be advisable to have at dressing stations a certain number of larger battle dressings. (These will not be distributed to guns’ crews. The dimension of the larger battle dressing is 11 y* inches square.) The number of the ordinary battle dressings to be furnished in advance of an engagement should be in the ratio of 40 to each 100 of the crew; of the extra large size in the ratio of 5 to every 100 men. While there might be no call for so many shell-wound dressings during an engagement, due allowance must be made for deterioration and loss after preparation and for the possibility of wreckage of some portion of the supplies during action. Some cases may need reapplication of dressings after the engagement. Explain that in applying one of these dressings, after opening the first-aid packet or the covering of the battle-dressing packet, the surface to be applied to the wound should not come in contact with anything else, and, above all, should not be touched by the fingers. Explain the possibility of avulsion of a limb or wide tearing of the abdominal wall necessitating a large dressing as temporary cover, and why the dressings are aseptic and not antiseptic, in view of various uses to which they may be put, as for exposed intestines, brain, etc. (e) Splints.—Hospital corpsmen and crew should be given instructions in the use of splints. The United States Army Splint Manual will be found of value. (f) Hemorrhage.—Explain digital pressure. Demonstrate the application of the tourniquet by applying it to the arm of one of the class. Require that this be practiced by each member of the class; have the pulse felt by the index finger to demonstrate that the bleeding would be effectively stopped. Demonstrate the application of the tourniquet to the upper part of the thigh, the middle of the leg, and the upper arm, explaining the anatomy of arterial supply to the regions. Require that this be practiced by each member of the class under instruction, having him first apply digital pressure, then a tourniquet. Explain dangers of tourniquet. Explain how wounds of the face and scalp and trunk may be con- trolled and dressed. Improvise a tourniquet from a strip of clothing and a bayonet; demonstrate its use on the arm, having the pulse felt to indicate its efficacy. (g) Fractures.—Pieces of board, a rifle, boat stretcher, pillow, or any similar object may be used as splints. Apply splints improvised from boards to the leg, securing the same by strands of rope or pieces of clothing. Emphasize importance of securing splints in place by bandages placed well away from site of fracture. Demonstrate extension and counterextension as used for the reduction of fractures. Require the class to practice these maneuvers. Display diagrams and illustra- tions, if possible, and practice the same methods as are illustrated. (h) Special wounds.—Illustrate the application of the compress in the first-aid package to a wound of the forearm. Apply it (1) simply for the purpose of dressing the wound; (2) securely, for the purpose of controlling superficial hemorrhage. Require that these procedures be practiced by all the members of the class. Demonstrate the application of the compress to wounds of the scalp, neck, chest, abdomen, buttock, arm, forearm, thigh, leg, and foot, as the instruction progresses. Discuss first-aid measures in treatment of burns, gas and chemical injuries. (i) Resuscitation of apparently drowned.—Demonstrate the various movements used in resuscitation. 2 Appendix D Manual of the Medical Department Bureau Circular Letter P Subject: Research Under Cognizance of the Bureau. (a) A more active utilization of the facilities available through the National Research Council, is being developed by the Navy Department. In order to fully cooperate with the movement, this Bureau desires information concerning research now in progress in which individuals in the Medical Department are engaged, either individually or in conjunction with others. (b) The National Research Council offers particularly advice as to where and how desired assistance can be secured. (c) The following information is, therefore, requested from medical officers within whose jurisdiction research is being prosecuted. (1) Nature of the problem and name of investigator. (2) Place where investigation is being conducted, if not indicated by letter- head. (3) Names of collaborators if they are other than technical assistants. (4) Phases of the research problem that are beyond the capacity of the local facilities, and for which outside assistance is desired. (5) Suggestions for research projects that would reasonably produce results beneficial to the naval service. (d) It will be noted that the information desired is not confined solely to the clinical field. (e) Information of a secret or confidential nature shall be communicated in accordance with the usual safeguards prescribed by Navy Regulations. (f) It is requested that this Bureau be notified promptly when new research projects are initiated. 1 Appendix D, Manual of the Medical Department Bureau Circular Letter P-1 July 1, 1940. Subject: First-aid Instruction and Treatment of Casualties. (836, 1201.) (a) In order that all officers and enlisted personnel in the naval service may be properly drilled in first aid, instructions therein shall be given to the crew and the divisional officers by the medical officer (art. 1346 (1) N. R.). Supplemental directives concerning this instruction may be promulgated by proper authority. (b) Certain members of the crew, such as stretcher bearers, repair party groups, or others, shall be given additional instruction in first aid to battle casualties. Such additional training shall be given as directed by type commanders or other authority. (c) Ships and stations shall supply the dummy dressings necessary for first-aid instruction. A small battle dressing without its cotton filler may be constructed as follows: From the standard gauze roll (of 4 thicknesses and to 9 inches wide) cut off a length of 30 inches. First fold from sides to middle to halve the width. Then fold so that the ends meet in the middle. Now fold a second time along the line where the free ends meet. The length has thus been reduced to about 7 inches, the width to 4 inches, and the thickness increased to 32 layers. Tear off a piece of unbleached muslin 5 by 72 inches. Lay the gauze compress on the center of the muslin strip and fasten it there by sewing along the ends and diag- onally from corner to corner. Each free end of the unbleached muslin is now torn down the middle to a point 6 inches from the pad so as to give a four-tailed bandage. Fold the pad at the center of its short dimension, gauze surfaces on the inside, muslin surface outside. Then fold the upper tails on themselves in layers the width of the upper half of the muslin back. On top of them the other two tails are similarly folded. Once more the dressing is folded, this time at right angles to previous foldings, so as to bring the tails of the binder in apposi- tion to each other and inside the dressing. Cover with a piece of unbleached muslin, 8 by 10 inches, wrapping like an ordinary parcel and securing with pins or thread. Mark with indelible pencil, stencil or rubber stamp, and sterilize. (d) The references listed in the following table should be used by instructors but are not to be considered restrictive. However, a full use of these references will result in more uniform instruction throughout the service. 1 CIRCULAR LETTER P-1 Subject References Drill Book for Hospital Corps, U. S. Navy, 1920 Hand- book of the Hospital Corps, U. S. Navy, 1939 Landing Force Manual, U. S. Navy, 1939 The Blue- jacket’s Manual, 1938 Chapters Pages Articles Pages (1) Handling, lifting, and transportation with and without VII 14-30 to 14=33 278-296 89-93 14-23, 14=24 269-272 93-98 14-25 267-269, 272,273 (4) Resuscitation of the apparently drowned and of the electri- 120-122, 123 14-51, 14-45 321-323 88,89 14-26 (6) Emergency treatment of burns and chemical and gas injuries. 116,117, 862-872 14-43, 14-44, 14-39 296, 297, 304 (7) Splinting and lifting for fractures of long bones and spine 105-114, 148-157 14-29 274-278 2 Appendix D, Manual of the Medical Department Circular Letter P-2 Subject: Supplies and Equipment for Landing Forces and Field Organizations. (1201, 1231 (b).) (a) The quantity and type of supplies and equipment provided by the Bureau of Medicine and Surgery for the use of Medical Department personnel serving with landing forces and organizations in the field are shown in the following publi- cations : (1) Field supply table of the Medical Department, U. S. Navy, 1927 (under revision). (2) Pamphlet on Field Supplies and Equipment, Medical Department, U. S. Navy, 1940 (under preparation). This pamphlet will be included as an item in Field Medical Supply Unit No. 5-A. (b) Materials which are provided by the U. S. Marine Corps to Medical De- partment personnel and organizations attached to the Fleet Marine Force are shown in the pamphlet (a) (2) above. This list is extracted from the Master Table of Tonnage Data and Basic Allowance for Fleet Marine Force Units, U. S. Marine Corps, 1940, and the Marine Corps Manual, art. 15-19 (6, 7). (c) The pamphlet, (a) (2) above, contains information under the following subheadings: (1) Introduction. (2) Field Medical Supplies and Equipment. (3) Rotating Stores in Field Medical Supply Units. (4) Table I.—Basic Allowance of Field Medical Supply Units for Ships. (5) Table II.—Basic Allowance of Field Medical Supply Units for Marine Corps Organizations. (6) Figure I.—Schematic Representation of Distribution of Medical Support in Landing Operations. (7) Tactical Distribution and Use of Field Medical Supply Units. (8) Analysis of Contents.—Field Medical Supply Units. (9) Table III.—Articles Furnished by U. S. Marine Corps to Medical Personnel or to Medical Organizations. (10) Field Uniforms.—Medical Department Personnel. July 1, 1940. 1 Appendix D, Manual of the Medical Department Bureau Circular Letter P-3 Subject: Individual Equipment and Clothing for Field Service. (1201, 1229(a), (b).) References: (a) Marine Corps Equipment, Supply and Tonnage Tables. (5) Marine Corps Manual, art. 15-19 (6, 7). (a) Individual equipment.— The following items of individual equipment will be issued by the Marine Corps quartermaster to medical department personnel who are serving with Marine Corps organizations in the field or in training for such service. Medical officer Chief petty officer Hospital corpsmen 1 Belt, pistol, web.. 1 1 1 1 1 1 2 2 Cover, for _ 1 2 2 Cup, for 1 2 2 1 1 1 1 1 1 3 3 1 1 Can, meat w/cover 1 1 1 1 Fork __ 1 1 1 Knife _ 1 1 1 1 Spoon-. 1 1 1 1 1 Helmet, steel- .V. 1 1 1 Knife, hospital corps-.. 1 1 Scabbard, for. I 1 1 Mask, gas 1 1 1 first aid 1 1 1 Pouch, for 1 1 1 Poncho. 1 1 1 Roll, bedding, v/pad 1 1 Roll; clothingl _ . 1 1 Tag, identification 2 2 2 Tape, for, yards. 1 1 1 Tent, shelter, each half 2 1 1 Line, guy, for 2 1 1 Pin, tent, for 10 5 5 2 1 1 1 1 1 1 1 Cot, field. 1 1 1 Net, mosquito, cot... 1 1 1 Net, mosquitoi head 1 1 1 (b) Clothing.— Naval officers are not issued items of clothing. The kind and quantity of Marine Corps uniforms required, worn with bronzed naval insignia (see Uniform Regulations, U. S. Navy, art. 134), may be purchased by officers of the Navy after CIRCULAR LETTER P-3 arrival at a Marine Corps post. It is usually impracticable to wear naval service uniforms in the field. Hospital corpsmen on duty with Marine Corps organizations in training for field activities will be issued the following articles of clothing gratuitously: Badges, rating, or mark, Hospital Corps (as required). 1 belt, trousers, woven. 1 belt, service, with buckle. 1 cap, garrison, service, summer. 1 cap, service, winter. 1 coat, service, winter. 1 hat, field, with head strap. 1 ornament, hat, bronze. 2 ornaments, collar, bronze, pair. 1 overcoat (when required by climatic conditions). 1 scarf, service, cotton. 2 shirts, cotton or flannel. 2 trousers, service, summer. 1 trousers, service, winter. Appendix D MANUAL OF THE MEDICAL DEPARTMENT Bureau Circular Letters R Physical Qualifications and Medical Records Division TABLE OF CONTENTS Subject Date in effect Ranks and Rates and Their Abbreviations July 1, 1939 Vasectomy July 1, 1939 Change in Visual Requirements for Midshipmen on Admission to the Naval Academy July 1, 1939 Physical Examinations for Aviation, Where Made — July 1, 1939 NMS-Aviation Form-1, Change in Instructions July 1, 1939 Visual Requirement for Candidates for Midshipman July 1, 1940 Reports, Modification of July 1, 1940 R-6. Certificate of Death, NMS-Form N, Instructions Govern- ing (ch. 19 sec. 1: 3424) July 1, 1940 R. Physical Requirements for Aviation Personnel July 1, 1940 Appendix D Manual of the Medical Department Bureau Circular Letter R Subject: Ranks and Rates and Their Abbreviations. The following ranks and rates and their abbreviations have been established by the Bureau of Navigation Manual and the Marine Corps Manual and will be employed as directed in paragraph 2252 of this manual. (a) Staff Corps, etc., shall be indicated by the following abbreviations, in parentheses, immediately following the abbreviations for ranks, e. g., Capt. (M. C.), Lieut. Comdr. (S. C.)., etc.: Medical Corps (M. C.) Dental Corps (D. C.) Supply Corps (S. C.) Chaplain Corps.. (Ch. C.) Construction Corps (C. C.) Civil Engineer Corps. (C. E. C.) Professors of mathematics (Math.) Retired (Ret.) Coast Guard Service (C. G. S.) Public Health Service (P. H. S.) Lighthouse Service (L. H. S.) (b) Nurse Corps (female): Superintendent Supt. Assistant superintendent Asst. Supt. Chief nurse Ch. Nurse. Nurse.. Nurse. Reserve nurse Res. Nurse. (c) Seaman Branch: Boatswain’s mate C. B. M., B. M. lc., etc. Coxswain Cox. Gunner’s mate.. C. G. M., G. M. lc., etc. Torpedoman.. C. T. M., T. M. lc., etc. Turret captain C. T. C., T. C. lc. Quartermaster. C. Q. M., Q. M. lc., etc. Signal man C. S. M., S. M. lc., etc. Fire controlman C. F. C., F. C. lc., etc. Seaman.. Sea. lc., Sea. 2c. Apprentice seaman A. S. (d) Artificer Branch: Electrician’s mate C. E. M., E. M. lc., etc. Radioman C. R. M., R. M. lc., etc. Telegraphers 1 C. T., T. lc., etc. Carpenter’s mate.. C. C. M., C. M. lc., etc. Patternmaker.. Pmkr. lc., Pmkr. 2c., etc. Shipfltter C. S. F., S. F. lc., etc. Sailmaker’s mate S. M. M. lc., S. M. M. 2c., etc. Printer C. Prtr., Prtr., lc., etc. Painter Ptr. lc., Ptr. 2c., etc. Artificer Branch, engine-room force: Machinist’s mate C. M. M., M. M. lc., etc. Water tender - C. W. T., W. T. lc., etc. Boilermaker C. Bmkr., Bmkr. lc., Bmkr. 2c. Metalsmith _ C. Msmth., Msmth. lc., Msmth. 2c. Molder Mldr. lc., Mldr. 2c. Fireman F. lc., F. 2c., etc. 1 Ratings not authorized in time of peace in the regular Navy. 1 CIRCULAR LETTER R (e) Special Branch: Yeoman C. Y., Y. lc., etc. Storekeeper C. S. K., 8. K. lc , etc. Pharmacist’s mate C. Ph. M., Ph. M. lc., etc. Hospital apprentice.. H. A. lc., H. A. 2c. Bandmaster Bmstr. First musician 1st Mus. Musician Mus. lc., Mus. 2c. Buglemaster... C. Bgmstr., Bgmstr. lc., Bgmstr. 2c. Bugler . Bug. lc., Bug. 2c. (f) Commissary Branch: Commissary steward C. C. Std. Ship’s cook S. C. lc., S. O. 2c., etc. Baker Bkr. lc., Bkr. 2c., etc. (g) Messman Branch: Officer’s steward Off. Std. lc., etc. Officer’s cook Off. Ck. lc., etc. Mess attendant M. Att. lc., M. Att. 2c., etc. (h) Aviation Branch: Aviation machinist’s mate A. C. M. M., A. M. M. lc., etc. Aviation metalsmith . A. C. M., A. M. lc., etc. Aviation carpenter’s mate A. C. C. M., A. C. M. lc., etc. Aerographer C. Aerog., Aerog. lc., etc. Photographer C. P., P. lc., etc. Aviation ordnanceman A. O. O. M., A O. M. lc., etc. (i) Marine (enlisted): Sergeant major SgtMaJ. Master gunnery sergeant MOySgt. Master technical sergeant MTSgt. Quartermaster sergeant QMSgt. Paymaster sergeant PMSgt. First sergeant IstSgt. Gunnery sergeant GySgt. Technical sergeant TSgt. Drum major Dim MaJ. Supply sergeant SupSgt. Platoon sergeant PISgt. Staff sergeant StfSgt. Sergeant Sgt. Mess sergeant MessSgt. Chief cook... ChCk. Field music sergeant FMSgt. Corporal Corp. Mess corporal Mess Corp. Field cook FdCk. Field music corporal FMCorp. Private first class PFC. Assistant cook ACk. Field music first class FM.ld. Private Pvt. Field music FM. 2 Appendix D Manual of the Medical Department Bureau Circular Letter R Subject: Vasectomy. Requests have been received regarding the Bureau’s attitude on the performance of the operation of double vasectomy within the naval service for the purpose of sterilization. The performance of the operation referred to double vasectomy for the sole purpose of sterilization is extremely controversial from many angles and the Bureau does not authorize this operation to be performed at a naval facility or by a medical officer of the United States Navy. Subject: Change in Visual Requirements for Midshipmen on Admission to the Naval Academy. In view of the number of rejections at the Naval Academy because of defec- tive color perception, the attention of medical officers is invited to paragraph 1428 (6), Manual of the Medical Department, which provides that all candidates for the Naval Academy shall satisfactorily pass the complete Stilling’s test. In conducting this test, medical officers shall see that candidates do not recite the plates from memory. Subject: Physical Examinations for Aviation, Where Made. (1543.) The following stations and ships are provided with the necessary equipment and trained personnel to conduct the physical examination for flying: Shore stations: Navy Yard dispensary: Boston, Mass.; Philadelphia, Pa. Naval hospital: Newport, R. I.; Canacao, P. I. Headquarters, Third Naval District, New York, N. Y. Naval air station: Lakehurst, N. J.; Anacostia, D. C.; Norfolk, Va.; Pensacola, Fla.; San Diego, Calif.; Seattle, Wash. Naval Academy, Annapolis, Md. Marine Barracks, Quantico, Va. Naval Reserve aviation base: Opa-Locka, Fla.; Robertson, Mo.; Kansas City, Mo.; Minneapolis, Minn.; Grosse lie, Mich.; Glenview, 111.; Long Beach, Calif.; Oakland, Calif. Marine Corps flying field, St. Thomas, V. I. Fleet air base: Coco Solo, C. Z.; Pearl Harbor, T. H. Activities afloat: Staff, aircraft Battle Force. Staff, aircraft Scouting Force. Staff, battleships, Battle Force. Staff, cruisers, Scouting Force. U. S. S. Saratoga, Lexington, Ranger, Yorktown, Enterprise, Wright, Langley. 1 CIRCULAR LETTER R Subject: NMS-Aviation Form-1, change in instructions. (a) Paragraph 4 of instructions on NMS-Aviation Form-1 which requires the forwarding of confidential letter is hereby canceled. (b) In the future, the following procedure shall be followed in examining and reporting upon individuals found not physically qualified or aeronautically adapted for duty involving flying: (1) Original examination (applicants for flight training): When, on original examination for flying, an applicant for flight training is found physically dis- qualified for the performance of such duty the report of examination (NMS- Aviation Form-1) will be submitted, via the commanding officer, in accordance with existing instructions. Abnormalities disclosed in the neuropsychiatric examination shall be included in the report of examination. (2) Examination of designated personnel: Student naval aviators, aviation cadets undergoing regular flight training, student aviation pilots, qualified naval avia- tors, qualified naval aviation pilot and qualified naval aviation observers who, on physical examination for flying, are considered not qualified for the perform- ance of their flying duties shall appear before a board of medical examiners, of which at least one member shall be a flight surgeon, for the purpose of establishing the nature of their defects and their qualifications for performance of: 1. Duty involving flying. 2. General duty not involving flying. In the event the defects disclosed as the result of such examination are consid- ered sufficient to disqualify for the performance of general duty not involving flying, the examinee shall appear before a board of medical survey in accordance with instructions contained in the Manual of the Medical Department. (c) The report of findings and recommendation of the board of medical exam- iners, together with the report of physical examination for flying (NMS-Aviation Form-1), shall be forwarded via official channels to the Bureau. (d) The foregoing instructions are not intended to apply to flying personnel who may be disqualified for the performance of their duties because of disabilities con- sidered as temporary. The disposition of such cases shall continue in accordance with existing policy. 2 August 21, 1939. Appendix D Manual of the Medical Department Bureau Circular Letter R SUBJECT: Visual Requirement for Candidates for Midshipman. REFERENCE: Manual of the Medical Department, 1938, paragraph 1432 (a). (a) The Secretary of the Navy has approved the following change in the Manual of the Medical Department, 1938. In paragraph 1432, at the end of subparagraph (a) add the following sentence: “Hypermetropia, including hypermetropic astigmatism, of more than two diopters shall cause the rejection of the candidate.” (b) In the above reference and elsewhere in the manual the use of a cycloplegic is required in the examination of candidates for midshipman. The Bureau directs that homatropin 4% shall be the cycloplegic used in this refraction. (c) Insert this change in Appendix D as the last sheet under Bureau Circular Letters R. In reference paragraph insert this notation “See circular letter R”. Reference paragraph as revised will be reprinted at a later date. Appendix D of the Manual of the Medical Department Bureau Circular Letter R Subject: Reports, modification of. References: Manual of the Medical Department 1938: (1) Paragraph 1529. (2) Paragraph 2206. (3) Paragraph 3423. (a) The Secretary of the Navy has approved the following changes in the Manual of the Medical Department, effective this date: (1) In paragraph 1529 add a new subparagraph as follows: “(c) When an enlisted man of the regular service is examined for transfer to the Fleet Reserve, a report of the physical examination shall be submitted to the Bureau on N MS-Form Y. This report shall show whether or not the man is physically qualified for active duty at sea. (See par. 2206 (g).)” (2) In paragraph 2206, subparagraph (g) modify the last sentence and add new sentence to read as follows: “Entries shall be made in both the old and in the new health record show- ing whether the individual is physically qualified for active duty at sea. No recommendations for ‘shore duty only’ shall be made. Any physical defects noted at time of transfer to the Fleet Reserve must be carefully recorded. (See par. 1529 (c).)” (3) In paragraph 3423, subparagraphs (i) to (1) inclusive are changed to read as follows: “(i) Reports of medical survey shall be made out and submitted to the Bureau via the commanding officer and the officer convening the board. The Bureau requires the original and three copies of each report. “O') After the Bureau has acted on the report, copies will be forwarded to the Bureau of Navigation or to the Major General Commandant, U. S. Marine Corps, in case of Marine Corps personnel, and one of these copies, showing the action taken by the Navy Department on the report, will be returned to the activity from which it originated for the information or com- pliance of the commanding officer. “(k) No patient who has been surveyed will be disposed of until the activity submitting the report has been informed, by receipt of the returned copy, or otherwise officially notified, of the action taken by the NaVy Department on the report. “(Z) When recruits with less than 6 months’ service are surveyed, an extra copy of the report will be prepared in each case and forwarded to the Bureau via the recruiting office where the man was enlisted for the medical officer’s information and comment.” (g) Insert this change in appendix D as the last sheet under Bureau Circular Letters R. In reference paragraphs insert this notation. “See circular letter R for change.” Reference paragraphs as revised wfill be reprinted at a later date. Decembek 8, 1939. 1 Appendix D, Manual of the Medical Department Bureau Circular Letter R-6 July 1, 1940. Subject: Certificate of Death, NMS-Form N, Instructions Governing. (Ch. 19 Sec. 1; 3424.) (a) Copies of certificate of death (form n) required.—The original and four legible copies of the certificate shall be forwarded to the ‘Bureau of Medicine and Surgery. Forward one copy only for supernumeraries other than ex-service naval personnel. One copy shall accompany the body when required. In a fleet, send an additional copy to the Commander in Chief. Retain a file copy. (b) Instructions governing submission of certificate of death (form n).— (1) Retired personnel.—Certificates for retired naval personnel saall be pre- pared and forwarded to the Bureau of Medicine and Surgery by the medical officer having cognizance of the case. In the event that the deceased was not under the professional care of a medical officer of the Navy at the time of death, the medical officer of the naval district within which the individual died shall obtain a certificate of death from the proper civil authorities and shall prepare and forward Form N to the Bureau. (2) Fleet Reserve.—Certificates shall be prepared for transferred members of the Fleet Reserve (16- and 20-year men) in the same manner as for personnel on the retired list. (3) Inactive Reserve.—Certificates shall not be prepared for personnel of the Naval Reserve, (other than Fleet Reserve) on inactive duty. However, in lieu thereof, a report of death in letter form shall be prepared to include all pertinent information obtainable, such as name in full; rank or rate; file or service number; date and place of birth; source of information; date, place, and cause of death; and name and address of next of kin. This letter shall be forwarded to the Bureau of Navigation. A copy of this letter, together with the terminated health record, shall be forwarded to the Bureau of Medicine and Surgery. (4) Veterans’ Administration Patients.—Certificates shall be prepared in cases of Veterans Administration patients and forwarded direct to the Veterans Admin- istration (district manager). Forward one copy to the Bureau of Medicine and Surgery. (5) Supernumeraries.—Certificates in cases of ex-service naval personnel who were carried at the hospital as supernumerary patients, shall be prepared and for- warded to the Bureau of Medicine and Surgery, together with medical history sheets. In case of supernumeraries other than ex-service naval personnel, for- ward only one copy of certificate to the Bureau. (6) Death Occurring While on Leave, etc.—When naval personnel die while on leave, or in a civilian hospital at home or abroad, or under other circumstances where the services of a medical officer of the Navy were not available, the medical officer of the ship or station to which the deceased was attached shall obtain a certificate of death from the proper civil authorities. The medical officer shall then prepare the certificate and forward to the Bureau, together with the support- ing papers and terminated health record. 1 CIRCULAR LETTER R-6 (7) Death occurring while aioaiting orders, detached duty, etc.—For naval personnel on waiting orders, or detached or independent duty, or not directly attached to any command, the medical officer of the naval district within which the individual dies shall prepare the certificate from such facts as may be in his possession. (8) Death of service personnel at St. Elizabeths Hospital.—Upon the death of naval personnel in St. Elizabeths Hospital for the Insane, a certificate shall be prepared by the medical officer of the Navy assigned to duty in that institution. (c) Instructions governing preparation of certificate of death (form n).— (1) The cause(s) of death shall be accurately determined and all means avail- able and necessary for this purpose should be used. Attention is called to the duty of medical officers to make postmortem examinations under certain condi- tions. Autopsy findings shall be entered on the certificate in all cases. (2) The cause(s) of death, both principal and contributory (joint, secondary), shall be stated in the terms of the U. S. Navy Nomenclature of Disease and In- juries, with diagnosis number(s), and key letter(s) in cases of injury. (3) In cases where the death is obvious, and the body has not been recovered, the certificate shall be prepared and forwarded to the Bureau. Line No. 11 shall read “body not recovered.” (4) In cases of disappearance, where death has not been definitely established, a certificate shall not be prepared until final action has been taken by the Depart- ment in the case. (5) In cases where the misconduct and line of duty status have not been estab- lished, enter “undetermined” on line No. 10. Otherwise, the misconduct status shall be stated in every case. (6) When retired officers or transferred fleet reservists die while under the care of a medical officer, a statement shall be made that the disease or injury causing death “is” or “is not” connected with previous service. (7) Whenever two or more morbid conditions enter into the causation of a death, particular care shall be exercised in determining which is the principal cause of death. In this determination, morbid conditions resulting directly or indirecth' from external causes, serious operations, or perforation of important organs must be given careful consideration. The principal cause of death usually is the disease, injury, or complication of longest duration which terminates in death. In general, as the principal cause of death, any one of the chief infective diseases is preferred to any other cause of death; a disease more frequently fatal than the others which may be present; and an acute disease to one which is chronic. Contributory causes of death are important complications of the principal cause; morbid conditions related to but not complications of the principal cause; and important diseases or conditions present with the principal cause. (8) The “Summary of facts relative to the death” shall contain.—Pertinent facts concerning the origin (misconduct) of the disability causing death; important diagnostic data, antemortem and postmortem (if autopsy is held); character and date of operations; duration and principal points in the course of the fatal disease, injury, or poisoning; and other facts supporting the statement of cause of death. (9) “Disposition of remains” refers to the disposition of the body made by the ship or station to which the deceased was attached. Do not hold the form until the finial disposition or place of interment is known. If known, enter date and place of interment. (10) State whether or not a Court of Inquiry or a Board of Investigation will be held. 2 NMS—FORM N (11) A rolled impression of the right index finger shall be made in space pro- vided on Form N. (12) In order that the identity of a body may be positively established, the rolled impression of the right index finger shall be compared with the prints found in the service record. Further identification shall be made with personal characteristics such as marks, scars, teeth, etc., noted in health record and service record. (13) All requests for copies of certificates shall be forwarded to the Bureau of Medicine and Surgery for action. Appendix D, Manual of the Medical Department Bureau Circular Letter R July 1, 1940. Subject: Physical Requirements for Aviation Personnel. SERVICE GROUPS, NAVAL AVIATORS (a) For the purpose of assignment to unrestricted flight duties, pilots of naval aircraft (heavier-than-air), are divided into three service groups. The policies relating to these service groups, and the physical requirements prescribed for each, as approved by the Bureau of Navigation, are: 1. Service group 1—(aa) Definition of employment.—Pilots with less than 20 years’ naval service. Unrestricted flying. (bb) Physical requirements.—The physical requirements shall be the same as now set forth in section XXIII, chapter II, of the Manual of the Medical Depart- ment, U. S. Navy. 2. Service group 2—(aa) Definition of employment.—Pilots with from 20 to 30 years’ naval service. Will not be assigned to VF squadrons or as active student instructors unless their special fitness therefor has been determined. (bb) Physical requirements.—(For unrestricted flying within the service group.) The physical requirements shall be the same as prescribed for service group 1, with the following exceptions: (1) Visual acuity shall be not less than 10/20 for each eye unaided by glasses, provided that where visual acuity is less than 13/20 for either eye, it shall be corrected by lenses to 20/20 and the correction shall be worn while flying. (2) Depth perception shall not exceed 35 mm. with glasses. (3) Accommodation below the requirements for age is permissible, provided that accommodation for each eye shall not be less than 3 diopters without correction. (4) Moderate defects of hearing may be permitted, but shall not exceed the mini- mum of 7/15 whispered voice, binaural. 3. Service group 3—(aa) Definition of employment.—Pilots with 30 or more years’ naval service who normally will be expected to perform flights in executive or broad command status. Solo flying will be performed in such basic types of naval aircraft as may be prescribed by the Chief of the Bureau of Aeronautics as deemed commensurate with their physical and service qualifications. (bb) Physical requirements.—(For unrestricted flying within the service group.) The physical requirements shall be the same as prescribed for service group 1, with the following exceptions: (1) Visual acuity shall be not less than 8/20 for each eye, unaided by glasses, provided that where visual acuity is less than 13/20 for either eye, it shall be corrected by lenses to 20/20 and the correction shall be worn while flying. (2) Depth perception shall not exceed 35 mm. with glasses. (3) Accommodation below the requirements for age is permissible, provided that accommodation for each eye shall not be less than 3 diopters with the aid of glasses, which correction shall be worn while flying. (4) Heterophoria: Muscle balance of the eyes shall be within the standards prescribed for service group 1, provided however, that where the examinee has defective vision which is correctible by glasses within the limits prescribed in subparagraph (a) 3 (bb) (1) above, such 1 CIRCULAR LETTER R correction may be worn while undergoing the test for heterophoria and shall be worn while flying. (5) The angle of convergence test may be omitted, unless specifically indicated with relation to other associated findings near the dis- qualifying limits. (6) Hearing shall be the same as prescribed for service group 2. (7) Blood pressure: Th3 diastolic blood pressure shall not exceed 95 mm. Hg. The systolic blood pressure shall normally not exceed 155 mm. Hg. (b) Should any pilot fail to meet the physical requirements prescribed for unrestricted flying in one of the foregoing groups, such failure shall be set forth in the report of physical examination for flying (NMSAv-Form 1), with the inclusion for consideration of one of the following recommendations: 1. Be permitted to continue unrestricted flight status of his service group sub- ject to waiver by the Bureau of Navigation. 2. Be restricted to flight .duties next higher service group, i. e., from 1 to 2, or 2 to 3. 3. Be restricted to flight duties of a lessened tempo commensurate with present (temporary) physical condition. (Limited to pilots recuperating from injuries or hospitalization.) 4. Restricted to flight duties requiring one unrestricted pilot-of service group 1 or 2 in the plane. 5. Flight status ceases. (c) The reports of physical examination for flying (NMSAv-Form 1) shall be prepared and forwarded to the Bureau of Medicine and Surgery in accordance with existing instructions. NONFLYING PERSONNEL (d) Physical requirements for nonflying personnel groups 8 to 10, inclusive, (paragraph 1539 (a), Manual of the Medical Department, U. S. Navy) are as follows: 1. Naval aviation observer.—For naval aviation observer, candidates shall nor- mally be required to meet the standard physical requirements prescribed for the general service with the following additional requirements for flying, namely, accommodation of the eyes, circulatory efficiency, nasopharynx, equilibrium, and the neuropsychiatric examination. However, for assignment to flying duty as tactical reconnaissance observer or aircraft gunnery observer, personnel shall in addition to the physical requirements specified for naval observer, have vision of not less than 20/20 in each eye, unaided by glasses, and shall have normal color vision as determined by the Stilling’s test. Reports of examination shall be made on NMSAv-Form 1, as provided in paragraph 1564 of the Manual of the Medical Department, U. S. Navy. 2. Naval flight surgeon.—Naval flight surgeons ordered to duty involving flying (not in control of aircraft), shall meet the standard physical requirements pre- scribed for naval aviation observer (general), subparagraph (c) (1) above. Report of examination shall be made on NMSAv-Form 1, as provided for naval aviators. 3. Student naval flight surgeon.—The physical requirements prescribed for student naval flight surgeons are the same as those prescribed for qualified naval flight surgeons, provided that for the purpose of flight indoctrinal training, in order to be physically qualified to solo elementary type aircraft, vision shall be not less than 15/20 each eye, unaided by glasses, and depth perception shall not exceed 25 mm. Failure to meet these special requirements of the eyes shall serve to disqualify for solo flying only, but shall not disqualify for other indoctrinal training involving flying, leading to the designation of flight surgeon. The 2 PHYSICAL REQUIREMENTS report of examination shall be made on NMSAv-Form 1, as provided in paragraph 1540, Manual of the Medical Department, U. S. Navy. 4. Antiaircraft and aircraft machine gunners.—Antiaircraft and aircraft machine gunners shall meet the general physical requirements provided for naval observer (general), subparagraph (c) (l) above, with the following additional requirements: (go) Vision shall be not less than 20/20 for each eye unaided by glasses. (bb) Depth perception shall be not more than 25 mm. as now prescribed for naval aviators. (cc) Color vision shall be normal as determined by the Stilling’s test. (ee) Normally, the eyes will not be refracted. However, where evidence of myopia is suspected, the eyes will be refracted and evidence of myopia will disqualify. (ff) Personnel designated for assignment to duty as antiaircraft and aircraft machine gunners shall report for physical examination by a flight surgeon prelim- inary to such duty. Local commanding officers shall require such personnel under their command to be physically examined in accordance with these standards, once each year. An entry shall be made in the special duty abstract of the indi- vidual’s health record indicating the result of the examination, and the responsible commanding officer officially notified as to the individual’s physical qualifications for such duty. Report of this physical examination will not be made to the Bureau of Medicine and Surgery, the entry in the health record will serve for this purpose. 5. Other nonflying personnel, group 10 {par. 1539 (a), Manual of the Medical Department, V. S. Navy).—Other nonflying personnel ordered to duty involving flying, for which specific physical requirements have not been prescribed, shall, preliminary to engaging in such flying duties, be examined physically to determine their physical fitness to engage in aerial flights. The examination shall relate primarily to the circulatory system, equilibrium, neuropsychiatric stability, patency of the eustachian tubes, with such additional consideration as the in- dividual’s specific flying duties may indicate. The result of these examinations will be entered in the special duty abstract of the individual’s health record and their respective commanding officers notified as to their physical qualifications, No report of these examinations will be submitted to the Bureau of Medicine and Surgery. 3 Appendix D MANUAL OF THE MEDICAL DEPARTMENT Bureau Circular Letters X Naval Medical Center Section I. The Naval Medical School TABLE OF CONTENTS Subject Date in effect Service, Medical July 1, 1939 Blood Groups, Designation of July 1, 1939 Section II. The Naval Dental School Service, Dental July 1, 1939 Appendix D Manual of the Medical Department Bureau Circular Letter X Subject: Service, Medical (a) Clinical, service.—The Naval Medical School provides the Medical Center and the general service, on request, the following clinical diagnostic facilities—electrocardiography, basal metabolism determinations, and clinic for physical examinations, allergy, endocrinology, and other special problems for clinical investigation. The Naval Medical Center will upon request, addressed to the commanding officer, render opinion and recommendation on clinical problems. Complete clinical data should be forwarded including name and rank or rate of patient, where attached, tentative diagnosis and other clinical information such as laboratory findings, microscopic slides, and x-rays when indicated. All items should bear clear identification marks to avoid confusion as to origin of item and localization of lesion. In joint conditions of the limbs, x-ray of the corresponding unaffected part should be included. X-ray pictures of fractures should be taken in two directions as nearly perpendicular to each other as possible. In chest cases stereograms should be taken if available apparatus permits, and also a lateral and left oblique. Postal Regulations permit mailing noninflammable film “when packed in sufficiently strong containers; each outside container shall be plainly marked “X-ray films—not dangerous." (b) Laboratory service.—The Naval Medical School provides routine clinical laboratory service to the Medical Center and to the general service on request. (1) Tissue specimen.— 1. The gross specimen is particularly desired. However, if this is not practicable sections of not less than 2 centimeters square should be forwarded The simplest preservative is 10 percent formalin to which a small piece of calcium carbonate has been added. Unless the tissue is well fixed before being prepared for shipment, 10 times its volume of fixative solution is neces- sary. If the tissue is to be examined for protozoan infestation, fix it in Zenker’s fluid for 12 to 24 hours. Preparation of Zenker’s fluid: Mercuric chloride 5.0 grams. Potassium dichromate 2.5 grams. Distilled water 100 c. c. Add 5.0 cubic centimeters of glacial acetic acid just before using. Remove the tissue after 12 to 24 hours. Wash in water for 12 hours. Mail in 70 percent alcohol tinged with iodine. Caution.—Do Dot leave tissue in Zenker’s fluid longer than 24 hours. 2. The following form presents the detail and form of clinical data required to accompany tissue specimen: 1 CIRCULAR LETTER X Request for Pathological Examination From. Date. To: Naval Medical School, Department of Pathology, Washington, D. C. 1. It is requested that a histopathological examination be made on the following specimen of tissue forwarded in 10 percent formalin solution. For protozoa, special fixation is necessary. See instructions (b) (3) 1. of this letter. Antemortem. Postmortem. CLINICAL HISTORY Name Age Race Sex Occupation Location of lesion Duration Gross appearance Blood findings: W. B. C R. B. C Hgb% Differential Serological reaction (Kahn) Remarks Clinical Diagnosis. _ Signature S. Specimens for tumor registry.—Sections, or part of the gross tissue of all tumors removed, shall be forwarded to the United States Naval Medical School, Washington, D. C., for registration, accompanied by pertinent clinical data, necropsy and any histopathological reports. The objects of this registry are to compile a central file wherein data is available at any time for the service at large; to operate as a check on clinical diagnosis by histo- pathological methods, and for instruction purposes. (2) Blood specimen.— 1. Serological.—Blood for serological examination (Kahn test, etc.) should be taken from a vein or collected in a Wright’s tube and set aside until the clear serum separates from the clot. The serum should then be removed by means of a capillary pipette and forwarded in sealed capillary tubes or small vials. Minimum amounts forwarded should be 2.5 cubic centimeters of blood serum. It is important that strict asepsis be observed in collecting specimens of this nature. 2. Chemical examination.—Blood for chemical examination may be sent as oxalated blood (1.0 mgm. lithium oxalate per cubic centimeter of whole 2 MEDICAL, SERVICE blood or 2.0 mgm. of potassium oxalate per cubic centimeter of whole blood) or as a filtrate after (Folin-Wu) tungstic acid precipitation of the proteins. Samples should be guarded against bacterial contamination. Minimum amounts should be 15 cubic centimeters of whole blood or 60 cubic centi- meters of the filtrate. The use of too much oxalate must be avoided. The data accompanying the specimen should give the method of preparation. Sugar will disappear rapidly after 20 hours, especially if the specimen be agitated, but other substances for Which examination is ordinarily made will yield results sufficiently accurate for clinical purposes for about 2 days. S. Blood films.—At least six well-prepared films, unstained and fixed in absolute methyl alcohol, dried and forwarded in a suitable container which should have provision for the separation of the slides. (3) Stool specimen.— 1. To be examined for intestinal protozoa.—The stool should be fixed and preserved in Schaudinn’s solution. A portion of the fresh stool in the amount of about 2 grams is well mashed up in 5 to 10 times the amount of fixative (preservative). (Schaudinn’s solution is made up as follows: Two volumes of a saturated solution of mercuric chloride in water and one volume of 95 percent ethyl alcohol—stock solution. Immediately before use, glacial acetic acid is added to the strength of 5 percent.) The specimen should be shipped immediately. The label on the bottle and the request for examina- tion should note that the specimen is fixed and preserved in Schaudinn’s solution. 2. To be examined for helminth eggs.—The stool should be fixed 20 minutes in hot 10 percent formalin (4 percent formaldehyde gas). After fixation the material should be gradually transferred to 70 percent ethyl alcohol for pres- ervation. (The label on the bottle containing the specimen and the request for examination should note that the specimen has been fixed in formalin and is being shipped in 70 percent ethyl alcohol.) S. To be examined for worms.—Worms, adult and larval forms, should be placed directly in hot (80° C.) 70 percent ethyl alcohol where they may remain indefinitely. (Label on container should specify preservative used.) (4) Water specimen.— 1. Chemical analysis.—The accompanying letter should state whether a sanitary or mineral analysis is desired, and also the source from which the water was obtained (spring, well, etc.), locality, and any other pertinent in- formation. The minimum amount required for a sanitary analysis is 1 gallon and for a mineral analysis is 3 gallons, the latter to be forwarded in 1-gallon containers. 2. Bacteriological examination.—In collecting samples of water for bac- teriological examination, the following precautions should be observed. Forward at least 100 cubic centimeters of water in sterile containers. Time elapsing between collection and beginning of the analysis should not be more than 6 hours for impure water and not more than 12 hours for relatively pure water. If the specimen is to be sent some distance, it should be packed in ice. Do not pack in dry ice. (5) Toxicological specimen.—A complete history is important. In case of autopsy material forward at least the following material in clean, sterile glass containers packed in ice: Stomach, containing contents; intestines, about 3 feet, 3 CIRCULAR LETTER X containing contents; urine remaining in bladder; and liver and kidney 200 grams each. If forwarded some distance, in place of ice, cover material with 5 percent formalin solution and include in a separate container a sample of the formalin solution used. Where examination of material for volatile poisons, such as ether or alcohol, is desired, the material may be shipped in ice or frozen with dry ice. Certain cases will require material in addition to the above. Reference should always be made to a standard work on toxicology. When in doubt as to the exact material or the quantity of the material to forward, a letter giving the history of the case and the kind and extent of the examination wanted should be addressed to the Commanding Officer, United States Naval Medical School Washington, D. C. (6) The laboratories are also prepared to make analyses of samples of air and milk. (7) Testing of materials —The laboratories are prepared to test certain materials including insulin and hypochlorite preparations. (8) Photography.—The Naval Medical School maintains photographic labora- tory facilities and is prepared to furnish the following types of work: Clinical and general photo-micrography reproduction ana copying including microfilm repro- duction of records. It can render assistance in illustrative work. (9) Multigraphing and mimeographing.—This service is available to the Medical Center and Bureau. 4 Appendix D Manual of the Medical Department Bureau Circular Letter X Subject: Blood groups: Designation of. (a) In the future, the International Classification, using letters to replace the Jansky numerical classification, will be the official method of reporting blood groups, in the Medical Department of the United States Navy. (b) Distributed among the red blood cells of three of the four recognized groups are two agglutinogens termed, respectively, A and B, A being present in group A, B in group B, both in group AB, and neither in Group O. (O really means "zero.”) Thus the designations adopted, by using the letters O, A, B, AB, indi- cate directly the agglutinogen content of the red blood cells. Cells of group Serum of groups 0(I)‘ A (II) B (III) AB (IV) 0 (I)* - A (II) + _ + _ B (III) - + — AB (IV) - - + + + _ International classification ’Numerals indicate Jansky classification. — Indicates no agglutination. + Indicates agglutination. Group 0: Red blood cells contain no agglutinogens and are therefore not agglu- tinated by sera of any group. Members of this group are known as ‘‘universal donors.” Group A: Red blood cells contain agglutinogen A and are not agglutinated by sera of groups A or AB. In other words no agglutination with sera of groups showing the letter A. (Attention is invited to a paper, The International Classi- fication Groups, U. S. Naval Medical Bulletin, 1928, XXVI: 603.) Group B: Red blood cells contain agglutinogen B and are not agglutinated by sera of groups of B or AB. In other words, no agglutination with sera of groups showing the letter B. Group AB: Red blood cells contain agglutinogens A and B in combination and are not agglutinated by the serum of group AB. In other words, no agglutination with the one group showing letters AB in combination. Important.—In order to avoid the danger existing when either donor or recipi- ent belongs in an atypical group, in addition to grouping donor and recipient, direct matching should always be carried out prior to transfusion. 1 Appendix D Manual of the Medical Department Bureau Circular Letter X Subject: Service, Dental. (a) The Naval Dental School is one of the administrative units included in the Naval Medical Center and is commanded by an officer of the Dental Corps who is charged with all duties relating to its administration and is responsible for its efficiency. (b) The Naval Dental School will offer commissioned and enlisted personnel of the naval establishment such courses of instruction as may from time to time be determined by the Bureau to accord with current needs of the service. The school will also furnish dental prosthetic treatment for authorized cases. (c) The course of instruction for dental officers will cover such period as may be determined by the Bureau, and will consist of a course of postgraduate instruction and indoctrination and will embrace the following subjects: Clinical dentistry, prosthodontia, radiology, oral surgery and anesthesia, manual of the medical department, duties of dental officers afloat and ashore, chemical warfare gases, battle organization afloat; naval regulations, naval customs, traditions and usages. Instruction in expeditionary or field service. Standardization of dental operating room routine and control; procurement, custody and disposition of naval dental instruments and equipment; dental records and reports; collateral duties of a dental officer. In all these subjects special attention shall be given to those features pertaining to the practical duties of naval dental officers with the objective of rendering efficient dental service. (d) Course of instruction for dental technicians (general).—(1) To pro- vide for the training of additional hospital corpsmen as dental technicians (general), classes to receive approximately 4 months instruction will be organized at the Naval Dental School twice a year, in February and September. The following conditions will be brought to the attention of prospective candidates: (2) Any hospital corpsman, regardless of rating is eligible. His request for instruction should have the indorsement of a dental officer as to his aptitude or qualifications for this training, and his request forwarded to the Bureau for approval. (3) Prospective candidates should have 30 months obligated service or agree to extend their enlistments. (e) Course of instruction for dental technicians (prosthetic).—Dental technicians (general) who desire to qualify as dental technicians (prosthetic) should make application to the Bureau. The application should have the indorse- ment of the dental officer as to the dental technicians mechanical inclination and aptitude for this extended training, and if approved by the Bureau they will be recommended for transfer to a naval dental prosthetic laboratory for instruction in this specialty, and upon successfully completing this training will be issued a certificate, and be designated dental technician (prosthetic). (f) Hospital corpsmen who were formerly designated dental technician and who are desirous of resuming this specialty may make application to the Bureau to be redesignated dental technicians. 1 Appendix D MANUAL OF THE MEDICAL DEPARTMENT Bureau Circular Letters Y Preventive Medicine Division TABLE OF CONTENTS Subject Date in effect The Control of Communicable Diseases July 1, 1939 Form A, Instructions July 1, 1939 Emergency Oxygen Administration Apparatus July 1, 1939 Heating and Ventilation July 1, 1939 Field and Camp Sanitation July 1, 1939 Tetraethyl Lead July 1, 1939 Bismosol—Precautions Regarding July 1, 1939 Thio-Bismol July 1, 1939 Dispatches; Use of Navy Diagnosis Numbers in July 1, 1939 Disinfecting Stations July 1, 1939 Quarantine Inspection and Fumigation of Aircraft July 1, 1939 INSTRUCTIONS Bureau Circular Letter Y, titled The Control of Communi- cable Diseases,has been completely revised and reprinted. This reprint replaces, and shall be substituted for, a similar letter on this subject in Appendix D of the Manual of the Medical Department. Appendix D Manual of the Medical Department Bureau Circular Letter Y-l April 1, 1941. Subject: The Control of Communicable Diseases. Reference: (a) Reprint No. 1697, from Public Health Reports, United States Public Health Service (Revised 1940). (b) Manual of the Medical Department, paragraph 2616. 1. The United States Public Health Service has granted this Bureau permission to reprint reference (a) for inclusion in this appendix. This public document was published in Public Health Reports, Vol. 50, No. 32, August 9,1935. It was revised in 1936 and published as refer- ence reprint No. 1697. 2. This report defines terms and describes the communicable dis- eases briefly from the epidemiological viewpoint. It provides au- thentic data and is included here for information and guidance in the control of communicable diseases in the Navy. 3. The report of a committee of the American Public Health Asso- ciation as reprinted in reference (a) follows: In October 1916 a committee of the Health Officers’ Section of the American Public Health Association was appointed to prepare standard regulations for the administrative control of the communicable diseases for which notification is usually required by State and municipal health authorities throughout the United States. The report of this committee was published in Public Health Reports, volume 32, No. 41, October 12, 1917. This report was revised during 1926 by the successor of the original committee, to reconcile it with advances in the medical sciences in the previous 10 years. The revised report, approved by the American Public Health Association on Octo- ber 14, 1926, and officially approved by the United States Public Health Service, was published in the Public Health Reports, volume 41, No. 51, December 17, 1926. The general form of presentation and much of the matter of the 1926 revision was used in the Report of the Committee on Communicable Disease Control of the White House Conference, published in 1931. The revision published in 1935, Public Health Reports, volume 50, No. 32, August 9, 1935, was made by the Subcommittee on Communicable Disease Con- trol, of the Committee on Research and Standards of the American Public Health Association, and it was officially approved by the United States Public Health Service. The present revision has been called for because of immediate needs connected with military training and the advisability of having procedures for communicable disease control based as nearly as practicable upon identical and authoritative information. The Subcommittee on Communicable Disease Control of the Committee on Research and Standards of the American Public Health Association has been responsible for the present text as officially approved by the Association and by the United States Public Health Service. The terms used are first defined. Each disease is briefly described with regard to its clinical and laboratory recognition, the etiological agent, the source of infection, the mode of transmission, the incubation period, the period of commu- nicability, susceptibility and immunity, and prevalence. Following this are described methods of control—first, those affecting the indi- vidual, contracts, and immediate environment; and second, general and specific measures bearing upon the control or prevention of the disease in question. 2 CONTROL OF COMMUNICABLE DISEASES Inasmuch as the laws under which various boards and departments of health operate require differences in the legal phraseology of rules, regulations, or sec- tions of sanitary codes dealing with the control of communicable diseases, the committee has refrained from preparing formal regulations under each disease. As the report is at present submitted, any health officer, board of health, or legis- lative body having the power to make rules or regulations, or to enact sections of sanitary codes dealing with the control of communicable diseases can, by ref- erence to the description of the disease and recommendations for methods of control herewith presented, prepare the necessary text upon which the educa- tional and administrative acts of the health officer will be based.* The present committee is indebted, as its predecessors have been, for expert opinion and critical comment upon its provisional text, to many physicians and others, both within and without the Association, and acknowledgment of their contributions to the accuracy and completeness of the report in its present form is herewith gratefully expressed. Haven Emerson, M. D., Chairman; James A. Doull, M. D.; James P. Leake, M. D.; Ralph S. Muckenfuss, M. D.; Alton S. Pope, M. D.; George H. Ramsey, M. D.; Ernest L. Stebbins, M. D.; Subcommit- tee on Control of Communicable Diseases of the Committee on Research and Standards of the American Public Health Associa- tion. Lists of Diseases Principal List List of communicable diseases for which notification is usually required in the States and cities of the United States Page Actinomycosis 6 Anthrax 6 Chickenpox (varicella) 8 Cholera 8 Conjunctivitis, acute infectious (of the newborn, not including trachoma) 10 Dengue 10 Diphtheria 11 Dysentery, amebic (amebiasis)— 12 Dysentery, bacillary 14 Encephalitis, infectious (lethargic and nonlethargic) 15 Favus 16 German measles (rubella) 17 Glanders 17 Gonorrhea 18 Hookworm disease (ancylostomi- asis) / 19 Influenza 20 Leprosy 22 Malaria 22 Measles (rubeola) 24 Meningococcus meningitis (cere- brospinal fever) 26 Mumps (infectious parotitis) 27 Paratyphoid fever 27 Page Plague, bubonic, septicemic, pneu- monic ; . 29 Pneumonia, acute lobar 30 Policnnlyelitis 31 Psittacosis , 32 Puerperal infection (puerperal septicemia) 33 Rabies 34 Rocky Mountain spotted (or tick) fever 35 Scarlet fever (scarlatina) 35 Septic sore throat 37 Smallpox (variola) 38 Syphilis 39 Tetanus 40 Trachoma 41 Trichinosis 42 Tuberculosis, pulmonary 44 Tuberculosis, other than pulmo- nary 45 Tularemia 46 Typhoid fever 47 Typhus fever 49 Undulant fever (brucellosis) 49 Whooping cough (pertussis) 50 Yellow fever 51 ♦In endeavoring to prepare an informative text rather than to propose standard proce- dures, or describe the prevailing practices of health departments, the opinion of the committee unhampered by tradition or local usage has been expressed. CONTROL OF COMMUNICABLE DISEASES 3 Supplementary Lists A Communicable diseases or infestations occurring in the United States and Insular Posses- sions, but for which notification to the health authorities is not everywhere required Page Aseariasis 53 Coccidioidomycosis (coccidioidal granuloma, “Valley fever”) 54 Common cold 55 Filariasis 55 Hemorrhagic jaundice (spiroche- tosis icterohemorrhagic, Weil’s disease) 56 Impetigo contagiosa 57 Lymphogranuloma venereum (in- guinale) and climatic bubo1 58 Page Pediculosis (lousiness) 59 Rat-bite fever (sodoku) 59 Relapsing fever 60 Ringworm (dermatophytosis) 61 Scabies (the itch) 61 Schistosomiasis 62 Vincent’s infection (Vincent’s an- gina, ulcerative or necrotic stomatitis, trench mouth) 63 Yaws (frambesia) 64 Diseases of concern to health officers because of their group or epidemic occurrence and the practicability of their prevention, and for these reasons often included among those notifiable to the health authority, but not to be considered communicable Page Page Botulism 65 Pellagra 66 Food infections and poisonings— 66 The committee adopted the following definitions of terms: 1. Carrier.—A person who, without symptoms of a communicable disease, harbors and disseminates the specific micro-organisms. As distinct from a carrier, the term “infected person” is used to mean a person in whose tissues the etiological agent of a communicable disease is lodged and produces symptoms. 2. Cleaning.—This term signifies the removal by scrubbing and washing, as with hot water, soap, and washing soda, of organic matter on which and in which bacteria may find favorable conditions for prolonging life and virulence; also the removal by the same means of bacteria adherent to surfaces. 3. Contact.—A “contact” is any person or animal known to have been suffi- ciently near an infected person or animal to have been presumably exposed to transfer of infectious material directly, or by articles freshly soiled with such material. 4. Delousing.—By delousing is meant the process by which a person and his personal apparel are treated so that neither the adults nor the eggs of Pediculus corporis or Pediculus capitis survive. 5. Disinfection.—By this is meant the destroying of the vitality of pathogenic micro-organisms by chemical or physical means. When the word “concurrent’’ is used as qualifying disinfection, it indicates the application of disinfection immediately after the discharge of infectious material from the body of an infected person, or after the soiling of articles with such infectious discharges, all personal contacts with such discharges or articles being prevented prior to their disinfection. When the word “terminal” is used as qualifying disinfection, it indicates the process of rendering the personal clothing and immediate physical environment of the patient free from the possibility of conveying the infection to others, at the time when the patient is no longer a source of infection. 6. Disinfesting.—By disinfesting is meant any process, such as the use of dry or moist heat, gaseous agents, poisoned food, trapping, etc., by which insects and animals known to be capable of conveying or transmitting infection may be destroyed. 7. Education in personal cleanliness.—This phrase is intended to include all the various means available to impress upon all members of the community, young and old, and especially when communicable disease is prevalent or during epidemics, by spoken and printed word, and by illustration and suggestion, the necessity of: (1) Keeping the body clean by sufficiently frequent soap and water baths. 1 This title does not include granuloma venereum (inguinale), which is a different clinical condition. 4 CONTROL OF COMMUNICABLE DISEASES (2) Washing hands in soap and water after voiding bowels or bladder and always before eating. (3) Keeping hands and unclean articles, or articles which have been used for toilet purposes by others, away from mouth, nose, eyes, ears, and genitalia. (4) Avoiding the use of common or unclean eating, drinking, or toilet articles of any kind, such as towels, handkerchiefs, hairbrushes, drinking cups, pipes, etc. (5) Avoiding close exposure of persons to spray from the nose and mouth, as in coughing, sneezing, laughing, or talking. 8. Fumigation.—By fumigation is meant a process by which the destruction of insects, as mosquitoes, fleas, bedbugs, and body lice, and animals, as rats, is accomplished by the employment of gaseous agents. 9. Isolation. **—By isolation is meant the separating of persons suffering from a communicable disease, or carriers of the infecting micro-organism, from other persons, in such places and under such conditions as will prevent the di- rect or indirect conveyance of the infectious agent to susceptible persons. 10. Quarantine.*—By quarantine is meant the limitation of freedom of move- ment of persons or animals who have been exposed to communicable disease for a period of time equal to the longest usual incubation period of the disease to which they have been exposed. It is still considered necessary to require strict isolation of the patient for the period of communicability, and quarantine or immunization of contacts in certain diseases, notably smallpox. However, in some other diseases, such as poliomyelitis and encephalitis, isolation of the patient has but little apparent effect in limiting the spread of the disease, and the period of communicability is not known with reasonable accuracy in any given case. Case-to-case infection is relatively infrequent in these latter two diseases; and yet the patient must be regarded as a potential source of infection and suit- able precautions must be taken, even if these barriers to transmission of the dis- ease are but partially effective. Uncertainty as to the exact duration of the period of communicability does not justify neglect of reasonable isolation meas- ures but rather adds to our obligation to educate patients, the family, and the attending physician in the advantages to be had from separating the sick from the well, and in taking precautionary measures voluntarily when the presence of a communicable disease is suspected and before a -diagnosis is established, after the official period of isolation is past, and generally during the epidemic prev- alence of such diseases in the community. The five specific objectives of personal cleanliness as defined above (7), if conscientiously attempted, will materially aid in reducing the amount and fre- quency of infection. Isolation of a patient with a communicable disease from visitors is often of benefit to the patient by reducing the likelihood of additional and complicating infections, as well as a protection to others; quiet, freedom from excitement and fatigue of visits, and complete rest are important factors in the medical and nursing management of such patients and directly contribute to recovery. 11. Renovation.—By renovation is meant, in addition to cleansing, such treat- ment of the walls, floors, and ceilings of rooms or houses as may be necessary to place the premises in a satisfactory sanitary condition. 12. Report of a disease.—By report of a disease is meant the notification to the Health Department and, in the case of communicable disease in animals, also to the respective Department of Agriculture, or Livestock Sanitary Author- ity which has immediate jurisdiction, that a case of communicable disease ex- ists or is suspected of existing in a specified person or animal at a given address. Each administrative health jurisdiction will ordinarily determine what diseases should be reportable, according to their prevalence or their practical importance from the points of view of the administrator, the epidemiologist, and the statis- tician. It is expected that local or State regulation will require the reporting of any unusual or group expression of illness which may be of public concern whether 2 In view of the various ambiguous and inaccurate uses to which the words “isolation” and “quarantine” are not infrequently put, it has seemed best to adopt arbitrarily the word “isolation” as describing the limitation put upon the movements of the known sick or “carrier” individual or animal, and the word “quarantine” as describing the limitations put •upon exposed or “contact” individuals. 2 When the term “isolation” is used in connection with such diseases as the common cold. Influenza, chickenpox, and mumps, it is not to be understood that the establishment of iso- lation is, under ordinary circumstances, a necessary or practicable procedure for official requirement or enforcement, but a practice to be instituted under the direction of the attending physician, and its duration to be generally, if not exclusively, at his discretion. CONTROL OF COMMUNICABLE DISEASES 5 or not known to be or suspected of being communicable in nature, regardless of its inclusion in the lists on pages 2 and 3. 13. Susceptible.—A “susceptible” is a person or animal who is not known to have become immune to the particular disease in question by natural or artificial process. 14. Virus, filterable.—The term “filterable virus” as defining the etiological agent of certain diseases is used in the sense of a causal agent differentiated from other kinds of infectious agents such as bacteria, protozoa, etc. Many of these filterable viruses can be grown in vitro in the presence of living susceptible cells and such cultures will produce regularly typical diseases in animals and in man. The term “filterable virus” has a significance comparable to that of bacterium, spirochete, or protozoon. The term “filterable virus” is as definite a description of an etiological agent as is the statement that the typhoid bacillus causes typhoid fever. The idea conveyed by the statement that a filterablb virus is the etiological agent is that the cause of this disease is known, even though present knowledge does not permit further precision in distinguishing among fil- terable viruses except by reference to the name of the disease produced by each. The items considered necessary for presentation by the committee with regard to each disease are the following: 1. Recognition of the disease; clinical criteria ; laboratory verification. 2. Etiological agent. 3. Source of infection. 4. Mode of transmission. 5. Incubation period. 6. Period of communicability. 7. Susceptibility and immunity. 8. Prevalence. 9. Methods of control: A. The infected individual, contacts, and environment. 1. Recognition of the disease and reporting. 2. Isolation. 3. Concurrent disinfection. 4. Terminal disinfection. 5. Quarantine. 6. Immunization. 7. Investigation of source of infection. B. General measures. C. Epidemic measures (occasionally requiring separate mention). Therapy, whether nonspecific or specific, is not considered to come within the scope of administrative control of communicable diseases, except in a few instances in which there is obligation or authority to provide materials and services for the treatment of infected individ- uals with the object of abbreviating the duration of the communicable stage of the disease. Wherever specific therapeutic products are best, or only available through the facilities or funds of the Department of Health, the provision of these, as well as the provision of labora- tory diagnostic aids, is a recognized function of the Department of Health in the interest of early, accurate, and effective treatment of in- fected persons. Numerous products used in the treatment of or for the develop- ment of immunity against communicable disease are supplied by many State and city health departments from their own laboratories or by purchase from commercial sources, such as those used in diphtheria, smallpox, tetanus, rabies, meningococcus meningitis, syphilis, pneu- monia of certain types, etc. Certain measures in the control of some diseases are of particular importance, on account either of their efficiency in preventing the IMPORTANT MEASURES IN BOLD-FACED TYPE CONTROL OF COMMUNICABLE DISEASES disease or of the danger of its spread if they are neglected, and also on account of their proved practicability. These are emphasized in the text by being printed in bold-faced type. Principal List Actinomycosis 1. Recognition of the disease.—A local or general, acute or chronic suppurative process combined with growth of connective tissue, and characterized by the presence in the lesions of vegetations or colonies of the specific micro- organism, identifiable by microscopic examination of discharges from the lesions. It may be confused with pulmonary or generalized tuberculosis. 2. Etiological agent..—Actinomyces hominis and other species of this genus. 3. Source of infection.—Unknown. Possibly in some cases of actinomycosis in man, Actinomyces hominis previously existed as a saprophyte in the oral cavity (carious teeth, interstices between teeth, and crypts of tonsils), 4. Mode of transmission.—Among cattle, principally by grains, grasses, and other cattle fodder, and stable bedding contaminated by discharges from lesions of the disease, infecting abrasions or wounds of oral cavity or body surface. It is not probable that the disease is transmitted from man to man. It may be transmitted from animal to man, but only rarely and indirectly through infection of oral or skin wounds by contaminated materials. The disease sometimes follows extraction of carious or broken teeth, or accidental injury, particularly to the jaws. 5. Incubation period.—Undetermined and variable. 6. Period of communicability.—As long as open lesions remain, as proved by the presence of the infectious agent on microscopic or cultural tests. 7. Susceptibility and immunity.—Susceptibility in cattle and man is general. Acquired immunity does not follow occurrence of the disease in man, and artificial immunity is not practicable. 8. Prevalence.-—Infrequent among humans. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms, con- firmed by microscopic examination of discharges from the lesions. 2. Isolation: None, provided the patient is under adequate medical supervision. 3. Concurrent disinfection: Of discharges from lesions and articles soiled therewith. 4. Terminal disinfection: By thorough cleansing. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: In some cases exposure to infected cattle may be important. B. General measures: 1. Observance of hygiene of oral cavity. 2. Inspection of meat, with condemnation of carcasses or infected parts of carcasses of infected animals. 3. Destruction of known animal sources of infection. Anthrax 1. Recognition of the disease.—Two forms occur—external, due to direct inocula- tion through a cut or abrasion, and internal, caused by ingestion or inhala- tion of the bacilli or their spores. Following the initial papule and vesicle at the external site of inoculation, an eschar develops and then hard edema- tous swelling of deeper and adjacent tissues. Freedom from pain is usual. Constitutional symptoms do not parallel the gravity of the lesions. Con- firmation by microscopic examination of the lesions and discharges for B. anthracis. Internal anthrax resembles intestinal poisoning, toxic pneu- monia, or meningitis; the recovery of the bacilli from the blood or spinal fluid confirms the diagnosis. 2. Etiological agent.—Anthrax bacillus, Bacillus anthracis. 3. Source of infection— Hair, hides, flesh, and feces of infected animals. CONTROL OF COMMUNICABLE DISEASES 7 4. Mode of transmission.—Inoculation as by accidental wound or scratch, inhala- tion of spores of the infectious agent, ingestion of insufficiently cooked meat, and mechanically by flies and mosquitoes. 5. Incubation period.—Within 7 days, usually less than 4. 6. Period of communicability.—During the febrile stage of the disease and until lesions have ceased discharging. Infected hair and hides of infected animals may communicate the disease many months after slaughter of the animal and after drying of hide, fur, or hair, unless disinfected. 7. Susceptibility and immunity.—Man is not as susceptible as the domestic animals, especially the herbivora, but more so than the carnivora. Im- munity may develop following an attack of the disease. Artificial active immunity, widely used for domestic animals, is not appropriate for humans. 8. Prevalence.—Rare and sporadic in humans and associated only with the oc- currence of the disease in cattle, or with handling hide and hair products from infected animals. In epidemic form in cattle in various foreign countries from time to time. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical and bacteriolog- ical. 2. Isolation of the infected individual until the lesions have healed. 3. Concurrent disinfection: Of the discharges from lesions and articles soiled therewith. Spores can be killed only by special measures such as steam under pressure or burning. 4. Terminal disinfection: Thorough cleaning. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Search for the product of the infected animal, and trace to origin for discovery of disease in sporadic or epidemic form in domestic animals, where it will be found in all but rare instances. B. General measures: 1. Animals ill with disease presumably anthrax should be isolated immediately in the care of a veterinarian. Animals proved to have the disease should be killed and promptly destroyed, preferably by incineration. 2. Immunization of exposed animals under direction of the United States Department of Agriculture, or State livestock sanitary authority. 3. Post-mortem examination should be made only by a veterinarian or in the presence of one. 4. Milk from an infected animal should not be used during the febrile period. 5. Control and disinfection of effluents and trade wastes and of areas of land polluted by such effluents and wastes from factories or premises, where spore-infected hides or other infected hide and hair products are known to have been worked up into manufactured articles. 6. Every shipment of raw hides, wool, hair, or bristles from sources which are not known to be free from anthrax infection should be examined by an expert bacteriologist. 7. A physician should be constantly employed by every company handling raw hides, or such companies should operate under the direct supervision of a medical representative of the health department. 8. Every employee handling raw hides, hair, or bristles who has an abrasion of the skin should immediately report to a physician. 9. Special instruction should be given to all employees handling raw hides in regard to the necessity of personal cleanliness. 10. Tanneries and woolen mills should be provided with proper ven- tilating apparatus so that dust is promptly removed before reaching the respiratory tract of human beings. 11. Disinfection of hair, wool, and bristles from sources known to be or suspected to be infected, before they are used or sorted. 8 CONTROL OF COMMUNICABLE DISEASES 12. The sale of hide from an animal infected with anthrax should be prohibited. A violation of this regulation should be im- mediately reported to the appropriate State livestock sanitary authority by telegram, stating the time, place, and purchaser to whom the hide was sold. The report should also be sent to the person purchasing the hide. Carcasses should be dis- posed of under the supervision of the appropriate livestock sanitary authority. Imported hides are subject to regulations administered by the United States Bureau of Animal Industry. In the event that infection is introduced, the State livestock sanitary authorities have jurisdiction over infected animals and the local or State health authorities have jurisdiction over infected persons. Chickenpox (Varicella) 1. Recognition of the disease.—Clinical picture is of an acute disease with a slight fever, mild constitutional symptoms, and an eruption, maculopapular for a few hours, often not observed, vesicular lasting 3 to 4 days, leaving a granular scab. Vesicles tend to be more abundant on the covered than on the exposed parts of the body, and frequently appear in different stages on the same region of the body. The vesicles may be so few as to escape observation. 2. Etiological agent.—A specific filterable virus. 3. Source of infection.—The infectious agent is presumably present in the lesions of the skin and of the respiratory tract; lesions of the latter, appearing early and sometimes inapparent, may render the disease communicable before the exanthem is in evidence. 4. Mode of transmission,—Directly from person to person; indirectly through articles freshly soiled by discharges from an infected person. 5. Incubation period.—Two to three weeks. 6. Period of communicability.—Probably not more than 6 days after the appear- ance of the first crop of vesicles, and certainly not more than 10 days. Especially communicable in the early stages of the eruption. One of the most readily communicable of diseases. 7. Susceptibility and immunity.—Susceptibility is practically universal among those who have not previously had the disease. An attack confers per- manent immunity, with rare exceptions. Passive temporary immunity may be conferred by the use of convalescent serum from those recently recovered. 8. Prevalence.—Universal. Probably 90 percent of persons have had the disease by the time they are 15 years of age. Not uncommon in early infancy. Winter and spring are seasons of greatest prevalence in North America* 9. Methods of control: A. The infected individual, contacts, and environment; 1. Recognition of the disease and reporting: The chief public health importance of this disease is that cases thought to be chickenpox in persons over 15 years of age, or at any age during an epidemic of smallpox, are to be investigated to eliminate the possibility of their being smallpox. 2. Isolation: Exclusion from school, and avoidance of contact with nonimmune persons should be made effective. 3. Concurrent disinfection : Articles soiled by discharges from lesions. 4. Terminal disinfection: Thorough cleaning. 5. Quarantine: None. 6. Immunization : Passive immunization of susceptible children may be of value in institutions when exposure is feared, or under exceptional conditions in individual cases. 7. Investigation of source of infection: Of no importance unless in persons over 15 years of age or when smallpox is suspected or is locally prevalent. B. General measures: None. Cholera 1. Recognition of the disease.—In a few mild cases, diarrhea may be the chief or only symptom. In the typical case, rice-water stools, vomiting, and general CONTROL OF COMMUNICABLE DISEASES 9 symptoms of dehydration occur with thirst, pain, and coma. The cholera vibrios are found in the stools. 2. Etiological agent.—Cholera vibrio, Vibrio comma. 3. Source of infection.—Bowel discharges and vomitus of infected persons, and feces of convalescent or healthy carriers. Ten percent of contacts may be found to be carriers. 4. Mode of transmission.—By food and water polluted by infectious agent; by contact with infected persons, carriers, or articles freshly soiled by their discharges; by flies. 5. Incubation period.—One to five, usually three, days, occasionally longer if the healthy carrier stage, before development of symptoms, is included. 6. Period of communicability.—Usually 7 to 14 days or longer and until the infectious organism is absent from the bowel discharges. A high degree of communicability is usual. 7. Susceptibility and immunity.—Susceptibility is general, although natural immunity appears to exist to a limited degree. Acquired immunity is uncertain. Active artificial immunity for about 1 year may be obtained by vaccines. 8. Prevalence.—Absent in North America (except when introduced from abroad). Appears in epidemic form frequently in the Philippines. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms con- firmed by bacteriological examination of stools. 2. Isolation of patient in hospital or screened room during com- municable period. 3. Concurrent disinfection: Prompt and thorough disinfection of the stools and vomited matter. Articles used by and in con- nection with the patient must be disinfected. Food left by the patient should be burned. 4. Terminal disinfection: The room in which a sick patient was isolated should be thoroughly cleaned. 5. Quarantine: Contacts for 5 days from last exposure, or longer if stools are found to contain the cholera vibrio. 0. Immunization: Prophylactic immunization of contacts is useful and advisable. 7. Investigation of source of infection: Search for unreported cases and carriers. Investigate possibility of infection from polluted drinking water or from contaminated uncooked foods. B. General measures: 1. Rigid personal prophylaxis of attendants by scrupulous cleanli- ness, disinfection of hands each time after handling patient or touching articles contaminated by dejecta, the avoidance of eating or drinking anything in the room of the patient, and the prohibition of those attendant on the sick from entering the kitchen. 2. The bacteriological examination of the stools of all contacts to determine carriers. Isolation of carriers. 3. Water should be boiled, if used for drinking or toilet pur- poses, or if used in washing dishes or food containers, unless the water supply is adequately protected against contamination or is so treated, as by chlorination, that the cholera vibrio cannot survive in it. 4. Careful supervision of food and drink: Where cholera is prevalent, only cooked foods should be used. Food and drink after cooking or boiling should be protected against contamination, as by flies and human handling. C. Epidemic measures: Inspection service for early detection and isolation of cases; examination of persons exposed in infected centers for detec- tion of carriers, with isolation or control of carriers; cleaning of rooms occupied by the sick, and the detention, in suitable camps for 5 days, of those desirous of leaving for another locality. Those so detained should be examined for detection of carriers. 10 CONTROL OF COMMUNICABLE DISEASES Conjunctivitis, Acute Infectious (of the Newborn, not including Trachoma) (This title to replace the terms Gonorrheal ophthalmia, Ophthalmia neona- torum, and Babies’ sore eyes.) 3. Recognition of the disease.—Acute redness and swelling of the conjunctiva of one eye or of both eyes, with muco-purulent and purulent discharge in which the infecting micro-organism is identifiable by microscopic and cultural methods. 2. Etiological agent.—The gonococcus or some member of a group of pyogenic organisms, including the hemoglobinophilic bacilli. 3. Source of infection.—Discharges from conjunctivae, or adnexa, or genital mucous membranes of infected persons. 4. Mode of transmission.—Contact with an infected person or with articles freshly soiled with discharges of such person. 5. Incubation period.—Irregular, but usually 36 to 48 hours. 6. Period of communicability.—During the course of the disease and until the discharges from the infected mucous membranes have ceased. Readily communicable. 7. Susceptibility and immunity.—Susceptibility is general. Acquired immunity does not follow an attack of the disease. 8. Prevalence.—Occurrence varies widely according to the observance or neglect of prophylactic use of a solution of silver nitrate or equivalent prepara- tion in the eyes of the newborn by the attendant at the delivery. An infrequent complication in the present-day care of the newborn. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease: Clinical symptoms, confirmed where possible by bacteriological examination 2. Isolation: None, provided the patient is under adequate medical supervision. 3. Concurrent disinfection: Disinfection of conjunctival discharges and articles soiled therewith. 4. Terminal disinfection: Thorough cleaning. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection—among persons recently in contact with the patient: The disease in the newborn is almost always due to infection from the genital tract of the mother. B. General measures: 1. Use of silver nitrate solution in the eyes of the newborn; ante- partum treatment of mother if gonorrhea is suspected. 2. Systemic treatment with an appropriate chemotherapeutic agent, such as sulfapyridine or sulfathiazole. 3. Education as to personal cleanliness and as to the danger of the use of common towels and toilet articles. 4. Carrying out of the measures indicated in methods for control of gonorrhea. Dengue 1. Recognition of the disease.—An acute febrile infection of sharp onset, usually with two paroxysms of short duration. Intense headache, joint and muscle pains, and irregular eruption are usual. 2. Etiological agent.—A specific filterable virus. 3. Source of infection.—The blood of infected persons during first 5, usually dur- ing first 3, days of the disease. 4. Mode of transmission.—By the bite of infected mosquitoes, Aedes aegypti (or Aedes albopictus in the oriental tropics), from 11 days after biting a patient until the death of the mosquito. 5. Incubation period.—Three to 15 days, most often 5 or 6 days. 6. Period of communicability.—From the day before onset to the fifth day of the disease. Degree of communicability depends on prevalence of in- fected humans and abundance of Aedes aegypti mosquitoes. 7. Susceptibility and immunity.—Susceptibility apparently universal. Acquired immunity may be temporary, but is usually permanent. CONTROL OF COMMUNICABLE DISEASES 11 8. Prevalence.—Occurs only where the vector Aedes mosquitoes exist, mainly in tropics and subtropics. When occurring in epidemic form in the United States, begins usually in southernmost States, moving north until the range of the vector mosquito is stopped by climate or the season of the year. Common, and in frequent epidemics, in the Philippines. Oc- curs equally among males and females; less among indigenous than among visiting or transient whites where the disease commonly occurs. 9. Methods of control: A. The infected individual, contacts, and environment. 1. Recognition of the disease and reporting. 2. Isolation: The patient must be kept in a screened room. 3. Concurrent disinfection: None. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Search for unreoorted or undiagnosed cases and for the Aedes aegypti mosquito and its breeding places. B. General measures: Measures directed toward elimination of mos- quitoes (Aedes aegypti). Screening of rooms. Diphtheria 1. Recognition of the disease.—An acute febrile infection, generally of the air passages, especially of tonsils, throat, and nose, marked by a patch or patches of dirty white and grayish membrane, from which cultures of the diphtheria bacillus may be obtained. Cases of diphtheritic infection in infants and of nasal diphtheria at all ages are often missed because of the lack of definite local symptoms. 2. Etiological agent. — Diphtheria bacillus, Corynebacterium diphtheriae (the Klebs-Loeffler bacillus). 3. Source of infection.—Discharges from diphtheritic lesions of nose, throat, con- junctiva, vagina, and wound surfaces. Secretions from the nose and throat of carriers of the bacillus. 4. Mode of transmission.—Directly by personal contact, indirectly by articles freshly soiled with discharges, or through infected milk or milk products. 5. Incubation period.—Usually 2 to 5 days, occasionally longer if the carrier state precedes the development of clinical symptoms. 6. Period of communicability.—Variable, until virulent bacilli have disappeared from the secretions and the lesions. Usually 2 weeks or less, seldom over 4 weeks. In exceptional cases virulent bacilli remain in the throat and discharges from 2 to 6 months. 7. Susceptibility and immunity.—Infants born of mothers with an established immunity are relatively immune for the first 6 months of life. By the ninth month of life this passive congenital immunity has been lost in a high percentage of infants. Subsequently children and adults develop immunity apparently in approximate proportion to their contact with as- sociates who carry the diphtheria bacillus with or without exposure to persons with recognized attacks of the disease. It is usual to find about half of the children of school age and three-quarters of adults in large cities immune. Such accidental immunity is less frequent among rural and small-town populations. Passive temporary immunity (10 days to 3 weeks) and active immunity of relatively permanent duration can be developed artificially. Recovery from attack of the disease, especially if with the aid of therapeutic diphtheria antitoxin, is not necessarily fol- lowed by active immunity. 8. Prevalence.—Endemic and epidemic. Two-thirds or more of the urban cases are in children under 10 years of age and two-thirds or more of the urban deaths occur in children under 5 years of age. More common in temperate zones than elsewhere, and in fall and winter months. Reduction in incidence, death rate, and case fatality rate has been progressive and marked in the past 30 years.4 * The falling birth rate and -widespread immunization of young children in the past decade have in some cities and rural areas altered the age distribution of cases of diphtheria to a marked degree. 12 CONTROL OF COMMUNICABLE DISEASES 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting. By clinical symptoms with confirmation by bacteriological examination of dis- charges. 2. Isolation: Until 2 cultures from the throat and 2 from the nose, taken not less than 24 hours apart, fail to show the presence of diphtheria bacilli. Isolation may be terminated if the micro-organism reported as morphologically “positive,” al- though persistently present, proves to be an avirulent form. Where termination by culture is impracticable, cases may be terminated with fair safety as a rule 16 days after onset of the disease. A virulence test should be made if practi- cable where positive throat cultures are reported 3 weeks or longer after onset of the disease. 3. Concurrent disinfection of all articles which have been in contact with the patient, and all articles soiled by dis- charges of the patient. 4. Terminal disinfection: At the end of the illness, thorough airing and sunning of the sick room, with cleaning or renovation. 5. Quarantine: All intimate child contacts, and adult contacts whose occupation involves handling of foods or close association with children, until shown by bacteriological examination not to be carriers. 6. Immunization: Passive immunization with antitoxin is rarely necessary for exposed persons over 5 years of age, for whose protection daily examination by a physician or nurse suffices. Infants and young children exposed to diphtheria in the family should receive a prophylactic dose of antitoxin without prior Schick testing, unless they are known to have been immunized. 7. Investigation of source of infection: In unreported cases, in car- riers, and milk. B. General measures: 1. All children should be immunized against diphtheria. The following procedure is recommended: At 6 to 9’ months of age either two doses of diphtheria toxoid, alum precipi- tated, or three doses of fluid diphtheria toxoid, at one month intervals. This same procedure should be applied to all children at or below 6 years of age if immunization has been neglected in infancy.8 Children given an immunizing treatment during infancy should receive a single reinforc- ing dose on entrance to school. 2. Older children, and adults especially exposed, including teachers, nurses, and physicians, found to be Schick-positive should be actively immunized. In order to minimize local and constitu- tional reactions in members of these groups, it is desirable to carry out a preliminary “toxoid reaction test,” nonreactors to receive toxoid and reactors multiple small doses of suitably diluted toxoid. 3. Pasteurization of milk supply. 4. Educational measures to inform the public, and particularly the' parents of little children, of the advantages of toxoid im- munization in infancy. Dysentery, Amebic (Amebiasis) 1. Recognition of the disease.—Insidious and undetermined onset characterizes mild acute cases, with digestive disturbance, anorexia, diarrhea or consti- pation, and usually little abdominal discomfort. Severe acute cases fol- lowing massive infection may simulate acute appendicitis, or other acute surgical abdominal condition with high temperature and severe prostration. B Active immunization by any method should not be presumed to be successful without routine Schick testing or testing a representative sample of those inoculated 3 months after such procedure. CONTROL OF COMMUNICABLE DISEASES 13 The subacute and chronic forms of the disease vary widely in the extent of local and constitutional symptoms. There may or may not be diarrhea or constipation; or these may alternate in the same patient. 2. Etiological agent.—Endamoeba histolytica. 3. Source of infection.—The bowel discharges of infected persons and of carriers. 4. Mode of transmission.—By drinking contaminated water and by eating infected foods, especially those that are commonly served cold and moist, and hand- to-mouth transfer of the infected material from moist objects soiled with discharges of an infected individual or carrier; by flies. 5. Incubation period.—From 2 days in severe infections to several months in subacute and chronic cases; commonly 3 to 4 weeks. 6. Period of communicability.—During course of infection and until repeated microscopic examination of stools shows absence of the Endamoeba his- tolytica (either trophozoites or cysts). Direct transmission unusual. 7. Susceptibility and immunity.—Susceptibility to infection or to the carrier state is general; relatively few persons harboring the organism develop recognized symptoms; no artificial immunity. 8. Prevalence.—Not a common disease clinically recognized in continental North America but occurring often as an unrecognized disease. Epidemic out- breaks are rare. It is estimated that almost 5 percent of the population are carriers of cysts. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the- disease and reporting: Clinical symptoms confirmed by microscopic examination of stools. 2. Isolation: None. 3. Concurrent disinfection: Sanitary disposal of the bowel dis- charges. Hand washing after use of toilet. 4. Terminal disinfection: Cleaning. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Microscopic examination of stools of inmates of the household, or of work associates of the infected person, and of other suspected contacts, should be supplemented by search for direct contamination of water and foods by human feces. B. General measures: 1. Sanitary disposal of human feces. 2. Protection of potable water supplies against fecal contamina- tion, and boiling drinking water where necessary. Chlorin- ation of water supplies as generally used has been found inadequate for the destruction of cysts. 3. Supervision of the general cleanliness, of the personal health and sanitary practices of persons preparing and serving food in public eating places, especially moist foods eaten raw. The routine examination of food handlers to eliminate carriers from such occupations is of little or no practical value. 4. Education in personal cleanliness, particularly washing hands with soap and water after evacuation of the bowels. 5. Control of fly breeding and protection of foods against fly con- tamination by screening. 6. Avoidance of cross-connections between public and private auxiliary water supplies and of back-flow connections in plumbing systems. 7. Instruction of convalescent and chronic carriers in personal hygiene, particularly as to sanitary disposal of fecal waste, and hand washing after use of toilet. C. Epidemic measures: In case of epidemics due to relatively massive doses of infectious material, active measures should be employed to discover the source of infection, and to advise the public and the medical profession of the early and characteristic symptoms, of the serious immediate and remote results of such infection, and of the good results of treatment if instituted early. 14 CONTROL OF COMMUNICABLE DISEASES Dysentery, Bacillary 1. Recognition of the disease.—Tbe disease exhibits an acute onset with diarrhea, in severe cases causing fever, tenesmus, and frequent stools con- taining blood and mucus. The milder cases are difficult to recognize clinically because of variability of symptoms. By adequate laboratory examination the infecting organism can usually be identified. 2. Etiological agent.—Dysentery bacilli, Shigella dysenteriae, Shigella para- dysenteriae, and other species of the genus Shigella. 3. Source of infection.—The bowel discharges of infected persons and carriers. Healthy carriers are common. 4. Mode of transmission.—By eating contaminated foods, and by hand-to-mouth transfer of contaminated material; by flies; from objects soiled with discharges of an infected individual or of a carrier; by drinking con- taminated water. 5. Incubation period.—1 to 7 days. 6. Period of communicability.—During the acute phase of the disease and until the micro-organism is absent from the bowel discharges. The stools may become negative rapidly, but chronic carriers occur. 7. Susceptibility and immunity.—Susceptibility is general among children, but less so, and the disease less severe, in adults. A relative and not per- manent immunity follows recovery from the disease. 8. Prevalence.—Endemic, epidemic, and sporadic, but shares with other enteric infections in striking and progressive reduction wherever water supplies are rendered safe, sewage is disposed of in a sanitary manner, milk is pasteurized, and infant hygiene is of a good order. Most common in the summer months. Institutional outbreaks are frequent. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: * Clinical symptoms confirmed by bacteriological tests. 2. Isolation: Infected individuals during the communicable period of the disease, particularly rigid personal precautions by attendants. 3. Concurrent disinfection: Bowel discharges. 4. Terminal disinfection: Cleaning. 5. Quarantine: None. 6. Immunization: No method of immunization is satisfactory. Vac- cines contain only a few of the many antigens and in addition reactions from their use may be severe. 7. Investigation of source of infection: Important in epidemics; investigation of food, water, and milk supplies, general sani- tation, and search for carriers may serve to detect the source and prevent further spread. For sporadic cases such in- vestigation is time-consuming and gives meager results. B. General measures: 1. Protection and purification of public water supplies, together with prevention of subsequent contamination. 2. Pasteurization of public milk supplies; use of boiled milk for infant feeding. 3. Supervision of preparation and handling of other foods, par- ticularly those which are moist and eaten raw. 4. Hand washing, by food handlers in particular, following use of toilet. 5. Prevention of fly-breeding; screening. 6. Sanitary disposal of human excreta. 7. Persons known to be infected, and their attendants, should be excluded from handling food for public consumption, and from handling the family food supply if possible. 8. The exercise of rigid precautions in known cases of bacillary dysentery is requisite but is inadequate as a safeguard against the ever-present risk of infection from concealed sources. Reduction of high infant mortality rates is depend- B Groups of cases of acute diarrheal disorder should always be reported to the health officer at once, even in the absence of exact determination of the nature of the disease. CONTROL OF COMMUNICABLE DISEASES 15 ent upon prevention of diarrhea and enteritis. Infant hy- giene, including breast feeding, scrupulous cleanliness at all times in the preparation and handling of food for children, and continuous attention to diet in order to avoid minor digestive disturbances that may lower resistance to the infec- tion will do much toward accomplishing this aim. As a precautionary measure, all cases of infantile diarrhea should be regarded as bacillary dysentery. Prevention of epidemics of bacillary dysentery by guarding against massive dissemina- tion of infection should be a major concern, particularly in prisons, camps, and institutions. Encephalitis, Infectious (Lethargic and Nonlethargic) 1. Recognition of the disease.—Largely clinical. At least 4 forms occur in the United States: the Vienna type (originally called lethargic von Economo, later called type A), the St. Louis type, the Eastern equine type, and the Western equine type. The last three resemble each other and the Japanese type B (which is not known to occur in the United States) more than any of them resemble the Vienna type. The Vienna type is the most chronic and variable in course, often with a mild febrile onset, later with symptoms of brain or nerve involvement, such as slight menin- geal irritation, somnolence, diplopia or evident paralysis of eye muscles, insomnia, restlessness, twitching, myoclonia, catatonia, with or without fever; and still later at times, slow, semirigid movements, coarse tremor, masklike expression or other disturbances of motility, psychic or be- havior disturbances, often with exacerbations and remissions over several years. Though an individual case of the St. Louis type may be indis- tinguishable from the Vienna type, in the St. Louis type the onset is usually more abrupt as to fever and headache, with drowsiness rather than deep sleep, disorientation, motor disturbances but very infrequent paralysis of the eye muscles, meningeal irritation with an increase of cells in the spinal fluid more uniformly than in the Vienna type, and usually complete and fairly prompt recovery in the nonfatal cases. All ages are attacked in all four types, children and young adults more frequently in the Vienna and Western equine types, the older ages in the St. Louis (and Japanese B) types, very young children in the Eastern equine type. The Western equine type is somewhat similar clinically to the St. Louis type, while the Eastern equine type has been a more severe and fatal disease in humans and is likely to leave nervous and mental sequellae in the patients who survive. These forms of enceph- alitis are to be distinguished from post- or para-infectious encephalitis which follows or accompanies such infections as measles, vaccinia, and chickenpox, by the history of the other infection immediately preceding. 2. Etiological agent.—Probably a virus for the Vienna type; a specific filterable virus for each of the other types. 3. Source of infection.—Unknown. Birds are a probable reservoir of infection for the Eastern equine type. 4. Mode of transmission.—In the case of the equine types of encephalitis several species of the Aedes mosquito have been shown to be capable of transmitting the virus under laboratory conditions. 5. Incubation period.—Four to twenty-one days for the St. Louis type. 6. Period of communicability.—Unknown. 7. Susceptibility and immunity.—Natural immunity or immunity resulting from an attack are assumed to occur, but have not been proved except by the ability of the blood serum to neutralize viruses of the St. Louis, and Eastern and Western equine types. 8. Prevalence.—The Vienna type was first distinctly recognized in 1917, but had occurred before, and has since been prevalent in many parts of the world, especially from 1920 to 1926, infrequently now. The St. Louis type was especially prevalent in the St. Louis area in 1933, where there was an incidence of 100 per 100,000 population, but this type has occurred elsewhere before and since. The Vienna type occurs at all seasons of the year but more frequently in late winter and spring. The other types occur notably in late summer and fall outbreaks. 16 CONTROL, OF COMMUNICABLE DISEASES 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms, assisted by microscopical and chemical examination of the spinal fluid if lumbar puncture is performed. Virus has been isolated from the brain tissue of fatal cases of all types except the Vienna type. Development of specific neutralizing power in the blood serum of patients may be an aid to identification of the type if suitable laboratory facilities are available. 2. Isolation : For 1 week after onset. 3. Concurrent disinfection: Discharges from the nose, throat, and bowel, and articles soiled therewith. 4. Terminal disinfection : None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Search for prior cases in the community and for unreported cases among the associates of the patient may develop useful epidemiological information, but so far has been of no practical value in control of the different types of this disease. B. General measures: Mosquito control if practicable. Aedes vexans, which has been suspected in the spread of the Eastern equine virus to human cases, would usually be difficult to control. Favus 1. Recognition of the disease.—A parasitic fungus disease of the skin, usually on the scalp, marked by cup-shaped yellowish crusts covering the hair follicles. 2. Etiological agent.—Trichophyton schoenleini (Achorion schoenleini). 3. Source of infection.—Lesions of skin, particularly on scalp, rarely on nails. 4. Mode of transmission.—Direct contact with patient, and indirectly through toilet articles. 5. Incubation period.—Unknown. 6. Period of communicability.—Until skin and scalp lesions are all healed as shown by absence of scaling and erythema, to be confirmed by microscopic exami- nation, culture, and absence of fluorescence under a suitable ultraviolet light. 7. Susceptibility and immunity.—Infection by this fungus is frequent with the presence of another patient in the family, and with neglect of personal cleanliness. 8. Prevalence.—Rare in children in North America, and when occurring can usually be traced to immigrants from southern and eastern Europe. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms con- firmed by microscopic examination of crusts, and cultures on Sabouraud’s medium. 2. Isolation : Exclusion of patient from school and other public places until lesions are healed. Patient should wear a light, tight- fitting cotton skull cap constantly. This must be changed frequently and boiled. 3. Concurrent disinfection: Toilet articles of patient. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Search for unreported and unsuspected cases among immediate home or play or work associates of the patient. B. General measures: 1. Elimination of common utensils, such as hair brushes and combs. 2. Provision for adequate and intensive treatment and cure of cases of favus at hospitals and dispensaries, to abbreviate the period of infectivity of the patient. CONTROL OF COMMUNICABLE DISEASES 17 German Measles (Rubella) 1. Recognition of the disease.—A febrile infection occurring frequently in epi- demics, characterized by a polymorphous rash, sometimes resembling that of measles, sometimes that of scarlet fever, and sometimes of both at the same time; few or no constitutional symptoms but almost always enlarge- ment of post-auricular, sub-occipital and cervical, and occasionally of other, lymph nodes. Usually absence of leukocytosis. 2. Etiological agent.—Unknown. 3. Source of infection.—Secretions of the mouth and possibly of the nose. 4. Mode of transmission.—By direct contact with the patient or with articles freshly soiled with the discharges from the nose or throat of the patient. 5. Incubation period— From 14 to 21 days; usually about 16 days. 6. Period of communicability.—From onset of catarrhal symptoms for at least 4 days, but not more than 7; the exact period is undetermined. Highly communicable. 7. Susceptibility and immunity.—Susceptibility is general among young children. An attack usually confers permanent immunity. 8. Prevalence.—Epidemic in expression, occurring mostly in childhood, but more in adults than is the case with measles. Commoner in urban than in rural communities, and oftener in winter and spring than at other seasons. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: See note below. 2. Isolation: Of no practical value. 3. Concurrent disinfection: None. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Of no importance except to clarify doubts created by clinical difliculty in distinguishing this disease from scarlet fever in its early stages. B. General measures: None. Noth.—The reason for notification of this disease is that it may be confused with scarlet fever during its early stages; each person having symptoms of the disease should therefore be placed under the care of a physician and the case should be reported to the local depart- ment of health. 1. Recognition of the disease.—Occurs in two forms, one external affecting the skin and known as “farcy”, and an internal form known as “glanders.” It may appear as an acute or chronic disease, with widely variable symp- toms, the diagnosis being established by one or other of the following biological reactions: The complement fixation test, the mallein test, the agglutination test, or by nonspecific reactions, such as the Straus reaction, if confirmed by culture and identification of the Malleomyces mallei, or by autopsy where diagnosis has been uncertain at time of death. 2. Etiological agent.—Glanders bacillus, Malleomyces mallei (Bacillus mallei). 3. Source of infection.—Discharges from open lesions of mucous membranes, or of the skin of human or equine cases of the disease (i.e., pus and mucus from the nose, throat, and bowel discharges from infected man and horse). 4. Mode of transmission.—Contact with a case or with articles freshly soiled by discharges from a human or equine case. 5. Incubation period.—Undetermined; usually 1 to 5 days. 6. Period of communicability.—Until bacilli disappear from discharges or until lesions have healed. 7. Susceptibility and immunity.—Susceptibility appears to be common. Immu- nity is believed to follow recovery from the infection. 8. Prevalence.—Rare and sporadic and almost exclusively in men occupied about horses. In widespread and local epidemics as an epizootic in horses. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting. 2. Isolation: Human case at home or hospital; for infected horses destruction rather than isolation is advised. Skin contact Glanders 18 CONTROL OF COMMUNICABLE DISEASES with the lesions in the living or dead body is to be scru- pulously avoided. 3. Concurrent disinfection: Discharges from human cases and articles soiled therewith. 4. Terminal disinfection: Stables and contents where infected horses are.found. 5. Quarantine of all horses in an infected stable until all have been tested by specific reaction, and the removal of infected horses and terminal disinfection of stable have been accomplished. 6. Immunization: None of established value or generally accepted. 7. Investigation of source of infection: Carriers not known in humans. Search for infected horses especially in sales sta- bles, by observation and specific laboratory tests. B. General measures: 1. The abolition of the common drinking trough for horses. 2. Sanitary supervision of stables and blacksmith shops. 3. Semiannual testing of all horses by a specific reaction where the disease is common. 4. Testing of all horses offered for sale where the disease is common. Note.—In this disease, as in all infectious or communicable diseases from which both animals and humans suffer, cases occurring in animals should be reported to the Depart- ment of Agriculture or livestock sanitary authority, and human cases should be reported to the Department of Health, reciprocal notification thereafter to be accomplished through official interdepartmental channels. Gonorrhea 1. Recognition of the disease.—Occurring initially as an infection of one of the mucous membranes, most frequently of the genital tract, urethra in both sexes, the vaginal or uterine mucosa in the female, the disease develops as an acute or chronic process in adjacent or remote tissues, among the latter especially as arthritis and endocarditis. Relapsing and chronic inflamma- tory discharging conditions at the site of original attack are common. Demonstration of the etiological agent in the lesions or discharges is the best and only certain diagnostic procedure. 2. Etiological agent.—Gonococcus, Neisseria gcmorrhoeae. 3. Source of infection.—Discharges from lesions of inflamed mucous membranes and glands of infected persons, viz, urethral, vaginal, cervical, conjunctival mucous membranes, and Bartholin’s or Skene’s glands in the female, and Cowper’s and the prostate glands in the male. 4. Mode of transmission.—By direct personal contact with infected persons, and indirectly by contact with articles freshly soiled with the discharges of such persons. In adults by sexual intercourse; in children by other personal and indirect contact with discharges. 5. Incubation period.—One to 8 days, usually 3 to 5 days. 6. Period of communicability.—As long as the gonococcus persists in any of the discharges, whether the infection be an old or a recent one. Readily com- municated in sexual intercourse. 7. Susceptibility and immunity.—Susceptibility appears to be general. Acquired immunity does not occur generally, but some degree of transient local immunity may appear during infection. One attack does not protect against subsequent infection. 8. Prevalence.—Widespread in both sexes and at all ages, but most common among men from 18 to 40 years of age and among women at a little earlier age. Endemic, sporadic, and epidemic. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms, con- firmed by bacteriological examination or serum reaction. 2. Isolation : When the lesions are in the genitourinary tract, exclu- sion from sexual contact, and when the lesions are conjunc- tival, exclusion from school or contact with children, as long as the discharges contain the gonococcus. 3. Concurrent disinfection: Discharges from lesions and articles soiled therewith. 4. Terminal disinfection : None. 5. Quarantine: None. 6. Immunization: None. CONTROL, OF COMMUNICABLE DISEASES 19 7. Investigation of source of infection: Each acute case should be traced to probable source of infection and appropriate control and treatment of this spreader of disease instituted. In- fected persons may become carriers for periods not yet deter- mined with certainty, but occasionally for a year or more. B. General measures: 1. Provision of accurate and early diagnosis and careful treat- ment of infected persons with an appropriate chemothera- peutic agent such as sulfapyridine or sulfathiazole. Search should be made for all recent contacts with infected pa- tients and provision made for following all cases until acute manifestations have subsided. 2. Education in matters of sexual hygiene, particularly as to the fact that continence in both sexes at all ages is compatible with health and normal development. 3. Repression of commercialized prostitution, and associated use of alcoholic beverages, by police or other competent authority. 4. Restriction of advertising of services or medicines for the self- treatment of sex diseases, etc. 5. Elimination of common towels and toilet articles from public places. 6. Use of prophylactic silver solution in the eyes of the new- born. 7. Personal prophylaxis should be advised and made available for use before or immediately after sexual intercourse to those who expose themselves to infection. 8. Exclusion of persons in the communicable stage of the disease from occupations involving contact with children. Hookworm Disease (Ancylostomiasis) 1. Recognition of the disease.—The symptomatology varies greatly in accordance with the degree of infection and other factors. The presence of only a few worms may give rise to no symptoms. Moderate to severe infections may be characterized by abdominal pain, indigestion, flatulence, abnormal or depraved appetite, and distended abdomen. Some cases show severe diarrhea; others may have alternate constipation and diarrhea. The skin is sallow, dry, and harsh. The patient is depressed and listless, and the features expressionless. Children may show marked physical and mental retardation. Severe secondary anemia may be present and there is usually an eosinophilia. In severe cases, there is frequently edema in various parts of the body, particularly in the dependent portions. Der- matitis or so-called “ground-itch” may be present on the feet or other parts of the body coming in contact with contaminated soil. Systemic symptoms are usually more pronounced in patients on an inadequate or unbalanced diet and those suffering concomitantly from malaria and other debilitating conditions. Diagnosis is established by finding hookworm ova in the stools. 2. Etiological agent.—In the continental United States, Necator americanus, rarely Ancylostoma duodenale. 3. Source of infection.—Usually soil contaminated with infective larvae from ova in stools deposited by infected persons. Larvae usually penetrate through the skin, although infection can take place by mouth. 4. Mode of transmission.—The infective or third-stage larvae penetrate the skin, usually of the foot, and pass via the lymphatics to the inferior vena cava and the right heart, thence in the blood stream to the lungs, where they pierce the capillary walls and pass into the alveoli. They then pass up the bronchi and trachea to the throat, whence they are swallowed and finally reach the small intestine, where they develop to maturity. Infec- tion can take place by mouth from water, soil, or contaminated objects harboring infective larvae; however, the chief mode of infection is through the skin. 5. Incubation period.—No incubation period occurs comparable to that observed in bacterial and virus infections. Onset of symptoms varies widely in time, according to the intensity of the infection, from 2 to 3 weeks in massive infections (commonly 7 to 10 weeks), to many months or even 20 CONTROL OF COMMUNICABLE DISEASES years where infection or reinfection is by small numbers of worms. The free living form may exist in the soil under favorable conditions for several weeks. Eggs are found in the stools in about 4 to 6 weeks after the larvae penetrate the skin, and develop the next generation of larvae 5 to 8 days after being deposited on soil, under favorable conditions. 6. Period of communicability.—Infected individuals remain potential spreaders of infection as long as they remain infected and continue to pollute soil. Third-stage larvae may remain alive in soil for several weeks under favorable conditions. 7. Susceptibility and immunity.—Susceptibility to infection is universal. In general adults are less frequently infected than children, and Negroes less frequently than whites. Some degree of immunity is developed by a person who has had an infection. 8. Prevalence.—Widely endemic in areas having favorable soil, moisture, and temperature for development, and where winter temperatures are not sufficiently low to destroy larvae in soil. Occurs in the southern United States as far north as Kentucky; particularly prevalent in the sandy plain of the Atlantic Coast and Gulf States. Both incidence and inten- sity of infection have decreased during the last 25 years but the disease is still a serious problem in some parts of the continental United States and in Puerto Rico. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Microscopic exam- ination of bowel discharges. 2. Isolation: None. 3. Concurrent disinfection: Sanitary disposal of bowel discharges to prevent contamination of soil and water. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Each case and carrier is a potential or actual spreader of the disease. All family contacts should be examined. 8. Treatment: For the removal of worms from the intestinal tract appropriate treatment of clinical cases with tetrachlor- ethylene, hexylresorcinol, or carbon tetrachloride, with preference in the order named. B. General measures: 1. Education as to dangers of soil pollution and methods of prevention. 2. Prevention of soil pollution by installation of sanitary dis- posal systems for human discharges, especially sanitary privies in rural areas, and education of the public in the use of such facilities. 3. Personal prophylaxis by cleanliness and the wearing of shoes. Influenza 1. Recognition of the disease.—Whether occurring in a pandemic, in endemic- epidemic incidence, or as sporadic cases, this disease is characterized in its typical form by sudden onset, fever of 1 to 7 days’ duration, accom- panied by excessive prostration, aches and pains in back and limbs, coryza, sore throat, and bronchitis, and not uncommonly by pneumonia as a complication. During epidemics when such cases occur in large numbers and oyer a wide area, other cases of less distinctive type are found to be epidemiologically related to typical cases, and in these the diagnosis would not be made without such obvious association. The clinical criteria of influenza are quite indefinite, particularly in absence of widespread prevalence of the disease. Microscopic or other labora- tory procedures are of no practical value in determining or excluding the diagnosis of influenza. 2. Etiological agent.—A filterable virus has been isolated in certain epidemics. 3. Source of infection.—Probably discharges from the mouth and nose of in- fected persons and articles freshly soiled by such discharges. CONTROL OF COMMUNICABLE DISEASES 21 4. Mode of transmission.—Believed to be by direct contact, by droplet infection, or by articles freshly soiled with discharges of the nose and throat of infected persons. 5. Incubation period>—Short, usually 24 to 72 hours. 6. Period of communicability.—Undetermined; possibly in prodromal as well as in the febrile stage and convalescent stages. 7. Susceptibility and immunity.—Susceptibility is general, although natural resistance or relative immunity appears to protect from one-quarter to three-quarters of persons intimately exposed to the disease even during widespread epidemics. Acquired immunity resulting from an attack of and recovery from the disease is of short duration (a few months to a year) perhaps effective only against a certain strain or strains of the virus. 8. Prevalence.—Uncertain in pandemic, local epidemic, and sporadic occurrence, by reason of indefinite clinical symptoms. In epidemics may affect up to 50 percent of the population. Occurs pandemically in cycles with inter- vals of several decades. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: By clinical symptoms only. Uncertain in interepidemic periods. 2. Isolation: During acute stage of the disease, especially in severe cases and those complicated by pneumonia. 3. Concurrent disinfection: Discharges from the nose and throat of the patient. 4. Terminal disinfection: None. 5. Quarantine: None, but visiting the patient should be discouraged. 6. Immunization: None. 7. Investigation of source of infection: Of no practical value. B. General measures: 1. During epidemics efforts should be made to reduce opportunities for direct contact infection, as in crowded halls, stores, and street cars. Kissing, the use of common towels, glasses, eat- ing utensils, or toilet articles should be avoided. In isolated towns and institutions infection has been delayed and some- times avoided by strict exclusion of visitors from already infected communities. The closing of the public, parochial, and private schools has not been effective in checking the spread of infection. The judicious use of masks by nurses and other attendants may prove of value in preventing infection in hospitals. Scrupulous cleanliness of dishes and utensils used in preparing and serving food in public eating places should be required, including the subjection of such articles to disinfection in hot soapsuds. In groups which can be brought under daily professional inspection, the isolation of early and suspicious cases of respiratory tract inflammation, particularly when accompanied by a rise in temperature, may delay the spread of the disease. To minimize the severity of the disease, and to protect the patient from sec- ondary infections and thus reduce mortality, patients should go to bed at the beginning of an attack, and not return to work without the approval of their physician. Appropriate chemotherapy should be instituted at once if evidence of secondary pneumonia appears. 2. Large aggregations of young adults unaccustomed to such association create a danger of spread of influenza when it is prevalent, especially when the individuals are sub- jected to chilling, much fatigue, or deprivation of cus- tomary bodily comforts. 3. Crowding of beds in hospitals and institutions to accommodate increased numbers of patients and other inmates is to be espe- cially avoided. Increased spacing between beds in wards and dormitories should be carried out to reduce the risk of attack, and of the occurrence of pneumonia. 22 CONTROL OF COMMUNICABLE DISEASES Leprosy 1. Recognition of the disease.—The disease is to be identified by lesions of the skin and mucous membranes and by neurological manifestations. Con- firmation by microscopic examination is usually possible in cutaneous and mixed types of the disease but may be difficult or impossible in macplo- anesthetic and neural cases. 2. Etiological agent.—Leprosy bacillus, Mycobacterium leprae. 3. Source of infection.—Discharges from lesions. 4. Mode of transmission.—Intimate and prolonged contact with infected indi- viduals and some other as yet undetermined factor are apparently necessary. 5. Incubation period.—Prolonged, undetermined, from 1 to several years. 6. Period of communicability.—Commences when lesion becomes open, i. e., discharges leprosy bacilli; continues until healing. Patients with demon- strable acid-fast bacilli in smears from skin or mucous membranes are potentially “open” cases even if demonstrable ulceration be not present. Communicable only in certain geographic areas; in continental United States notably in States bordering on the Gulf of Mexico. 7. Susceptibility and immunity.—Susceptibility uncertain; no racial immunity. 8. Prevalence.—Endemic in some Gulf coast areas, Hawaii, Philippines, and Puerto Rico. Sporadic in North America and rare. Oftener among adolescent and young adult males. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms con- firmed by microscopic examination where possible. 2. Isolation: Isolation of bacteriologically positive cases occurring in endemic form in national leprosarium until a condition of apparent arrest has been present for at least 6 months, as determined by clinical observation and by absence of acid- fast bacilli on repeated examinations. Paroled and other negative patients should be reexamined periodically, the sug- gested interval being 6 months. 3. Concurrent disinfection: Discharges and articles soiled with dis- charges. 4. Terminal disinfection: Thorough cleaning of living premises of patient. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: This should be undertaken especially in cases of apparently recent origin. The long and uncertain period of incubation, and the length of intimate con- tact believed to be necessary, make the discovery of the source of infection a matter of great difficulty. B. General measures: 1. In endemic areas leprosy is usually contracted in childhood but it may be acquired in adult life. Infants should be separated from leprous parents at birth, and in educational efforts stress should be placed upon the greater risk of exposure in early life. 2. Lack of information as to the determining factors in the spread and communication of the disease makes any but general advice in matters of personal hygiene of no value. 3. As a temporary expedient, patients may be properly cared for in general hospitals, or if conditions of the patient and his environment warrant, he may be allowed to remain on his own premises under suitable regulations. 4. In those parts of the United States in the temperate zone farther north where the disease shows no tendency to spread, suit- able medical and nursing care of infected persons is sufficient. Malaria 1. Recognition of the disease.—A group of specific infectious fevers due to invasion of the red blood cells by one of at least three types of Sporozoa of the genus Plasmodium. These fevers occur endemically or epidemically CONTROL OF COMMUNICABLE DISEASES 23 and are associated with a symptom complex fairly characteristic of each variety, marked particularly by periodicity of fever and symptoms due to the growth and development of the organism. Enlargement of the spleen, secondary anemia, and the characteristic recurrence of chills and fever as clinical findings are confirmed by observing presence of the malaria parasites in blood film on microscopic examination. Mosquitoes of the anopheline family are the only known vectors. 2. Etiological agent.—The several species of micro-organisms: Plasmodium vivax (tertian), Plasmodium malariae (quartan), Plasmodium falciparum (estivo-autumnal). 3. Source of infection.—The blood of an infected individual. 4. Mode of transmission.—By bite of the infected Anopheles mosquitoes. The mosquito is infected by biting an individual suffering from acute or chronic malaria. The parasite develops in the body of the mosquito for from 10 to 14 days (21 days for quartan), after which time the sporo- zoites appear in its salivary glands. The disease may be transmitted by blood transfusion or by injecting whole human blood; also by common use of unsterilized hypodermic syringe (as by drug addicts). 5. Incubation period.—Varies with the type of species of infecting micro-organism and the amount of infection, usually 14 days in the tertian variety. 6. Period of communicability.—-As long as the sexual form of the malaria micro- organism exists in the circulating blood in sufficient quantities to infect mosquitoes. In untreated cases this may last for months. 7. Susceptibility and immunity.—Susceptibility is universal, although the symptoms of an attack in a Negro are usually less severe than in a white person. Some relative immunity appears to follow repeated attacks of the disease, presumably because the immunity finally covers all of the local strains of the species involved; these attacks confer no immunity to infection with another species of plasmodium, and only slight immunity to a newly introduced strain of the same species. A state of good nutrition is believed to be a factor in maintaining resistance to the disease and in spontaneous recovery. 8. Prevalence.—Endemic and sporadic, more frequent among children than adults, among Negro children more than among white children. Partic- ularly prevalent in the southeast coastal plain, Mississippi Valley south of St. Louis, in eastern Texas and Oklahoma, central New Mexico, in Louisiana and Arkansas, and slightly in California and Oregon. Serious in Puerto Rico and the Philippines. Seasonal occurrence of tertian type in early summer, estivo-autumnal and tertian in early fall. Usually rises to a sharp peak about every seven years and slowly but progressively falls thereafter. Epidemic outbreaks more common during peak years. The disease accompanies newly impounded waters in the Mississippi Valley and Atlantic seaboard. 9. Methods of control: A. The infected individual and environment: 1. Recognition of the disease and reporting: Clinical symptoms, always to be confirmed by microscopical examination of the blood. Repeated examination of blood films may be necessarv. 2. Isolation: The individual with malarial parasites in his blood should be protected from the bites of mosquitoes. With the exception of this simple precaution, isolation and quarantine are of no avail. 3. Concurrent disinfection: None. Destruction of Anopheles mos- quitoes in the dwelling. 4. Terminal disinfection: None. Destruction of Anopheles mosqui- toes in the dwelling. 5. Quarantine: None. 6. Immunization: None. The administration of prophylactic doses of quinine or atabrine should be insisted on for visitors con- stantly exposed to infection and unable to protect themselves against Anopheles mosquitoes. This is not in an exact sense prophylaxis but early therapeusis. 7. Specific therapy: Quinine sulfate is preferred for routine treatment and atabrine is found by some to be equally 24 CONTROL OF COMMUNICABLE DISEASES reliable. Small daily doses of plasmochin appear to lower the relapse rate. 8. Investigation of source of infection: Breeding places and house infestation by Anopheles mosquitoes should be sought for and larvae and mosquitoes destroyed when and where possible. Dissection of house-caught mosquitoes reveals which of the species found is the important vector. The breeding places of this particular species should be located and its reproduc- tion prevented. B. General measures; 1. Employment of known measures for destroying larvae of anophelines and the eradication of breeding places of such mosquitoes. 2. Blood examination of persons living in infected centers to deter- mine the incidence of infection. 3. Screening sleeping and living quarters; use of mosquito nets. 4. Killing mosquitoes in living quarters. 5. Education of the public as to the mode of spread and methods of prevention of malaria. 6. Adequate curative treatment of persons with clinical attacks of malaria. Measles (Rubeola) 1. Recognition of the disease.—Clinical characteristics are fever, catarrhal symp- toms in eyes and nose and throat in the prodromal stage, as well as at the height of the disease, an early eruption in the mouth, Koplik spots, later an exanthem and enanthem, and a branny desquamation during convalescence. When the disease is prevalent, or a susceptible child has -been exposed to a case of measles, the diagnosis should be suspected on appearance of the fever and catarrhal symptoms, without waiting for confirmatory eruptions, and isolation precautions should be instituted at once. 2. Etiological agent.—A specific filterable virus. 3. Source of infection.—Buccal and nasal secretions of an infected individual. 4. Mode of transmission.—Directly from person to person; indirectly through articles freshly soiled with the buccal and nasal discharges of an infected individual. The most easily transmitted of the communicable diseases. 5. Incubation period.—About 10 days from date of exposure to onset of fever; 13 to 15 days to appearance of rash; uncommonly longer or shorter. When convalescent serum has been used, but too late to prevent infection, the incubation period may be as long as 21 days. 6. Period of communicability.—During the period of catarrhal symptoms and until the cessation of abnormal mucous membrane secretions; minimum period of 9 days: from 4 days before to 5 days after the appearance of the rash. 7. Susceptibility and immunity.—All persons must be considered susceptible until they have had the disease, except that most babies born of mothers who have had the disease are immune for the first few months of life. Natural immunity may last into adult life in rare instances. Permanent acquired immunity is usual after recovery from an attack. Passive immunity may be established for a few weeks, but not more than 4, by the use of 4 to 10 cc. of convalescent measles serum or 20 to 50 cc. of whole blood of immunes, or if citrated blood is used, 25 to 60 cc. Serum of immunes may be con- centrated, or immune globulin may be used. 8. Prevalence.—Universal. Probably 80 to 90 percent of all persons surviving to the twentieth year of life have had an attack, and rarely does a person go through life without having had measles. Occurs most commonly in chil- dren between 5 to 14 years of age, but many cases are in children under 5. Endemic in large population units. In remote or insular groups epidemics occur on contact with a case in a visitor. Highest incidence from March to June in North America. Frequency of epidemics depends on size of community or proximity to a large center, amount of communication between large and small population groups, accretion of population by births, and other less exactly determined factors. Much more likely to result in death from complicating pneumonia in children under 2 than at higher ages. CONTROL OF COMMUNICABLE DISEASES 25 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms. Special attention to rise of temperature, Koplik spots and catarrhal symptoms in exposed individuals. 2. Isolation: During period of communicability for the sake of the patient as well as others. 3. Concurrent disinfection: All articles soiled with the secretions of the nose and throat. 4. Terminal disinfection: Thorough cleaning. 5. Quarantine: When the disease is very prevalent and in large com- munities, quarantine of exposed susceptible children is im- practicable and of no value. Exclusion of exposed susceptible school children and teachers from school until 14 days from last exposure may be justifiable under sparsely settled rural conditions. This applies to exposure in the household. Ex- clusion of exposed susceptible children from all public gather- ings under the same conditions for the same period. If the date of only exposure is reasonably certain, an exposed suscep- tible child of school age may be allowed to attend school for the first 7 days of the incubation period. Quarantining of insti- tutions of young children and of wards or dormitories where exposure is suspected is of value. Strict quarantine of wards of infants if a case occurs in an institution is important. 6. Immunization: By the use of the serum or whole blood of con- valescent patients, or of any healthy adults who have had measles, or by the use of immune globulin, given within 5 days after first exposure to a known case of measles, the attack in the exposed person may be averted in a considerable percentage of instances; if not averted, the disease may be modified. Given later, but at a time prior to the clinical onset of the disease, convalescent serum usually modifies the sever- ity of the attack and the patient probably acquires the usual lasting immunity to the disease. 7. Investigation of source of infection: Search for exposed suscepti- ble children under 3 years of age is profitable. Carriers are not known to occur. Every effort should be made to have all cases reported early in the disease by the physician, or, if there is none in attendance, by parent or guardian. The chief object of discovering cases is to give all possible protection to the very young or debilitated against infection, to administer passive immunization if practicable, and to secure adequate medical care for those infected. B. General measures: 1. Daily examination of exposed children and of other possibly ex- posed persons. This examination should include record of the body temperature. A nonimmune exposed individual ex- hibiting a rise of temperature of 0.5° C. or more should be promptly isolated pending diagnosis. 2. Schools should not be closed or classes discontinued, but daily observation of the children by physician and nurse should be provided for. 3. Education as to special danger of exposing young children to those exhibiting fever and acute catarrhal symptoms of any kind, particularly during years and seasons of epidemic prevalence of measles. 4. In institutional outbreaks, immunization with convalescent serum of all minor inmates who have not had measles is of value in checking the spread of infection and in reducing mortality. No new admissions and no visitors under 16 years of age should be permitted in an institution for children, during a measles outbreak in the community or in the institution. 5. The immunization of infants and children under 3 years of age with convalescent serum or whole adult blood in families where cases of measles occur in older children or adults should be encouraged by the department of health and by private physicians. CONTROL OF COMMUNICABLE DISEASES Meningococcus Meningitis (Cerebrospinal Fever) 1. Recognition of the disease.—An acute infectious disease with sudden onset, fever, headache, nausea, rigidity of neck, and in epidemics not infrequently petechial spots on the skin. The specific micro-organism in one of its several types may in some cases be found in the early stages by blood culture, and usually during the course of the disease in the spinal fluid, and in the discharges of the retronasal surfaces. The disease occurs in epi- demic and sporadic manner. 2. Etiological agent.—Meningococcus, Neisseria intracellularis. 3. Source of infection.—Discharges from the nose and mouth of infected persons. Clinically recovered cases, and healthy persons not known to have had the disease but recently in contact with cases or other carriers, may act as carriers and are commonly found, especially during epidemics. Such healthy carriers are found independent of epidemic prevalence of the disease, even up to 5 to 10 percent of a general population. 4. Mode of transmission.—By direct contact with infected persons and carriers and indirectly by contact with articles freshly soiled with the nasal and mouth discharges of such persons. 5. Incubation period.—Two to ten days, commonly seven; tends to be short in epidemics; in rare instances the period may be longer when a carrier develops the disease. 6. Period of communicability.—During the clinical course of the disease and until the specific micro-organism is no longer present in the nasal and mouth discharges of the patient. The same applies to healthy carriers as far as persistence of infectious discharges is concerned. Readily communi- cable in crowded living conditions among persons of lowered resistance. 7. Susceptibility and immunity.—Susceptibility is limited. Acquired immunity from having had the disease, apart from immediate clinical relapses, may be of long duration but is uncertain. There is no artificial immunity. Resistance to infection appears to be low when those exposed to crowded conditions of living are also fatigued and ill fed. 8. Prevalence.—Usually low incidence of sporadic cases. Within a community in epidemics at long but irregular intervals. The cases are mostly in children and in young adults, but occur at all ages. Local epidemics commonly related to chronic or emergency overcrowding of living quarters, as in ships, barracks, and lodging houses or slums, and usually in the winter or spring. No limitations in geographical distribution. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms con- firmed by the microscopic and bacteriological examination of the spinal fluid, and by bacteriological examination of nasal and pharyngeal secretions. 2. Isolation of infected persons until 14 days after onset of the disease or until negative swabs are obtained from the naso- pharynx. 3. Concurrent disinfection: Of discharges from the nose and mouth or articles soiled therewith. 4. Terminal disinfection: Cleaning. 5. Quarantine: None. 6. Immunization: Nona 7. Investigation of source of infection : Impracticable. 8. Prompt treatment with an appropriate chemotherapeutic agent such as sulfathiazole or sulfanilamide, or a combination of serotherapy and chemotherapy, may be useful in limiting communicability. B. General measures: 1. Education as to personal cleanliness and necessity of avoiding contact and droplet infection. 2. Prevention of overcrowding such as is common in living quarters, transportation conveyances, working places, and especially in barracks, camps, and ships. C. Epidemic measures: 1. Increase the separation of individuals and the ventilation in living and sleeping quarters for such groups of people as CONTROL OF COMMUNICABLE DISEASES 27 are especially exposed to infection because of their occu- pation or some necessity of living conditions. Chilling, bodily fatigue, and strain should be minimized for those especially exposed to infection. Mumps (Infectious Parotitis) 1. Recognition of the disease.—An acute specific infection characterized by fever, swelling, and tenderness of the salivary glands, usually of the paro- tid, sometimes of the sublingual or submaxillary glands. Involvement of ovaries and testicles is most frequent in persons over puberty; rarely, involvement of the central nervous system is encountered early or later in the course of the disease. 2. Etiological agent.—A specific filterable virus. 3. Source of infection.—Secretions of the mouth and possibly of the nose. 4. Mode of transmission.—By direct contact with an infected person or with articles freshly soiled with the discharges from the nose and throat of such infected persons. 5. Incubation period.—From 12 to 26 days. The most common period 18 days, accepted as usual. A period of 21 days is not uncommon. 6. Period of communicability.—Limits not definitely established, but probably beginning at least 1 or 2 days before development of distinctive symp- toms and( persisting no longer than the swelling of a salivary gland. 7. Susceptibility and immunity.—Susceptibility believed to be general. Im- munity follows an attack but second attacks of the disease are not rare. Brief passive immunity may follow inoculation with convalescent serum or whole blood. 8. Prevalence.—This disease is decidedly less prevalent than the other common communicable diseases of childhood such as measles, whooping cough, and chickenpox. Winter and spring are the seasons of greatest prevalence. Its occurrence is sporadic and epidemic except in large cities, where it is endemic. Close aggregations of young people favor outbreaks. 9. Methods of control: A. The infected individual, contacts, and environment: The following procedures are in common use but cannot be relied upon as means of effective control of the disease. 1. Recognition of the disease and reporting: The diagnosis is usu- ally made on swelling of the parotid gland. 2. Isolation: Separation of the patient from nonimmune children and young children and young people, and exclusion of the patient from school and public places for the period of pre- sumed infectivity, particularly when the disease appears in children’s institutions or among young recruits. 3. Concurrent disinfection: None. 4. Terminal disinfection: None. 5. Quarantine: None. Exposed susceptible persons should be reg- ularly inspected for the presence of initial symptoms of the disease, such as fever, or swelling or pain of the parotid or submaxillary glands, for 3 weeks from the date of last ex- posure. Exposed children medically certified as having had the disease should not be excluded from school as susceptibles. 6. Immunization: None. Passive temporary immunity by conva- lescent serum or blood still in experimental stage. 7. Investigation of source of infection: Search for unreported or recent cases among associates of the patient in school or family or other group of young people. Carriers are not known to occur. B. General measures: None. Paratyphoid Fever 1. Recognition of the diseasej—A general infection with the paratyphoid bacillus characterized especially by continued fever and involvement of the lymphoid tissues of the intestines, enlargement of the spleen, and a variety of constitutional symptoms, sometimes rose spots on the trunk, CONTROL OF COMMUNICABLE DISEASES usually diarrheal disturbance. The infecting micro-organism may be found in the feces, blood, and urine.7 2. Etiological agent— Paratyphoid bacillus A, B, or C; Salmonella paratyphi, Salmonella schottmulleri, Salmonella hirshfeldii. 3. Source of infection.—Bowel discharges and urine of infected persons, and water or foods contaminated with such discharges of infected persons or of healthy carriers. Healthy carriers may be numerous in an out- break. 4. Mode of transmission.—Directly by personal contact; indirectly by contact with articles freshly soiled with the discharges of infected persons or through milk, water, or food contaminated by such discharges, probably by flies. 5. Incubation period.—Four to ten days; average, seven days. 6. Period of communicability.—From the appearance of prodromal symptoms, throughout the illness and relapses, during convalescence, and until re- peated bacteriological examination of discharges shows absence of the infecting organism. 7. Susceptibility and immunity.—Susceptibility is general. Natural immunity probably exists in some adults. Acquired immunity is usually permanent after recovery from the disease. Artificial active immunity of probably 2 years’ duration can be developed by the use of vaccines. 8. Prevalence.—Frequency has fallen with that of typhoid fever until in most parts of North America it is relatively rare, occurring sporadically or in small local carrier or contact epidemics. Probably nowhere endemic in North America. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms con- firmed by specific agglutination test, or by bacteriological examination of blood, bowel discharges, or urine. 2. Isolation: In fly-proof room, preferably under hospital conditions, of such cases as cannot command adequate sanitary environ- ment and nursing care in their homes. 3. Concurrent disinfection: Disinfection of all bowel and uri- nary discharges and articles soiled with them. 4. Terminal disinfection: Cleaning. 5. Quarantine: None. 6. Immunization: Of exposed susceptibles. 7. Investigation of source of infection: Search for common source in polluted water, milk, shellfish or other food, and individual sources as unreported cases and carriers. B. General measures: 1. Protection and purification of public water supplies. 2. Pasteurization of public milk supplies. 3. Limitation of collection and marketing of shellfish to those from approved sources. 4. Supervision of other food supplies, and of food handlers.8 5. Prevention of fly breeding. 6. Sanitary disposal of human excreta. 7. Extension of immunization by vaccination to persons especially subject to exposure by reason of occupation and travel, to those living in areas of high endemic incidence of typhoid fever, and to those for whom the procedure can be system- atically and economically applied, as military forces and in- stitutional populations, depending on prevalence of the disease. 8. Discovery and supervision of paratyphoid carriers and their ex- clusion from the handling of foods. 9. Exclusion of suspected milk supplies on epidemiological evidence pending discovery and elimination of the personal or other cause of contamination of the milk. _J„Th? humaI}ildi.se,ase, paratyphoid fever should not be confused with cases of food P®/[®oning or with infection due to enteritidis bacilli of animal origin. _ kj t not assu™ed that an entirely effective supervision of all food handlers can be achieved or would be administratively justified by results in view of the cost. Food handlers to Whom epidemiological evidence points as carriers should be brought under control of the health department. CONTROL, OT COMMUNICABLE DISEASES 29 10. Exclusion of suspected water supplies until adequate protection or purification is provided unless all water used for toilet, cooking, and drinking purposes is boiled before use. Plague, Bubonic, Septicemic, Pneumonic 1. Recognition of the disease.—An acute infection running a rapid, severe course, often terminating fatally, and characterized by extreme weakness, high fever, buboes, severe general symptoms, and sometimes accompanied by subcutaneous hemorrhage and pustules. The infecting micro-organism is regularly found in the buboes and skin lesions, and in the pneumonic type of the disease in the sputum. Pneumonic plague gives the picture of a virulent septic pneumonia. 2. Etiological agent.—Plague bacillus, Pasteurella pestis. 3. Source of infection.—Blood of infected rodents and, in the pneumonic form, the sputum of human cases. The primary or indigenous source of the disease is the so-called “sylvatic plague”, the animal reservoir among such rodents as the tarbigan of Manchuria, and the ground squirrel and other rodents of the United States. Infection may reach man from these sources, or more often through the medium of the rat. 4. Mode of transmission.—Direct, in the pneumonic form. In other forms the disease is generally transmitted by the bites of fleas (Xenopsylla cheopis and Ceratophyllus fasciatus), by which the disease is carried from rats to man, also by fleas from other rodents. Accidental, by inoculation. 5. Incubation period.—Commonly from 3 to 7 days, although occasionally pro- longed to 8 or even 14 days. 6. Period of communicability.—Pneumonic type intensely communicable during acute symptoms. Bubonic type not communicable from person to person. 7. Susceptibility and immunity.—Susceptibility is general, particularly to the pneumonic form. Natural immunity may exist but is rare. Lasting im- munity almost always results from recovery from an attack of the disease. Artificial passive immunity of about 3 to 4 weeks’ duration by antiplague serum, and active immunity of about 6 months’ duration by vaccines may be relied upon. 8. Prevalence.—Very rare in North America and insular possessions, and only sporadic cases, from exposure to infection in ground squirrels and other rodents in Pacific and Mountain States. Endemic in ground squirrels in large areas as far east as Montana, Utah, and New Mexico. Occasionally found in rats trapped at seaports. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms, confirmed by bacteriological examination of blood, pus from glandular lesions, or sputum. Animal inoculation of material from suspected cases. Investigation of all deaths during epidemics with autopsy and laboratory examination when indicated. 2. Isolation: Patient in hospital if practicable; if not, in a screened room which is free from vermin.9 3. Concurrent disinfection: Sputum and articles soiled therewith, in pneumonic type of the disease. 4. Terminal disinfection : Thorough cleaning followed by fumigation to destroy rats and fleas. Handling of the bodies of persons dying of plague under strict antiseptic precautions. 5. Quarantine: Contacts of pneumonic cases for 7 days. 6. Immunization: Ordinarily not practicable. 7. Investigation of source of infection: Search for human (in pneu- monic) and rodent (in bubonic) sources to which patient is known to have been exposed, among wild rodents, and par- ticularly the rat. •In plague pneumonia, personal prophylaxis to avoid droplet infection must be carried out by persons who come in contact with the sick. Masks or closely woven cloth with mica windows should be worn over the head and to the shoulders. A long gown and rubber gloves drawn over the sleeves of the gown should be provided. These articles should not be re- moved from the sick room until disinfected. 30 CONTROL OF COMMUNICABLE DISEASES B. General measures: 1. Extermination of rats and vermin by use of known methods for their destruction; destruction of rats on ships arriving from infected ports; examination of rats, ground squirrels, etc., in areas where the infection persists, for evidence of endemic or epidemic prevalence of the disease among them. 2. Ratproofing of buildings and elimination of breeding places and opportunities for the harboring and feeding of rats as a fundamental sanitary measure. 3. Ratproofing of ships. Pneumonia, Acute Lobar 1. Recognition of the disease.—An acute infection characterized by sudden onset with chill followed by fever, often pain in the chest, usually cough and dyspnea. In many cases in children, vomiting and convulsions occur at the onset. Recognition of the infecting micro-organism by microscopic and cultural examination is valuable. The X-ray may disclose pulmo- nary lesions prior to other evidence of pulmonary consolidation. 2. Etiological agent.—Various pathogenic bacteria commonly found in the nose, throat, and mouth, such as pneumococcus, Friedlander’s bacillus, influenza bacillus, staphylococcus, may cause lobar pneumonia. Pneumococci Types I to XXXII inclusive account for about 95 percent of the cases. Strep- tococcus hemolyticus produces an atypical pneumonia, interstitial in type, which may be confused with lobar pneumonia. 3. Source of infection.—Probably discharges from the mouth and nose of in- fected person or carrier and articles freshly soiled with such discharges. 4. Mode of transmission.—By direct contact with infected person or carrier, or with articles freshly soiled with the discharges of the nose and throat of such persons, and possibly from dust and minute suspended particles. 5. Incubation period.—Believed to be short, usually 1 to 3 days—not well deter- mined. 6. Period of communicabiliiy.—Unknown; presumably until the discharges of the mouth and nose no longer carry the infectious agent in an abundant amount or in a virulent form. 7. Susceptibility and immunity.—Susceptibility is general, accentuated by wet and cold and exposure, and apparently under certain conditions by bodily and mental fatigue, and by alcoholism. Natural immunity may occur, but is doubtful. Acquired immunity to the particular micro-organism may follow an attack of pneumonia; such immunity is of short duration. Artificial immunization whether active or passive is of questionable value for prevention. 8. Prevalence.—Common, and affecting at one time or other, between adoles- cence and old age, a large proportion of the population. No race or color and neither sex is exempt from likelihood of having this disease. Occurs in all climates and seasons, but most often in winter and spring and in regions where cold, windy, changeable, and inclement weather prevails. Occurs in epidemic form, particularly in institutions for adults. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms. Specific infecting organisms may be determined by serolog- ical and bacteriological tests early in the course of the disease, which may give basis for epidemiological studies and for specific therapy. 2. Isolation: Medical aseptic technique. 3. Concurrent disinfection: Discharges from the nose and throat of the patient. 4. Terminal disinfection: Thorough cleaning and airing. 5. Quarantine: None. 6. Immunization: None. 7. Prompt treatment with an appropriate chemotherapeutic agent such as sulfapyridine or sulfathiazole, or a combination of serotherapy and chemotherapy, may be useful in limiting communicability. CONTROL OF COMMUNICABLE DISEASES 31 B. General measures: 1. Whenever practicable and particularly in institutions, barracks, and on shipboard, crowding in living and sleeping places should be avoided. The general resistance should be con- served by good food, fresh air, sufficient sleep, temperance in the use of alcoholic beverages, and other hygienic meas- ures. Poliomyelitis 1. Recognition of the disease.—An acute infection with moderate initial fever, usually headache and gastro-intestinal symptoms such as vomiting and constipation, drowsiness alternating with irritability, hyperesthesia, stiff- ness of neck and spine, usually accompanied by an increase in pressure and in the number of cells in the spinal fluid, tremor, and exaggeration of the muscular reflexes. Later, local diminution of reflexes and local motor weakness (paralytic). Any of these symptoms may be absent, but the diagnosis of the cases which are not at some time paralytic is so fre- quently uncertain that only paralytic cases should be counted officially as poliomyelitis in comparing rates, due precautions being taken in the other cases. Paralysis may be sudden and cause death within a few hours of onset by cessation of respiration without clear-cut symptoms. There is a marked tendency for the paralysis to improve after it has reached its height. 2. Etiological agent.—A specific filterable virus. 3. Source of infection.—Nose and throat discharges of infected persons and car- riers, or articles recently soiled therewith. Bowel discharges also con- tain the virus, but reliable evidence of spread by water supply is lacking. Unpasteurized milk is a rare source of infection. 4. Mode of transmission.—The virus enters the brain by way of the olfactory nerves and bulb when introduced into the nose or nasopharynx of a sus- ceptible person, presumably from a carrier in most instances. 5. Incubation period.—rl“S- A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: By clinical symptoms. 2. Isolation: In home or hospital, maintained in each case until the end of the period of communicability. If med- ical inspection is not available, isolation for 21 days from onset for uncomplicated cases. 3. Concurrent disinfection: Of all articles which have been in contact with a patient and all articles soiled with discharges of the patient. 6 4. Terminal disinfection: Thorough cleaning. 5. Quarantine: Exclusion of exposed children and teachers from association with children, and food handlers from their work, until 7 days have elapsed since last exposure to a recognized case. 6. Immunization: Passive immunization by the injection of human convalescent serum or scarlet fever antitoxin affords pro- tection for about 12 days but such treatment of exposed persons is not warranted except under special circum- stances and then only after making a Dick test to determine actual need. It is better to observe closely the exposed individual and reserve specific treatment until clinical signs develop. Active immunization of Dick-positive persons may he desired on a private basis but is generally impracticable as a public health measure. 7. Investigation of source of infection: The responsible authority should determine definitely whether some food is the com- mon source (such as raw milk or milk products). In rural areas efforts to discover human sources of infection mav be of value. Beyond this little can be done since present means are not practicable for the identification of infected persons and carriers of hemolytic streptococci capable of causing scarlet fever. B. General measures: 1. Daily examination of exposed children and of other possibly exposed persons for a week after last exposure. Encourage removal of young susceptible contacts in the family to homes patient fnends for duration of communicable stage in the 37 CONTROL OF COMMUNICABLE DISEASES 2. Schools should not be closed but rather daily inspection of the children and teachers by a physician or nurse should be provided. 3. In school and institutional outbreaks immunization of all exposed children with scarlet fever toxin may be advisable. 4. In the presence of a sharp outbreak, modified isolation of persons with sore throat or upper respiratory tract infection, at least through the clinically active stage, particularly if exposure to scarlet fever patients be determined. 5. Education as to special danger of exposing young children to those exhibiting acute catarrhal symptoms of any kind. 6. Pasteurization of milk supply. Septic Sore Throat 1. Recognition of the disease.—Acute sore throat appearing in epidemic out- breaks, often of a highly virulent character, and accompanied by various general septicemic manifestations. The onset is likely to be abrupt with chill, high temperature, and vomiting. 2. Etiological agent.—Streptococcus (hemolytic type).10 3. Source of infection.—The human nasopharynx, usually the tonsils, any case of acute streptococcus inflammation of these structures being a potential source of infection, including the period of convalescence of such cases. The udder of a cow infected by the milker is a common source of infection. In such udders the physical signs of mastitis may be absent.11 4. Mode of transmission.—Direct or indirect human contact; consumption of raw milk contaminated by case or carrier or from an infected udder. 5. Incubation period.—One to three days. 6. Period of communicability.—In man, presumably during the continuance of clinical symptoms; in the cow, during the continuance of discharge of the streptococci in the milk, the condition in the udder tending to a spontane- ous subsidence. The carrier stage may follow convalescence and persist for some time. 7. Susceptibility and immunity.—Susceptibility general, but somewhat less in young children. Immunity, either natural or acquired, is uncertain, if it occurs at all. 8. Prevalence.—Usually in epidemics, in any geographic area except where milk supply is pasteurized. Most cases in adolescents and adult milk drinkers. Most often in spring and early summer, but may occur at any season. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms. Bacteriological examination of the lesions or discharges from the tonsils and nasopharynx may be useful. 2. Isolation: During the clinical course of the disease and convales- cence, and particularly exclusion of the patient from partici- pation in the production or handling of milk or milk products. 3. Concurrent disinfection: Articles soiled with discharges from the nose and throat of the patient. 4. Terminal disinfection: Cleaning. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Search for cases and car- riers among milkers and other handlers of unpasteurized milk, and for mastitis in milk cows. B. General measures: 1. Exclusion of suspected milk supply from public sale or use until pasteurized. The exclusion of the milk of an infected cow or cows in small herds is possible when based on bacteriological examination of the milk of each cow, and preferably the milk from each quarter of the udder at frequent intervals. Ex- 10 Bovine mastitis of staphylococcus origin may lead to epidemic outbreaks of gastro- intestinal disturbance in those who drink unpasteurized milk from a cow so infected. u Mastitis in the cow, due to bovine streptococci, is not a cause of septic sore throat in human beings unless a secondary infection of the udder by a human type of streptococcus takes place. 38 CONTROL OF COMMUNICABLE DISEASES elusion of human cases or carriers from handling milk- or milk products. 2. Pasteurization of all milk. 3. Education in the principles of personal hygiene and avoidance of the use of common towel, drinking and eating utensils. 4. In the absence of an epidemic, the milk of any cow with evidence of mastitis should be excluded from sale or use as a pro- tection in addition to pasteurization. Smallpox (Variola) 1. Recognition of the disease.—One to five days of febrile symptoms before the focal eruption, which is papular for 1 to 4 days, vesicular for 1 to 4 days, and pustular for 2 to 6 days, forming crusts which fall off 10 to 40 days after the first sign of the lesions, and leave pink scars which fade gradually. Unless scanty, the eruption is symmetrical and general, more profuse on prominences, extensor surfaces, and surfaces exposed to irrita- tion, than on protected surfaces, flexures, and depressions. Most abundant and earliest on the face, next on forearms, wrists, and hands, favoring the limbs, especially distally, more than the trunk. More abun- dant on shoulders and chest than on loins or abdomen, but the lesions may be so few as to be overlooked. The individual lesions are deep- seated and have an infiltrated base, except when modified naturally or by previous vaccination. Any case of purpura or hemorrhage into the skin with fever should be treated with smallpox precautions until an- other diagnosis is clear. 2. Etiological agent.—A specific filterable virus. 3. Source of infection.—Lesions of the mucous membranes and skin of infected persons. 4. Mode of transmission.—By contact with persons sick with the disease; this contact need not be intimate, but aerial transmission through more than a few feet is unlikely. By articles or persons contaminated by dis- charges of the sick, including feces and urine, but for a brief time. 5. Incubation period.—Eight to sixteen days, commonly twelve days. Cases with incubation period of 21 days are reported. 6. Period of communicability.—From first symptoms to disappearance of all scabs and crusts. 7. Susceptibility and immunity.—Susceptibility universal, but not every expo- sure of a susceptible person results in the disease. Acquired permanent immunity usually follows recovery from an attack of the disease. Second attacks are rare. Artificial immunity by vaccination is usually complete for 5 to 20 years, but relative susceptibility often occurs after 5 years. 8. Prevalence.—Distribution in sporadic or epidemic form; varies widely accord- ing to the immunity status of the population of an area and its exposure to infection from without. Cases occur most often in young adult males. Occurrence is most frequent in the winter and least in summer months. There is no regional or climatic limitation to its prevalence except as popu- lation groups are more or less well protected by vaccination. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms. The rapidly fatal or fulminating type and the very mild type may escape diagnosis until secondary cases appear. 2. Isolation: Hospital isolation in screened wards, free from vermin, until the period of infectivity is past. 3. Concurrent disinfection of all discharges: No article to leave the surroundings of the patient without boiling or equally effective disinfection. 4. Terminal disinfection: Thorough cleaning and disinfection of premises. 5. Quarantine: Isolation of all contacts until vaccinated with virus of full potency, and daily medical observation of these contacts until height of reaction is passed, if vaccination was performed within 24 hours of first exposure; otherwise for 16 days from last exposure. 6. Immunization: Vaccination. Only dermal vaccination with calf vaccine is recommended. 39 CONTROL OR COMMUNICABLE DISEASES 7. Investigation of source of infection: The immediate prior case should be sought industriously, and cases of reported chicken- pox associated in time or place carefully reviewed for error of diagnosis. Active cases of the disease without remaining constitutional symptoms must be sought, also passive car- riers recently in contact with cases, and exposed vaccinated persons who may have developed unrecognized forms of the disease, and thus be serving as sources of infection. B. General measures: 1. General vaccination in early infancy, revaccination of children on entering1 a school, and of entire population when the disease appears in a severe form. 2. Preservation of smallpox vaccine below freezing up to the hour of vaccination. This includes shipment between cakes of dry ice. 3. In order to avoid possible complications or secondary and subse- quent infections at the site of vaccination, it is important that the vaccination insertion be as small and superficial as practi- cable, not over one-eighth inch in any direction, and that the site be kept dry and cool. The use of shields or other dress- ings is to be condemned. The multiple pressure method is rec- ommended. Primary vaccination as soon after 1 week of age as possible is desirable. The time of vaccination should be adjusted to avoid skin lesions elsewhere on the body, and in older children to avoid the warmer months. Particular care should be used in primary vaccinations beyond the age of infancy. Previous immunity is not shown by the result of a vaccination unless a fully potent vaccine was used which had been kept continuously below freezing from the time of manufacture until the hour of use. Syphilis 1. Recognition of the disease.—A disease acquired by intimate personal contact or by transmission in utero, running a chronic course with local and con- stitutional manifestations, usually in a definite sequence although of in- finite variety. Confirmation of diagnosis is practicable and should be established in every instance by finding the spirochete in the lesions or discharges or by positive serological findings. 2. Etiological agent.—Treponema pallidum (Spirochaetapallida). 3. Source of infection.—Discharges from the lesions of the skin and mucous membranes, the blood of infected persons, and articles freshly soiled with such discharges or blood in which the Treponema pallidum is present. 4. Mode of transmission.—By direct personal contact with infected persons and indirectly by contact with discharges from lesions or with the blood of such persons, by sexual intercourse chiefly, by kissing, by dental and other sur- gical or technical accidents, congenitally from syphilitic mother through the placenta. 5. Incubation period.—About 3 weeks, minimum 10 days, occasionally 6 weeks or longer. 6. Period of communicability.—As long as the lesions are open upon the mucous membranes or skin, but practically limited to the first 2 years of the disease, except for congenital transmission. 7. Susceptibility and immunity.—Natural or acquired immunity is not known to exist. Recovery from an attack does not protect against subsequent infection. 8. Prevalence.—Widespread in all regions of the world, regardless of race, cli- mate, or geography, or of sex or age. Prevalence varies from less than one-half of 1 percent to 30 percent and over of local population groups, averaging probably about 1 percent of all the people of North America. Occurs in sporadic, local, or group epidemic, and commonly endemic form. Most commonly acquired by unmarried males between 20 and 40 years of age. Occurs in about 3 percent of all pregnant women. Differences in racial incidence are related to social rather than biological factors. 40 CONTROL OF COMMUNICABLE DISEASES 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms, confirmed by microscopical examination of discharges and by serum reactions. Treatment should never be instituted with- out laboratory confirmation. 2. Isolation: Essential for noncooperative patients at least until surface lesions have healed. No person while in the com- municable stage of syphilis should be permitted to engage in occupations of personal service in which he or she may infect others with syphilis, such as those of nurse or nursemaid, domestic servant, barber, hairdresser, chiropodist, manicurist, bath attendant, masseur, wet nurse. Sexual intercourse should be specifically warned against and so far as possible prevented for persons with syphilis until declared to be no longer in the communicable stage, by the physician respon- sible for treatment of the patient. 3. Concurrent disinfection of discharges and of articles soiled there- with. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Each case, particularly those cases of presumably recent origin, as the congenital form of the disease in infants, and early cases of the acquired disease, should be traced to the probable source of infection, appropriate control and treatment of this spreader of disease instituted, and further exposed contacts examined for un- suspected or unreported cases. B. General measures: 1. Provision for accurate and early diagnosis with special atten- tion to the prompt detection of infected persons, provision for their treatment to prevent open lesions during the first 2 years following their initial infection, due consideration for privacy of record consistent with effective control of the patient, and search for source of infection. 2. Education in matters of sexual hygiene, particularly as to the fact that continence in both sexes and at all ages is compatible with health and normal development. 3. Repression of commercial prostitution and associated use of alco- holic beverages, by the police or other competent authority. 4. Restriction of the advertising of services or medicines for self- treatment of sex diseases, and the prescribing of treatment by drug clerks. 5. Elimination of the use of common towels, cups, and toilet articles from public places. 6. Serological as well as clinical examination for syphilis should be part of the routine prenatal supervision of the expectant mother and if she is found to be infected, antisyphilitic treat- ment should be begun if possible before the end of the fifth month of pregnancy. 7. Routine serological blood tests should be employed as a part of every physical examination, particularly in the age group from 20 to 40 years. 8. Personal prophylaxis should be advised and be made available for use before or immediately after sexual intercourse to those who expose themselves to infection. 1. Recognition of the disease.—An acute infectious disease caused by the toxin of the tetanus bacillus; characterized by painful muscular contractions, primarily of the masseter and neck muscles, and secondarily of those of the trunk; rarely the rigidity is confined to the region of the injury. A his- tory and usually physical evidence of a wound of entry for infection is found. Superficial suppuration under a gauze dressing or a crust provides sufficient anaerobiasis for the tetanus bacillus to develop. Bacteriological Tetanus CONTROL OF COMMUNICABLE DISEASES 41 examination and mouse inoculation may be useful in confirmation of diagnosis. 2. Etiological agent.—Tetanus bacillus, Clostridium tetani. 3. Source of infection.—Soil, street dust, manure, and feces. 4. Mode of transmission.—Wound infection. 5. Incubation period.—Commonly 4 days to 3 weeks, dependent somewhat upon the character, extent, and location of the wound. Longer periods of incu- bation have been noted. Subsequent operative interference or local tissue changes may initiate the activity of quiescent bacilli at even lengthy intervals after the original wound infection. 6. Period of communicability.—Patient not infectious except in rare instances where wound discharges are infectious. 7. Susceptibility and immunity.—Susceptibility general, hut inoculated bacilli often fail to produce toxin. Artificial passive immunity for about 10 days’ duration can be relied upon from the use of tetanus antitoxin. An active immunity may be produced by the use of tetanus toxoid but this requires reinforcing doses at appropriate intervals and to meet particular exposures. 8. Prevalence.—World-wide distribution, following wound infection. Most fre- quent in North America among young males and in summer. Prevalent especially following wounds contaminated with manured soil. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms may be confirmed bacteriologically. 2. Isolation: None. 3. Quarantine: None. 4. Immunization: Ordinarily a subcutaneous injection of tetanus antitoxin (1,500 units) given on the day of the wound. A second injection within 10 days may he desirable in certain instances. Previous active immunization with tetanus toxoid is preferable for those likely to be exposed to infection with tetanus. 5. Investigation of source of infection: Of only academic interest, as the infecting organism is widely spread, especially through animal feces, in all inhabited places. 6. Concurrent disinfection: None. 7. Terminal disinfection: None. B. General measures: 1. Educational propaganda such as “safety first” campaign, and “safe and sane Fourth of July” campaign. 2. Prophylactic use of tetanus antitoxin where wounds have been acquired in regions where tetanus is prevalent, and in all cases where contaminated material may be em- bedded in the wound. 3. Removal of all foreign matter as early as possible from all wounds. 4. Avoidance of dressings for smallpox vaccinations. Trachoma 1. Recognition of the disease.—A specific destructive chronic inflammation of the conjunctiva, characterized by formation of granulations, either papillary or follicular, leading ultimately to formation of scar tissue, deformity of the eyelids, and involvement of the cornea. Microscopic examination of the conjunctival discharges and scrapings cannot be relied upon as an aid to diagnosis, but may exclude other infections. 2. Etiological agent.—A filterable virus. 3. Source of infection.—Secretions and purulent discharges from the conjunctivae and adnexed mucous membranes of the infected persons. 4. Mode of transmission.—By direct contact with infected persons and indirectly by contact with articles freshly soiled with the infective discharges of such persons. 5. Incubation period.—Undetermined. 6. Period of communicability.—During the persistence of lesions of the conjunc- tivae and of the adnexed mucous membranes or of discharges from such lesions. 42 CONTROL OF COMMUNICABLE DISEASES 7. Susceptibility and immunity.—Susceptibility is general, greater in children than in adults and increased by malnutrition, chronic irritation by dust, wind, exposure to the sun, and by carelessness of personal cleanliness. Natural or acquired immunity is not known to occur. 8. Prevalence.—Not uncommon in immigrants from southern and eastern Europe. Incidence high among mountain population of southern Appalachians, and in the Ozark regions of Missouri and Arkansas and to an extent of 5 to 25 percent among Plains and Pueblo Indians of the United States. In Canada the main focus is in southern Manitoba; rare in white, native born Canadians; in Indians, cases are distributed from Ontario westward through the prairie provinces and into British Columbia. Cases most common among children but may occur and persist at any age. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms. 2. Isolation: Exclusion of the patient from general school classes. Isolation of the patient is not necessary if he is properly treated and instructed in precautions against spread of se- cretions of the eye to others by common use of articles. The period of communicability apparently may be shortened by appropriate chemotherapy. 3. Concurrent disinfection of discharge and articles soiled there- with. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Careful search should be made of persons in any way intimately related or exposed to the patient, particularly members of the household, and play- mates and schoolmates. Carriers are not known to occur, but apparently healed scars of old lesions may be the site of reactivity and become sources of infection. B. General measures: 1. Search for cases by examination of school children, or im- migrants, and among the families and associates of recog- nized cases; in addition, search for acute secreting disease of conjunctivae and adnexed mucous membranes, both among school children and in their families, and treat- ment of such cases until cured. 2. Elimination of towels and toilet articles used in common. 3. Education in the principles of personal cleanliness and the necessity of avoiding direct or indirect transference of body discharges. 4. Control of public dispensaries where communicable eye diseases are treated, and creation of special treatment classes where the disease prevails. 5. Exclusion of infected immigrants at national boundaries, or preferably at foreign port of embarkation. 6. Routine examination of eyes of children admitted to institu- tions, or in industrial camps where the disease is prevalent. 7. Under certain conditions in areas of widespread prevalence of the disease, the prophylactic use of solutions of zinc sulfate (1 percent), or copper sulfate (0.5 percent) may prove a valuable protective measure for children. Trichinosis 1. Recognition of the disease.—In human beings confined to persons who have eaten raw or insufficiently cooked pork and pork products, or occasionally bear meat, containing viable trichinae. Characterized by onset of vari- able intensity according to the amount of infected meat eaten and the abundance of trichinae in the meat. Nausea, vomiting, or diarrhea may be present. Muscle soreness or pain, edema of face and eyelids, laryn- gitis, subcutaneous hemorrhages, cough, pain in the chest, difficulty in swallowing, and labored breathing may occur, even pneumonia or involve- CONTROL OF COMMUNICABLE DISEASES 43 ment of the central nervous system in some cases. An intermittent fever is usual. Eosinophilia is usually marked. It may occasionally be absent in overwhelming infections and in individuals suffering from concomitant bacterial or virus infections. The symptoms are extremely variable. Intradermal and precipitin tests should be employed as aids in diag- nosis. Direct microscopic examination of a biopsied sample of deltoid or gastrocnemius muscle, pressed, or digested in artificial gastric juice, may detect larvae after the 21st day of infection. Occasionally, larvae may be found in the blood or spinal fluid. 2. Etiological agent.—Trichinella spiralis. 3. Source of infection.—Uncooked or insufficiently cooked pork, less frequently meat of other animals. 4. Mode of transmission.—Only through consumption of meat containing viable infective larvae; adult worms and infective larvae occur in the same hosts. 5. Incubation period.—Usually the onset occurs 6 to 7 days after ingestion of the infective meat. In heavy infections gastrointestinal symptoms may ap- pear in 24 hours. 6. Period of communicability.—Disease is not transmitted by human host to man. 7. Susceptibility and immunity.—Susceptibility is general. Neither natural nor acquired immunity is known to occur in man. 8. Prevalence.—World-wide. The parasite is particularly widespread in the United States, about one in every 6 necropsies showing infection. Clinical cases probably occur more frequently than is indicated by morbidity reports and the disease is probably often confused with other illnesses. No selec- tion by age, sex, race, region, season, or climate except as these affect the custom of eating the insufficiently cooked flesh of infected hogs or other animals. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms, marked eosinophilia, and intradermal and precipitin tests, con- firmed after the third week of symptoms or fever by examina- tion of biopsied muscle for encysted larvae. 2. Isolation: None. 3. Concurrent disinfection: None. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Effort should be made to trace source of infection in pork or pork products believed to be involved. Examination of pressed or digested preparation may reveal trichina larvae. B. General measures: 1. Inauguration of local and State meat inspection to assure adequate processing of all pork products not processed under Federal inspection, and customarily eaten without further adequate cooking by the consumer. 2. Encouragement of farmers and hog raisers in the use of standard swine sanitation practices which will reduce opportunity for trichina infection in swine. 3. Control of rats, particularly on farms and around hog-raising establishments and stockyards. 4. Burial or other adequate disposal of rat and swine carcasses to prevent hogs from feeding on them. 5. Elimination of the current practice of feeding garbage and offal to swine or the adoption and enforcement of suitable laws and regulations ensuring cooking such material before its con- sumption by swine. 6. Cooking of all fresh pork and pork products by the consumer, at a temperature and for a time sufficient to allow all parts of the meat to reach a temperature of at least 150° F., unless it is known that these meat products have been processed under Federal or other official regulations adequate for the destruction of trichinae. 44 CONTROL OF COMMUNICABLE DISEASES 1. Recognition of the disease: A. Primary or first infection type: Characterized by hilum gland enlarge- ment or discrete parenchymal shadows in chest X-ray, usually with positive tuberculin test, sometimes accompanied by vague consti- tutional symptoms and rarely by erythema nodosum, all of which regress spontaneously except in occasional cases which develop meningitis or other progressive tuberculous disease. Recognition by history of contact and X-ray findings and confirmed by stain- ing, culture, and animal inoculation of stomach washings B. Adult or reinfection type: Characterized by insidious onset with parenchymal pulmonary infiltration, usually in the upper lobes recognizable by chest X-ray for a variable period of time before constitutional symptoms or physical signs appear. Pleurisy with effusion and unexplained hemoptysis are almost specific first symp- toms , cough, fever, fatigue, and weight loss accompany advanced disease, which is recognizable by X-ray and by physical signs of dullness and rales, and confirmed by staining, culture, and animal inoculation of sputum, or of stomach washings where sputum is absent or negative. Tuberculin test usually positive. Failure to find organisms on microscopic examination of sputum does not rule out tuberculosis; repeated examinations of concentrated sputum and of stomach washings by culture and animal inoculation will eventually demonstrate tubercle bacilli in the majority of active cases. 2. Etiological agent—-Tubercle bacillus (human), Mycobacterium tuberculosis (hominis) ; bovine type has been established as important in some areas (outside the continental United States) where milk is not pasteurized and infection of cattle is prevalent; avian type doubtful for human infections. 3. source of infection.—The specific micro-organism present in the discharges or articles freshly soiled from the discharges, from any open tuberculosis lesions, the most important discharge being sputum. Of less importance are discharges from the intestinal and genitourinary tracts, or from lesions of the lymph nodes, bone, and skin. 4. Mode of transmission. Usually through the discharges of the respiratory tract, occasionally through those of the digestive tract, by direct or indirect contact twitb infected persons, by means of coughing, sneezing, or other droplet infection, by kissing, by the use of contaminated eating and drink- ing utensils, and possibly by contaminated flies and dust. Infection rarelv occurs from casual contact, but usually results from the continued tvne of exposure characteristic of family relationships. 5. Incubation period.—Variable, dependent upon the type of the disease, dosage, age, and other factors. 6 ’ 6. Period of communicability —As long as the specific micro-organism is elimi- nated by the host. Commences when a lesion becomes an open one i e. discharging tubercle bacilli, and continues until it heals or death occurs’ The degree of communicability varies with the number and virulence of the bacilli discharged, the frequency of exposure, and the susceptibility of the persons exposed. 7. Susceptibility and immunity.—Susceptibility is general; highest in children under 3 years, lowest from 3 to 12 years of age, and relatively high for the rest of life; in aboriginal races greater than in races long exposed to the disease; in the undernourished, neglected, and fatigued more than in the well fed and well cared for. Silicosis is a predisposing factor Resist- ance of some degree is developed with age and by the maintenance of good nutrition. There is no evidence of natural specific immunity. o. Prevalence—Among the most common communicable diseases of man with less variation in incidence of infection according to race than in mor- tality. In most occidental nations its incidence and mortality are declin- ing. Age at which first infection occurs varies; children exposed in the household and in cities are infected earlier than rural children and those not so exposed, who may escape infection until adolescence or adult age. Mortality highest among infants, among adult males up to old age and rr!na?.0le/nCeninand •y01?ng Hdult females- Leading cause of death at ages 20 to 40. Aboriginal races when first exposed develop the disease in a rapidly fatal form, epidemic at times. P e Qlsease Tuberculosis, Pulmonary CONTROL OF COMMUNICABLE DISEASES 45 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: By use of the X-ray followed by thorough physical examination supplemented by tuberculin testing when necessary and confirmed by bacte- riological examination of sputum and other materials. Early discovery in contacts, particularly in family groups exposed to an open case of tuberculosis (“positive” sputum), is of great importance. 2. Isolation of such “open” cases as do not observe the precautions necessary to prevent the spread of the disease may prove advisable. A period of hospital or sanatorium treatment is very desirable in all cases to remove the patient as a focus of infection in his home, and to teach him the hygienic essentials of tuberculosis control as well as to increase his chances of recovery.13 3. Concurrent disinfection: Of sputum and articles soiled with it. Particular attention should be paid to prompt disposal or dis- infection of sputum itself, of handkerchiefs, cloths, or paper soiled therewith, and of eating utensils used by the patient. Patients should be trained in aseptic respiratory technique in sneezing, coughing, laughing, and talking. 4. Terminal disinfection: Cleaning and renovation. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Contacts of all known cases should be examined roentgenologically, with particular atten- tion to elderly persons with chronic cough. B. General measures: 1. Education of the public in regard to the danger of tuberculosis, the mode of spread, and the methods of control, with especial stress upon the danger of exposure and infection in early childhood. 2. Provision of X-ray and clinical facilities for examination of contacts and suspects, public health nursing service for home supervision of cases and for ensuring examination of contacts, and dispensary service for continuation of collapse therapy in ambulant cases and for clinical supervision of patients not otherwise so supervised. 3. Provision of adequate sanatorium facilities for isolation and treatment of active cases. A minimum of 2 beds per annual tuberculosis death in the community is a desirable ratio. 4. Elimination of the inhalation of silica dust in dangerous quantity in industrial establishments and trades. 5. Pasteurization of all milk supplies. 6. Improvement of habits of personal hygiene and betterment of living conditions among the underprivileged. 7. Improvement of housing conditions and nutrition of the poor. 8. Separation of babies from tuberculous mothers at birth. 9. Eradication of tuberculosis in cattle. Tuberculosis, Other Than Pulmonary 1. Recognition of the disease.—By local manifestations, by constitutional reac- tions, by specific reactions, and by identification of the tubercle bacillus in the lesions or their discharges through microscopic examination, cul- ture, or animal inoculation. 2. Etiological agent.—Tubercle bacillus (human and bovine), Mycobacterium tuberculosis (hominis et bovis). 3. Source of infection.—Discharges from mouth, nose, bowels, and genitourinary tract of infected human beings; the discharging lesions of bones, joints, and lymph glands; articles freshly soiled with such discharges; milk from tuberculous cattle. 12 “Collapse therapy” is of value in appropriate cases of the disease in shortening the period of communicability, as well as in reducing the case fatality. 46 CONTROL OF COMMUNICABLE DISEASES 4 Mode of transmission.—By direct contact with infected persons, by contami- nated food, and possibly by contact with articles freshly soiled with the discharges of infected persons. 5. Incubation period.—Unknown. 6. Period of communicability.—Until discharging lesions are healed. 7. Susceptibility and immunity.—Susceptibility is general and is greater in chil- dren than in adults. 8. Prevalence.—Much less common than the pulmonary form and more rapidly falling in incidence, representing less than 10 percent of total cases and deaths from the disease. Especially common in infants and young children where intimately exposed to parental infection and to bovine infection through unpasteurized milk from tuberculous cattle. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical signs and symp- toms confirmed by bacteriological examinations. 2. Isolation: None. 3. Concurrent disinfection: Discharges and articles freshly soiled with them. 4. Terminal disinfection: Cleaning. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Search should be made for possible original source in family, household, or other intimate contacts, and to discover previously unrecognized cases of sim- ilar origin, such a search to be aimed at discovery of infected but latent or arrested cases as well as those showing an active process. Special inquiry and investigation should be made to discover possible source of bovine tubercle infection where unpasteurized milk has been used in the family or particu- larly used uncooked by the patient B. General measures: 1. Pasteurization of milk and milk products and inspection of meats. 2. Eradication of tuberculosis in dairy cattle. 3. Patients with open lesions should be prohibited from handling foods. 4. Adequate hospital, sanatorium, and out-patient facilities for discovery, control, and clinical management. Tularemia 1. Recognition of the disease.—Whether the disease is acquired by the bite of the blood-sucking horse fly or the wood tick or from an infected abrasion or skin trauma or infected conjunctiva, or by ingestion of insufficiently cooked meat of infected rabbits, the onset is sudden, with pains and fever, and the patient is usually prostrated and confined to bed. If the disease follows a bite or a conjunctival infection or an infection through the skin, the lymph glands draining the area become swollen and tender and suppurate in about half the cases.. The fever is of 3 to 4 weeks’ duration, and the convalescence slow. The clinical diagnosis may be confirmed by animal inoculation, isolation of cultures, and agglutination reactions. Less reliable is the skin reaction. 2. Etiological agent.—Pasteurella tularensis (Bacterium tularense). 3. Source of infection.—Wild rabbits and hares, horse fly (Chrysops discalis), wood tick (Dermacentor andersoni and Dermacentor variabilis), wood- chuck, coyote, muskrat, opossum, tree squirrel, quail, skunk, water rat of Europe (Arvicola amphibus), cat, deer, dog, fox, hog, sage hen, and bull snake. 4. Mode of transmission.—By bites of infected flies and ticks and by inoculation through handling infected animals, as in skinning, dressing, or performing necropsies on infected animals, or by fluids from infected flies, ticks, rabbits, and woodchucks. Ingestion of insufficiently cooked rabbit meat. Rare cases occur from bites of coyotes, skunks, hogs, cats, and dogs, where the mouth of the animal was presumably contaminated from eating infected rabbits. Drinking contaminated water (observed in Russia). CONTROL OF COMMUNICABLE DISEASES 47 5. Period of incubation.—From 24 hours to 10 days, average slightly more than 3 days. 6. Period of communicability.—There is no authentic record of transfer of the disease from man to man. The infecting micro-organisms have been found in the blood of man during the first 2 weeks of the disease; in conjunctival scrapings up to 17 days; in the primary lesion on the finger up to 21 days; in the sputum up to 31 days; in lymph glands up to 5 months; in bone marrow (sternum) 18 days after onset; in olecranon bursa 5 months after onset; in ulcer of the hand (not primary lesion) 5 months after onset; in ascitic fluid (taken during life) 5 months after onset; in pleural fluid 5 months after onset; in spinal fluid 16 days after onset; in the spleen taken at autopsy up to 30 days. Flies are infective for 14 days; ticks through- out their lifetime. Refrigerated rabbits kept constantly frozen at —15° C. may remain infective for three and a half years. 7. Susceptibility and immunity.—All ages are susceptible. Permanent immunity follows recovery from an attack. An immune person may acquire through an abrasion on his hand and by contact with virulent material, a local tu- laremic papule which harbors virulent organisms but does not cause notable constitutional reaction. 8. Prevalence.—The disease has been found in every State of the United States except Vermont and Connecticut, also in Canada, Japan, Russia, Norway, Sweden, Italy, Austria, Czechoslovakia, Turkey, Alaska, and central Ger- many. It occurs every month of the year, but especially during the hunting season. The case fatality is about 5 percent. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Human cases should be reported to the health department. 2. Isolation: None. 3. Concurrent disinfection: Disinfection of discharges from the ulcer, lymph glands, or conjunctival sac. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection should be undertaken in each case. B. General measures: 1. Avoidance of the bites of, or handling of, flies and ticks when working in the infected zones during the seasonal incidence of blood-sucking flies and ticks. 2. The use of rubber gloves by persons engaged in dressing wild rabbits wherever taken, or when performing necropsies on infected laboratory animals. Employment of immune persons for dressing wild rabbits or conducting laboratory experiments. Thorough cooking of meat of wild rabbits. 3. Avoidance of raw drinking water in infected areas. Typhoid Fever 1. Recognition of the disease.—A general infection with the typhoid bacillus, characterized by a continued fever, and by involvement of the lymphoid tissues especially, with enlargement and often ulceration of Peyer’s patches, enlargement of the spleen, usually rose spots on the trunk, diar- rheal disturbance, and a variety of severe constitutional disturbances accompanying parenchymatous involvement of various viscera. The in- fecting micro-organism can be found in the blood, the feces, and the urine. 2. Etiological agent.—Typhoid bacillus, Eberthella typhi. 3. Source of infection.—Bowel discharges and urine of infected individuals. Healthy carriers are common. 4. Mode of transmission.—Conveyance of the specific micro-organism by direct or indirect contact with a source of infection. Among indirect means of transmission are contaminated water, milk, and shellfish, and probably flies. 5. Incubation period.—From 3 to 38 days, usually 7 to 14 days. 6. Period of communicability.—From the appearance of prodromal symptoms, throughout the illness and relapses during convalescence, and until re- 48 CONTROL OF COMMUNICABLE DISEASES peated bacteriological examinations of the discharges show continuous absence of the infecting organism. 7. Susceptibility and immunity.—Susceptibility is general. Natural immunity exists to some extent in adults. Acquired immunity of permanent dura- tion usually follows recovery from the disease. Artificial active immunity of probably 2 years’ duration can be developed by the use of typhoid vaccine. Protection persists for about one year at a high level. 8. Prevalence—Widespread throughout the world regardless of race, age, sex, climate, or geography. Formerly in most large cities of North America and in many extensive rural areas in endemic and epidemic form, and still endemic in some rural areas of the southern United States but commonly now occurring in sporadic cases and as small contact and carrier epidemics. Steadily falling in incidence, particularly in all urban areas supplied with water of a sanitary quality and pasteurized milk, and where human fecal waste is disposed of without polluting water supplies, food, or surface of the soil. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms con- firmed by specific agglutination test and bacteriological ex- amination of blood, bowel discharges, or urine. 2. Isolation: In flyproof room, preferably under hospital condi- tions, of such cases as cannot command adequate sanitary environment and nursing care in their homes. Release from isolation should be determined by two successive negative cultures of stool and urine specimens collected not less than 24 hours apart. 3. Concurrent disinfection: Disinfection of all bowel and urinary discharges and articles soiled with them. 4. Terminal disinfection: Cleaning. 5. Quarantine: None. 6. Immunization: Of susceptibles in the family or household of the patient who have been exposed or may be exposed during the course of the disease. 7. Investigation of source of infection: The actual or probable source of infection of every case should be determined by searching for common and individual sources (1) polluted water, milk, shellfish, and other food supplies, (2) un- reported cases and carriers. B. General measures: 1. Protection and purification of public water supplies. 2. Pasteurization of public milk supplies. 3. Limitation of collection and marketing of shellfish to those from approved sources. 4. Sanitary disposal of human excreta. 5. Supervision of other food supplies, and of food handlers. 6. Prevention of fly breeding. 7. Extension of immunization by vaccination to persons subject to unusual exposure by reason of occupation or travel, to those living in areas of high endemic incidence of typhoid fever, and to those for whom the procedure can be systematically and economically applied, as in the military forces and in- stitutional populations. 8. Discovery and supervision of such typhoid carriers, and their exclusion from the handling of foods, as epidemiological and bacteriological evidence indicate are of importance. 9. Exclusion of suspected milk supplies on epidemiological evidence pending discovery and elimination of the cause of contami- nation of the milk. 10. Exclusion of suspected water supply, until adequate protection or purification is provided unless all water used for toilet, cooking, and drinking purposes is boiled before use. 11. Education of the general public and particularly of food han- dlers concerning the sources of infection and modes of trans- mission of the disease. CONTROL OF COMMUNICABLE DISEASES 49 12. Instruction of convalescents and chronic carriers in personal hygiene, particularly as to sanitary disposal of fecal waste and handwashing after use of toilet, and restraint from acting as food handlers. Typhus Fever 1. Recognition of the disease.—Whether in the classical and severe epidemic form of the louse-transmitted disease or in the mild flea-borne and sporadic type, the onset is variable, often being sudden and marked by headache, chills, fever and general pains, and a macular eruption on the fifth or sixth day, toxemia, and a quite definite course terminating in rapid lysis after about 2 weeks of fever. A positive Weil-Felix reaction is valuable as confirmation of the diagnosis. 2. Etiological agent.—Rickettsia prowazeki. 3. Source of infection.—The only known source is the blood of infected persons or infected rats. 4. Mode of transmission.—The infectious agent is transmitted from man to man by lice (Pediculus corporis) and from rat to rat or man by fleas (Xenopsylla cheopis). 5. Incubation period.—From 6 to 14 days, most often 12 days. 6. Period of communicability.—In the presence of lice, highly communicable until 36 hours have elapsed after the temperature reaches normal. 7. Susceptibility and immunity.—Susceptibility is general. One attack con- fers immunity, which is not always permanent. 8. Prevalence.—Widespread. Flea-borne typhus predominantly in late summer and fall; louse-borne predominantly in winter and spring. The case fatality of flea-borne typhus is 2 percent, and of louse-borne typhus 20 to 40 percent. 9. Methods of control: A. The infected individual, contacts, and environment; 1. Recognition of the disease and reporting: Cases should be promptly reported to the health authorities. 2. Isolation: In a vermin-free room. 3. Concurrent disinfection: Destroy all lice and louse eggs on the clothing or in the hair of the patient. 4. Terminal disinfection: None. 5. Quarantine: In the presence of lice, exposed susceptibles should be quarantined for 14 days after last exposure. 6. Immunization; Methods not applicable to conditions in the United States. 7. Investigation of source of infection: Particular attention should be paid to patient’s contact with rats, and with louse-infected persons or clothing. B. General measures: The elimination of rats. C. Epidemic measures: Delousing of persons, clothing, and premises. Undulant Fever (Brucellosis) 1. Recognition of the disease.—A general infection with gradual or insidious onset and characterized by irregular fever of uncertain but often prolonged dura- tion, profuse sweating, chills (or chilliness), pain in joints and muscles. Agglutination test and identification of the infecting micro-organism in the blood, tissues, or discharges of the patient are valuable aids in diagnosis. A mild, obscure form of the disease, diagnosed only with difficulty, may last for years. 2. Etiological agent.—Brucella melitensis (Alkaligenes melitensis, Micrococcus melitensis); Brucella abortus (Alkaligenes abortus); Brucella suis. 3. Source of infection.—The tissues, blood, milk, and urine of infected animals, especially goats, cattle, and swine. Laboratory infections take place readily. 4. Mode of transmission.—By ingestion of milk from infected animals and by direct contact with infected animals or animal products. 5. Incubation period.—Six to 30 days or more. 6. Period of communicability.—Practically not communicable from person to person but the organism is present in the urine, usually for 90 days with a range of 20 to 300 days. 50 CONTROL. OF COMMUNICABLE DISEASES 7. Susceptibility and immunity.—Susceptibility is not general, as most persons have some degree of natural immunity, especially to the abortus varieties of the infecting agent, or they have acquired partial immunity by ingestion of small doses of these. Immunity uncertain. 8. Prevalence.—Occurs more often in males than in females, and particularly in persons whose occupation brings them into relation with milk cows or goats, and in persons using unpasteurized milk of cows or goats. Found in every one of the United States and in Canada, affecting persons of any race. Occurs most often in the months of May to October. Many cases of a mild type doubtless occur without record. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: The clinical picture and particularly the undulant character of the fever, supplemented by exact determination through the use of agglutination tests and bacteriological examination of the blood and urine for the infecting micro-organism. 2. Isolation: None. 3. Concurrent disinfection: Ordinary sanitary precautions. Ex- treme care is necessary in laboratory work, especially when dealing with Brucella melitensis. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Investigation of source of infection: Human cases should be traced to the common or individual source of infection, usually to infected domestic goats, swine, or cattle, or to the unpasteurized milk products from cattle and goats. B. General measures: 1. Pasteurization of milk whether from cows or goats. 2. Search for infection among livestock by agglutination reac- tion and elimination of infected animals from the herd by segregation or slaughter. 3. Education of the public and particularly workers in slaughter houses, packing houses, and butcher shops, as to the nature of the disease, the mode of transmission, and the danger of handling carcasses or products of infected animals. Whooping Cough (Pertussis) 1. Recognition of the disease.—An acute infection involving the trachea and bronchi and characterized by a typical cough usually lasting from 1 to 2 months. The initial catarrh usually has an insidious onset manifested by an irritating cough. The cough gradually becomes paroxysmal usually within 1 to 2 weeks. The paroxysms are characterized by a repeated series of violent coughs, each series consisting of many coughs without intervening inhalation and often followed by the characteristic, sonorous, inspiratory whoop. Paroxysms frequently end with vomiting of clear, tenacious mucus. The etiological agent has been recovered by use of special culture plates exposed before the patient’s mouth during a cough in the catarrhal and early paroxysmal stage of the disease. A definite lymphocytosis is usually present. 2. Etiological agent.—Pertussis bacillus of Bordet and Gengou, Hemophilus pertussis. 3. Source of infection.—Discharges from the laryngeal and bronchial mucous membranes of infected persons. 4. Mode of transmission.—Contact with an infected person, or with articles freshly soiled with the discharges of such person. Healthy carriers are not known to occur. 5. Incubation period.—Commonly 7 days, almost uniformly within 10 days, and not exceeding 16 days. 6. Period of communicability.—Particularly communicable in the early catarrhal period before the typical cough confirms the clinical diagnosis. After the typical paroxysms are established, communicability gradually de- creases and becomes negligible for ordinary nonfamilial contact in about 3 weeks even though the spasmodic cough with whoop may persist The communicable stage must be considered to extend from 7 days after CONTROL OF COMMUNICABLE DISEASES 51 exposure to an infected individual to 3 weeks after onset of typical paroxysms. 7. Susceptibility and immunity.—Susceptibility is general. There is no natural immunity. The greatest susceptibility is in children between 6 months and 5 years of age, after which there is some decrease. One attack confers a definite and prolonged immunity, although second attacks do occur. A brief passive immunity may be conveyed to young children by convalescent serum or adult whole blood. Artificial active immunization is still in the experimental stage. Susceptibility is apparently higher in females at all ages than in males. 8. Prevalence.—Very prevalent, and a common disease among children everywhere regardless of race, climate, or geographical location. About half the re- ported cases in cities are in children under 5 years of age, and 90 percent in children under 10. Incidence and fatality rates are higher among females. Somewhat less prevalent in tropical than in temperate climates. Seasonal incidence variable, but mortality higher usually in spring months in North America. Cyclical occurrence irregular. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms, supported by a differential leucocyte count. 2. Isolation: Separation of the patient from susceptible children, and exclusion of the patient from school and public places for the period of assumed infectivity. It is of particular importance to protect children under 3 years of age against contact with any other children with cough and fever, of whatever origin, and especially if whooping cough is sus- pected or is known to be prevalent. Isolation of children over 2 years of age is impracticable, and even in those under 2 should not be insisted upon at the expense of fresh air in the open if weather permits. 3. Concurrent disinfection: Discharges from the nose and throat of the patient and articles soiled with such discharges. 4. Terminal disinfection: Thorough cleaning. 5. Quarantine: Limited to the exclusion of nonimmune children from school and public gatherings for 14 days after their last exposure to a recognized case. This applies to ex- posures in the household or under other similar conditions. This precaution may be omitted if exposed nonimmune children are observed with care by a physician or nurse on their arrival at school each day for 14 days after their last exposure to a recognized case. 0. Immunization: Use of prophylactic vaccination is recommended by some observers, but for public health practice is still in the experimental stage. There is some evidence that attacks are milder in the vaccinated. 7. Investigation of source of infection: An effort should be made to discover undiagnosed and unreported cases, with the main object in view of protecting young children from ex- posure, and thus reducing the mortality. Postponement of the age of infection at least until school age and great care in the management of the disease in young children offer some hope of reducing deaths from whooping cough although reduction of incidence by any means appears unlikely. Car- riers in the exact sense of this term are not known to occur. B. General measures: Education in habits of personal cleanliness and in the dangers of association or contact with those showing catarrhal symptoms with cough. 1. Recognition of the disease.—Clinical diagnosis usually rests upon sudden on- set, fever, prostration, slow pulse in relation to body temperature, severe headache and backache, congestion of mucous membranes, bleeding gums, black vomit in severe cases, and late jaundice, with brief duration of illness. Pronounced albuminuria and leukopenia are characteristic. A history of possible bites of infected mosquitoes is corroborative but ab- Yellow Fever 52 CONTROL OF COMMUNICABLE DISEASES sence of such or even failure to find Aedes aegypti mosquitoes in the vicinity does not necessarily exclude the diagnosis. Almost symptom- less and certainly unrecognizable cases of this infection occur among Negro races in Africa, and among very young cliJdren in tropical America. 2. Etiological agent.—A specific filterable virus. 3. Source of infection.—The blood of infected persons, monkeys, and probably some other wild animals. 4. Mode of transmission.—By the bite of infected Aedes aegypti mosquitoes, and of a few allied species. (It is not yet certain that some other suctorial insect may not be capable of acting as the transmitter.) 5. Incubation period.—Three to six days, rarely longer. 6. Period of communicability.—Two days prior to onset of fever and first 3 days of the fever, possibly 4. High degree of communicability where infected mosquitoes abound and there are many susceptible persons. 7. Susceptibility and immunity.—Recovery from an attack of the disease is regu- larly followed by immunity, apparently for life. There is no natural immunity. Brief artificial immunity may be developed by the use of con- valescent serum. Active immunity is quickly developed by the use of modified living virus. The duration of this is uncertain but it apparently lasts for several years. 8. Prevalence.—Endemic in certain species of monkeys (and perhaps other jungle animals) of northern and central South America, and probably of Central America. Rare epidemics among human beings; sporadic human cases, probably of jungle origin. Not known in the Pacific Basin. No case in North America or Puerto Rico for many years. Endemic among human beings and some wild animals of western and central Africa. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms. 2. Isolation: Isolate from mosquitoes in a special hospital ward or thoroughly screened room. It is necessary that the room or ward should he freed from mosquitoes hy fumigation, trapping, or highly responsible collection and destruction of the insects. Isolation necessary only for the first 4 days of the fever. 3. Concurrent disinfection: None. 4. Terminal disinfection: None, except for the purpose of destroy- ing mosquitoes in the house occupied by the patient and in the nearest neighboring dwellings, usually best by gaseous fumigation. 5. Quarantine: None. 6. Immunization: Immunity is quickly conferred by a single in- oculation with an attenuated strain of living virus. 7. Investigation of source of infection: Human carriers are not known to exist. Search for undiscovered mild and unre- ported cases of illness resembling yellow fever, examination of viscerotome specimens from bodies of persons dying less than 10 days after onset of an acute febrile illness, and systematic testing of immunity in groups related in time and proximity to the case in question are of epidemiological importance. Search for the Aedes aegypti mosquito and other species be- lieved to be capable of transmitting the infection should be particularly thorough in the vicinity of places of residence, work, or travel of known cases of the disease. B. General measures: 1. Immediate immunization of all persons in the community is the quickest control measure. 2. Destruction of mosquitoes in infected and adjacent homes should be done at once. 3. Eliminate breeding of Aedes aegypti mosquito throughout the community by organized service of inspection and sanitary control. 4. An inspection service for discovery of those ill with the disease is desirable whether the disease occurs in the classical, mild, or atypical form. CONTROL OF COMMUNICABLE DISEASES 53 Supplementary List A Communicable diseases or infestations occurring in the United States and Canada, and in the insular possessions, but for which notification to the health authorities is not everywhere required. Ascariasis. Coccidioidomycosis (coccidioidal gran- uloma, “Valley fever”). Common cold. Filariasis. Hemorrhagic jaundice (spirochetosis icterohemorrhagic, Weil’s disease). Impetigo contagiosa. Lymphogranuloma venereum (ingui- nale) and climatic bubo. Pediculosis (lousiness). Rat-bite fever (sodoku). Relapsing fever. Ringworm (dermatophytosis). Scabies (the itch). Schistosomiasis. Vincent’s infection (Vincent’s angina, ulcerative or necrotic stomatitis, trench mouth). Yaws (frambesia). Ascariasis 1. Recognition of the disease.—Frequently, the first sign of infection is the spon- taneous passage of an adult worm. The symptomatology is extremely vague except in heavy infections when individuals may exhibit digestive disturbances, abdominal pain, protruding abdomen, exaggerated nervous reflexes, restlessness, and disturbed sleep. The diagnosis usually depends on finding the ova in the stools. 2. Etiological agent.—Ascaris lumbricoides, the large intestinal round worm of man. 3. Source of infection.—Excreta of infected persons, particularly children, and articles soiled with such excreta in and about houses lacking facilities for sanitary disposal of human wastes. 4. Mode of transmisswn,.—By direct or indirect transmission of the embryonated eggs from soil or other polluted material to the mouth. The embryonated eggs hatch in the intestinal canal, penetrate the wall, and reach the lungs by the circulatory system. Most of those which reach the lungs in the blood stream move into the air passages, throat, and stomach, and thence to the small intestines. Pollution of soil may be carried by shoes into houses and conveyances and to some distances. 5. Incubation period.—The worms reach maturity in the body about 2 months after infection. 6. Period of communicability.—As long as mature female worms live in the intes- tine. The production of about 200,000 eggs a day permits a wide spread of fecal pollution even when the infection is light. 7. Susceptibility and immunity.—Susceptibility is general and even relative resistance to repeated infection cannot be relied upon. 8. Prevalence.—High incidence of infection is found where low standards of hygiene, lack of sanitary essentials, poverty, and ignorance create the conditions conducive to intensive pollution of soil in the immediate vicinity of houses. Children of the runabout and early school age are likely to be more frequently and more heavily infected than are older children and adults. Particularly prevalent among the people of the Appalachian plateau. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease by examination of the stools for ova. 2. Isolation: None. 3. Concurrent disinfection: Sanitary disposal of feces, and washing hands in soap and water after defecating and before eating. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Individual and environmen- tal sources of infection should be sought for in the persons and premises of the patient’s family particularly. 8. Treatment: Suitable treatment for the removal of adult worms from infected individuals with hexylresorcinol, oil of cheno- podium, or santonin, with preference in the order named. 54 CONTROL OF COMMUNICABLE DISEASES B. General measures: Provision for adequate facilities for proper fecal disposal and elimi- nation of soil pollution in areas immediately adjacent to the home, particularly in play areas of children. In rural sections, privies should be so constructed as to obviate dissemination of ascarid ova through overflow, drainage, and other factors. Education of all members of family, particularly children, to use toilet facilities available. Encouragement of satisfactory hygienic habits on the part of chil- dren in particular, especially the practice of washing the hands before handling food, and after defecating. Coccidioidomycosis (Coccidioidal Granuloma, “Valley Fever”) 1. Recognition of the disease.—Commencing as a small, slowly extending papule appearing upon some nonhealing trivial wound, the characteristic lesion becomes a pustule which develops into a papillomatous base with many minute abscesses. Soreness and pain accompany the extension of the process. When the lesion develops in the lungs from inhaling spores, the condition resembles pulmonary tuberculosis. Identification of the infecting organism in the fresh discharges, pus, etc., by bacteriological examination and laboratory animal inoculation, confirms the diagnosis. The acute benign pulmonary form of the disease (“Valley fever”) is common among newcomers in endemic areas, with symptoms similar to those of influenza, and with the development in some individuals of erythema nodosum. 2. Etiological agent.—Coccidioides immitis. 3. Source of infection.—Dust, soil, and vegetation contaminated with the spores of the fungus. 4. Mode of transmission.—Through wounds of the skin smeared with contami- nated soil or vegetation; inhalation of spores in dust and dry vegetation; and, in laboratories, inhalation of spores from cultures. 5. Incubation period.—Variable, 1 to 3 weeks in “Valley fever.” Undetermined for coccidioidal granuloma. 6. Period of communicability.—As long as open lesions persist. Direct communi- cation from person to person of little if any importance. 7 Susceptibility and immunity.—About four percent of newcomers to endemic areas are susceptible. Very few develop the granulomatous type of in- fection. There is evidence that an attack of the acute benign pulmonary type confers immunity. 8. Prevalence.—“Valley fever” is prevalent in endemic areas in Southern Cali- fornia, parts of Texas, and Arizona. Incidence highest in hot dry weather, most common in white females. Recovery is usually complete. Coccidioi- dal granuloma is of sporadic occurrence in endemic areas, most common in males. Case fatality about 50 percent in the granulomatous form; only very few “Valley fever” cases progress to this form. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical characteristics and bacteriological confirmation. 2. Isolation: None. 3. Concurrent disinfection: All discharges from skin lesions of the infected individual, from necrotic lymph nodes, the sputum, and articles soiled with these. 4. Terminal disinfection: Not important. 5. Quarantine: None; neither contacts nor carriers are known to be spreaders of the disease. 6. Investigation of source of infection: Unprofitable except as a research effort. B. General measures: None, other than education of persons generally in California that agricultural workers and laborers should have prompt treatment of skin wounds. Laboratory workers should exercise particular care in handling cultures of the infecting micro-organism and dried material which may contain its spores. CONTROL OF COMMUNICABLE DISEASES 55 Common Cold 1. Recognition of the disease.—An acute catarrhal affection of the upper respira- tory tract, usually accompanied by a slight rise of temperature on the first day and chilly sensations with coryza, and general indisposition or lassitude lasting 2 to 7 days. 2. Etiological agent.—A filterable virus. 3. Source of infection.—Discharges from nose and mouth of infected persons. 4. Mode of transmission.—Usually directly by coughing, sneezing, and explosive manner of speech by which droplets are cast out into the air from the in- fected person to be inhaled by, or impinged on the face of, susceptible per- sons especially within short range of 3 feet or so; also by hand to face transfer of discharges, and indirectly by handkerchiefs, eating utensils, or other articles freshly soiled by discharges of the infected person. 5. Incubation period.—Probably between 12 and 48 hours; possibly as long as 72 hours. 6. Period of communicability.—While the virus remains in the discharges, an undetermined period, but believed to be limited to the early stages of the disease and probably no longer than a week from the onset. 7. Susceptibility and immunity.—Susceptibility universal. A period of at least relative immunity follows an attack of the disease and appears to be effec- tive for a month or so. 8. Prevalence.—Most persons, except those living in small isolated communities, have one or more colds each year. The incidence does not vary materially according to age, sex, race, or occupation, but incidence appears to be highest in children under 5 years of age. 9. Methods of control: A. The infected individual, contacts, and environment: 1. On recognition of the premonitory or early stage of a “cold” the infected person should avoid direct and indirect exposure of others, particularly little children, feeble or aged persons, or persons suffering from any other illness. 2. Isolation: Such modified isolation as can be accomplished by rest in bed for 1 or 2 days is to be advised. 3. Concurrent disinfection: The disposal of nasal and mouth dis- charges by the use of soft paper, by burning or putting in the toilet, or otherwise, to avoid contamination of hands and articles of common use, is to be urged. 4. Terminal disinfection : None, except airing and sunning room and bedding. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Unprofitable except as a research project B. General measures: 1. Education in the refinements of personal hygiene and disposal of nose and mouth secretions. 2. Maintenance of good bodily resistance by regular use of fresh air by day and by night, outdoor exercise, sufficient rest to avoid conscious fatigue, a balanced diet, regular bowel evacuation, and clothing appropriate to climate and use. Filariasis 1. Recognition of the disease.—Characterized by recurrent lymphadenitis and lymphangitis, particularly of the lower extremities, accompanied by febrile phenomena, chyluria, and later, evidence of lymphatic obstruction of the lower part of the body such as elephantiasis, varicose lymph glands, and lymph scrotum. Before the development of symptoms embryos are found in night blood; embryos are generally not found in the circulating blood after the development of marked symptoms. 2. Etiological agent.—A nematode worm. Several species of filariids are known to infect man; filariasis usually refers to infection with Wuchereria ban- crofti, which is the only species reported in the United States. 3. Source of infection.—Certain species of mosquitoes harboring the infective larvae. 56 CONTROL OF COMMUNICABLE DISEASES 4. Mode of transmission.—In North America generally transmitted by the mos- quito Culex fatigans. After this mosquito takes a blood meal from a person with circulating filaria embryos, the embryos develop in the mosquito into infective larvae in 14 to 21 days, at which time they migrate to the proboscis. From that location, they penetrate the human skin when brought in contact with it by the mosquito. 5. Incubation period.—Embryo fllariae are not found in blood until at least 9 months after exposure; symptoms are not likely to develop for several years. 6. Period of communicability.—In man, as long as embryos are present in the blood; not sooner than 9 months from the time of exposure. In the mosquito, 14 to 21 days after larvae have developed and are present in its head and proboscis. 7. Susceptibility and immunity.—As far as is known, all persons are suscep- tible and no immunity develops. 8. Prevalence.—Rare in the continental United States; previously reported cases practically limited to Charleston, S. C. It is believed that this focus of infection no longer exists. Common in most tropical and subtropical parts of the world including Puerto Rico, Virgin Islands, and Philippines. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting. 2. Isolation: Not practicable. 3. Quarantine: None. 4. Immunization: None. 5. Investigation of source of infection most important. Surveys of incidence and range in endemic foci. 6. Anti-mosquito measures should be undertaken against the trans- mitting mosquito, particularly in endemic areas. In the case of Culex fatigans, the mosquito generally breeds in filthy locations such as in septic tanks, collections of rain water in tin cans, etc. Screening of sleeping places of con- siderable value because Culex fatigans usually feeds at night. B. General measures: Education of the public concerning the mode of transmission of filariasis and methods of mosquito control. Hemorrhagic Jaundice (Spirochetosis Icterohemorrhagic, Weil’s Disease) 1. Recognition of the disease.—An acute infection characterized by malaise, prostration, gastrointestinal symptoms, muscular pains, and fever at the onset, followed by defervescence, jaundice, and signs of nitrogen reten- tion, of varying degree and duration. Relapses may occur. Severe cases develop hemorrhages at various sites and renal damage may be marked. About 50 percent of cases are without jaundice. Isolation of Leptospira icterohaemorrhagiae or L. canicola by inoculation of guinea pigs with the blood early in the course of the disease, or with the urine later, definitely identifies the condition. Positive serological tests strongly indicate the presence of Weil’s disease. 2. Etiological agent.—Leptospira icterohaemorrhagiae, found in the blood or urine of patients and in the renal tract of rats. L. canicola, primarily a spirochete of dogs, is found in some human cases. 3. Source of infection.—Urine of rats and dogs. Contaminated water and food stuffs are important. Foxes, sheep, cats, and mice are at times involved. 4. Mode of transmission.—It appears that ingestion of contaminated food and water plays a role and that continued exposure of abraded or unabraded skin to alkaline waters containing the Leptospirae may lead to infection. Sewer workers, fish workers, coal miners, and veterinarians are especially exposed to infection. 5. Incubation period.—Four to 19 days, average 9 or 10 days. 6. Period of communicability.—The urine of patients continues to contain or- ganisms for weeks or months following convalescence. Only one human case has been traced to direct contact. Ten to 50 percent of wild rats harbor Leptospirae in their kidneys. They are persistent carriers. 7. Susceptibility and immunity.—Susceptibility is general. Natural immunity does not exist and artificial immunity is still questionable. A refractory state develops following recovery, and immune bodies may be detected for a considerable period thereafter. CONTROL OF COMMUNICABLE DISEASES 57 8. Prevalence.—The disease is present in rats over the entire world. Dogs are also infected to a considerable degree. Man develops the disease when conditions are such as to allow unusually close contact between man and rats or dogs. Sporadic human cases have been reported from widely distributed cities in the United States. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Characteristic clin- ical symptoms, isolation of the organism from the blood or urine, and positive serological tests. 2. Isolation: None. 3. Concurrent disinfection: Urine and other discharges of patient. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None practical. 7. Investigation of source of infection: Search for rats or dogs har- boring the Leptospirae and for sources of food or water to which such animals have access, e. g., communal baths, fish- cleaning establishments, mines, sewers, etc. B. General measures: 1. Rat control by ratproofing, trapping, and poisoning. 2. Sanitary disposal of human wastes in civil and military environ- ment. 3. Destruction of Leptospirae in nature by drainage of mines and soil, and disinfection of water in fish-cleaning establishments with 1: 60 hypochlorite solution. 4. Education in the value of proper disposal of water, storing and keeping foods, and other general sanitary measures. 5. Protection of workers exposed to infection by preventing organ- isms from entering through the skin and mouth by the use of boots, gloves, avoidance of skin abrasions, etc. Impetigo Contagiosa 1. Recognition of the disease.—A purulent dermatitis occurring sporadically and in small epidemics and characterized by vesicular lesions turning to crust- ing seropurulent plaques, commonly on the face and often on the hands, sometimes widely scattered over the body. Bacteriological determination of the infecting micro-organism is of no importance. 2. Etiological agent.—Staphylococci and streptococci. 3. Source of infection.—Lesions on the skin of an infected person. 4. Mode of transmission.—By direct contact with the face and hands of an in- fected person and indirectly by contact with articles recently soiled by the moist discharges of the skin lesions. The infection is easily inoculable from place to place on the patient’s body by scratching. 5. Incubation period.—Undetermined, but usually within 5 days and often within 2. 6. Period of communicability.—While lesions remain unhealed. 7. Susceptibility and immunity.—Susceptibility general, especially among chil- dren. Immunity does not follow an attack of the disease. There is no artificial immunity. 8. Prevalence.—Common among children, especially in warm weather. Occurs sporadically and also in epidemic outbreaks in children’s institutions and summer camps. 9. Methods of control: * A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: On appearance of the characteristic clinical picture; it is of general importance only to prevent spread in schools and other groups of children. 2. Isolation: Exclusion from school and from contact with other children or debilitated persons until pustules are healed. 3. Concurrent disinfection: Cleanly disposal of dressings and moist discharges from the patient. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 58 CONTROL OF COMMUNICABLE DISEASES 7. Investigation of source of infection: On the appearance of a case in a group of children, the others should be watched. Among infants it is especially important to locate any skin infection in an attendant. All persons with skin lesions should be kept from even indirect contact with newborn babies. B. General measures: 1. Personal cleanliness, particularly the avoidance of common use of toilet articles among children. 2. Prompt treatment of the first case in a group of children will abbreviate the period of communicability and prevent exten- sion of lesions to new sites. Lymphogranuloma Venereum (Inguinale) and Climatic Bubo 1. Recognition of the disease.—Adenopathy, inguinal in male, pelvic in female, and history of exposure to venereal infection in tropics (climatic bubo) or in temperate climates. Natural infection limited to human beings, but experimentally transmissible to monkeys and mice, less readily to other species. Characterized by small herpetiform lesion of inoculation on ex- ternal genitalia or uterine cervix (rarely in mouth), usually transitory, followed by subacute or chronic adenitis and periadenitis, usually with multiple foci of suppuration; frequently the cause of rectal stricture. Associated with constitutional symptoms, fever, prostration, loss of weight, rheumatic affections, and skin reactions. Clinical diagnosis may be con- firmed by Frei antigen intradermal test, but not uniformly. 2. Etiological agent.—A specific filterable virus. 3. Source of infection.—Discharges from lesions. 4. Mode of transmission.—Direct contact by skin and mucous membranes, almost exclusively in sexual relations with infected persons, or indirectly by articles soiled with discharges from the lesions of such persons. 5. Incubation period.—One to four weeks. Glandular enlargement follows the initial lesion in 1 or 2 weeks. 6. Period of communicability.—As long as there are open lesions upon skin or mucous membranes. 7. Susceptibility and immunity.—Susceptibility appears to be general. Immunity apparently does not follow an attack of the disease. There is no artificial immunity. 8. Prevalence.—A common venereal infection in the Negro quarters of cities in the United States. Widely prevalent in the tropics and common among inmates and clients of brothels in seaports. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms. 2. Isolation: Exclusion of infected person from sexual contacts and from preparation and serving of food during period of com- municability. 3. Concurrent disinfection: Discharges and articles soiled therewith. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Search should be made for case of origin, particularly among prostitutes and among per- sons of Negro race, and among former residents of tropical and subtropical areas. B. General measures: 1. Education in matters of sexual hygiene, particularly as to the fact that continence in both sexes and at all ages is compatible with health and normal development. 2. Repression of commercial prostitution and associated use of alco- holic beverages by use of police and other competent authority and control of living premises. 3. Elimination of the use of common towels, cups, toilet articles, and eating utensils. 4. Personal prophylaxis should be advised and made available for use immediately after sexual intercourse to those who expose them- selves to opportunity for infection. CONTROL OF COMMUNICABLE DISEASES 59 Pediculosis (Lousiness) 1. Recognition of the condition.—The discovery of the adult louse on some one or more of the hairy parts of the body or in the clothing, or the nits attached to hairs or to threads of body clothing. Irritation of the skin and adjacent adenitis may result from the scratching which the lousiness incites. 2. Infesting agent.—Head louse (Pediculus capitis), body louse (P. vestimenti), and crab louse (P. pubis). 3. Source of infestation.—Usually the hairy parts of an infested person or, in the case of Pediculus vestimenti, the clothing of such a person. 4. Mode of transmission.—Direct contact with an infested person and indirectly by contact with clothing and headgear of such persons. 5. Incubation period.—Lice hatch in a week and reach sexual maturity in 2 weeks. 6. Period of communicability.—While live lice remain on the infested person or in his clothing, and until eggs (nits) in hair and clothing have been destroyed. 7. Susceptibility and immunity.—Neither term appropriate to such a condition as lousiness. All human beings become lousy under suitable conditions of exposure and lack of personal cleanliness. 8. Prevalence.—Universal where there is neglect of washing of the person and the body clothing. 9. Methods of control: A. The infested individual, contacts, and environment: 1. Recognition of the state of lousiness by direct inspection of school children for lice and nits and report to school authorities. 2. Isolation: Exclusion of the infested child from school until live lice are destroyed, and supervision until nits are removed from the hair of the head. 3. Concurrent disinfestation: Such washing of person and treat- ment of body clothing and toilet articles as will destroy lice and nits. 4. Terminal disinfestation: None. 5. Quarantine: None. 6. Investigation of source of infestation: Search for unreported and undetected cases of lousiness among companions, and especially among members of family and household. B. General measures: 1. Direct inspection of the heads and, when necessary, of the body and clothing where lousiness is found in groups of either children or adults, particularly of children in schools, institutions, and camp groups. 2. Provision of facilities, medicinal and hygienic, for freeing the persons and clothing of infested individuals and groups, of lice and nits. 3. Education in the value of bodily cleanliness by use of hot water and soap and of washing body clothing in a way to prevent the survival of lice. Rat-Bite Fever (Sodoku) 1. Recognition of the disease.—Usually a history of rat bite within 2 weeks or more; primary edematous lesion; swelling of regional lymph nodes; sharp febrile paroxysms alternating with afebrile intervals and accompanied by a rash of broad maculo-papules; presence of causative micro-organism in dark field preparations of blood of white mice, white rats, and guinea pigs inoculated from patient’s blood, primary lesion, lymph nodes, or skin macules, or (less frequently successful) in preparations other than blood direct from patient. Caution should be exercised lest the experimental mouse or rat is already naturally infected. 2. Etiological agent.—Spirillum minm (Spirochaeta morsus-muris). 3. Source of infection.—Usually bite of wild rat; rarely cat, weasel, ferret, dog, or bandicoot. 4. Mode of transmission.—During the bite, some of the animal’s blood escapes from the injured or diseased buccal mucosa into the wound, or the con- junctival secretion of the rat may contaminate the wound. Blood from an animal in the laboratory may infect man. 60 CONTROL OF COMMUNICABLE DISEASES 5. Incubation period.—Three to thirty days or more; usually one to three weeks. 6. Communicability.—Not transmitted from man to man. 7. Susceptibility and immunity.—No data for man; fatality may reach 10 percent in untreated cases. 8. Prevalence.—Distribution is world-wide. Surveys in Calcutta, Bombay, and Tokyo have shown 10 percent of wild rats infected. In the United States less than 100 human cases have been reported up to 1940. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: Clinical symptoms are more uniformly definite than laboratory confirmation, but latter should always be attempted with thoroughness. Prompt cure by arsphenamines is of diagnostic value. 2. Isolation: None. 3. Concurrent disinfection: None. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Not practicable except as suggested under General measures. B. General measures: Rat surveys and rat eradication. Avoidance of rat bites, especially by not sleeping on or near earthen floors or in rat-ridden communities and houses. Relapsing Fever 1. Recognition Of the disease.—Short febrile paroxysms lasting 2 or 3 days alter- nating with afebrile periods of 3 or 4 days; general macular eruption; presence of causative micro-organisfn in dark field preparations or stained films from patient’s blood taken at height of a febrile paroxysm, or from blood of white mice, white rats, or monkeys inoculated with patient’s blood at that time. 2. Etiological agent.—Borrelia recurrentis (Spirochaeta reewrentis, formerly known as Spirillum obermeieri). 3. Source of infection.—The genus of ticks, Ornithodoros, of which O. turicata and O. hermsi are examples, is the important source of human infection in the United States; O. talaje is a vector in Panama, Central and South America, while 0. moubata is the vector in tropical Africa. Lice (Pedicu- lus vestimenti and P. capitis) are the common vectors in Asia and Europe. 4. Mode of transmission.—By tick bite and louse bite. 5. Incubation period.—Up to 12 days, the average being 7. 6. Communicability.—On the American continent, only endemic foci are found, and spread from man to man is not apparent. Epidemics in Europe and Africa depend upon overcrowding and heavy infestation with lice and ticks. 7. Susceptibility and immunity.—Immunity is only partial. The case fatality for the European variety is about 4 percent. In India and Africa fatalities of 30 to 40 percent have been recorded, but no deaths have been reported for the United States. 8. Prevalence.—In the United States 258 cases were observed in Texas (1930-34), 100 in California (1930-35), and isolated cases in Colorado, Arizona, New Mexico, Idaho, Oregon, and Nevada. 9. Methods of control: A. The infected individual, contacts, and environment. 1. Recognition of the disease and reporting: Clinical symptoms with laboratory confirmation; curative action of arsphenamines also confirmatory. 2. Isolation: None. 3. Concurrent disinfection: None. 4. Terminal disinfection: None. 5. .Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Important. B. General measures: 1. Tick and louse eradication. 2. In endemic areas avoidance of sleeping in the open or in camps, especially near “dry caves” in Texas. CONTROL* OF COMMUNICABLE DISEASES 61 Ringworm (Dermatophytosis) (Of scalp, body, feet, and groin) 1. Recognition of the disease.—Inspection of the scalp and other parts of the body for the characteristics of the local lesion. Demonstration of the fungus in infected hairs or skin scales from the edges of lesions. In some cases identification of the species of fungus is important in determining choice of treatment. 2. Etiological agent.—Species of Microsporum, Trichophyton, or Epidermophyton. 3. Source of infection.—Lesions on scalps or bodies of infected persons, articles of clothing carrying the fungus or its spores, or infected hairs or scales shed by individuals and lodging in damp places. 4. Mode of transmission.—Directly by skin-to-skin contact with lesions of infected persons and indirectly by articles of wearing apparel or by surfaces con- taminated by scurf or scalings or hair from lesions. 5. Incubation period.—Undetermined. 6. Period of communicability.—As long as the fungus or its spores can be found at the site of the lesions. Transmission is easy in ordinary conduct of home or recreational pursuits, particularly those carried out indoors. 7. Susceptibility and immunity.—Susceptibility general. There is relative immu- nity to scalp infection by Microspomm audouini after 15 years of age. 8. Prevalence.—Widespread, varying with aggregation of people under conditions appropriate for spread, as at swimming pools. Foot ringworm more com- mon in adults, and the body, face, and head forms more so among children, especially in warm weather, and where crowded, as in schools and orphanages. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: All cases recognized on inspection of school children should be reported to school authorities. 2. Isolation: Children and adults with marked cases of the disease should be excluded from privileges in gymnasium and at swim- ming pools. Exclusion from school may be desirable in cases of ringworm of the scalp. There are too many carriers of foot ringworm to make control of them at all practicable. 3. Concurrent disinfection: Cleanliness of body and underclothes. Use cotton socks which can be boiled in case of infection of the feet. Shoes may be exposed to formaldehyde. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Among school children medical inspection should be used to detect unreported cases. In gym- nasia and buildings devoted to athletics, particularly swim- ming, search should be made as a routine, to exclude cases from common facilities. B. General measures: 1. Cleanliness of body and underclothing, thorough drying of feet. 2. Prompt and persistent treatment of the lesions should be urged. 3. Protection of feet against contamination in showers and dressing rooms and areas used by people with bare feet. 4. The use of disinfecting solutions may prove useful in connection with common bathing and dressing rooms. Scabies (The Itch) 1. Recognition of the disease.—Observation of the characteristic burrows of the itch mite. Its identification under a lens, or of the eggs scraped from the burrows, may be positive in skilled hands. 2. Etiological agent.—Sarcoptes scabiei, the itch mite. 3. Source of infestation.—Persons harboring the itch mite on their skin in burrows, particularly between the fingers. 4. Mode of transmission.—Direct contact with infested persons and indirectly by use of underclothing, gloves, bedding, etc., of such persons. 62 CONTROL OF COMMUNICABLE DISEASES 5. Incubation period.—Merely the length of time for the itch mite to burrow under the skin and lay eggs and start the itching and scratching, all of which may occur within 24 to 48 hours of original infestation. 6. Period of communicability.—Until the itch mites and the eggs are destroyed. 7. Susceptibility afnd immunity.—These terms are not appropriate to this condition. Anyone may become infested and immediately reinfested. 8. Prevalence.—Widespread and occurring sporadically and in epidemics. 9. Methods of control: A. The infested individual, contacts, and environment: 1. Recognition of the disease and reporting: The condition should be reported to the school authorities if discovered in school children. 2. Isolation: Children should be excluded from school until disin- fested. Persons should be denied common recreation and bathing facilities while infested. 3. Concurrent disinfestation: Care of body clothing and bedding until free from the infestation. 4. Terminal disinfestation: Underclothing and bed covering to be so treated by dry heat or washing as to destroy the mite and the eggs. 5. Quarantine: None. 6. Investigation of source of infestation: Search for unreported or unrecognized cases in companions or house or family mates of the infested individual. B. General measures: Cleanliness of body and underclothing and bed cover- ing especially. Schistosomiasis 1. Recognition of the disease.—History of skin contact with water known to con- tain the infected intermediate host followed by itching spots on the skin as the water dries. A few weeks later there is evidence of colitis or cystitis manifested by dysentery and hematuria, respectively, accompanied by leukocytosis and eosinophilia. This stage progresses and becomes com- plicated by cirrhosis and splenomegaly with ascites. Finding the ova in the stools or urine confirms the diagnosis. Massive larval infection may cause acute prostration and high fever. 2. Etiological agent.—Three species of schistosomes mature in man, Schistosoma mansoni in Central America, the West Indies, northern South America and Africa, S. haematobium in Africa and S. japonica in the Orient The ova of these three flukes are spined and are deposited by the females into the abdominal venules from which they work their way to the mucosa of the bowel or bladder. None of these flukes is indigenous to the continental United States but they are found in Puerto Rico and the Philippines. The larvae of some other schistosomes found in the United States may cause “swimmer’s itch” by penetrating the human skin. However, these schisto- somes do not infect man and the larvae die in the skin. 3. Source of infection.—Waters containing the intermediary snail host, contami- nated by human excrement containing the ova of the parasite. 4. Mode of transmission.—Ova hatch in the water and enter the snail host. In the snail multiplication occurs and swimming larval forms called “cer- cariae” develop, which leave the snail and upon contact with skin, pene- trate it to gain access to the blood stream. 5. Incubation period.—A dermatitis occurs at the time of penetration of the cer- cariae. At least one month, usually three, elapses after infection before the ova are found in the stools or in the urine. 6. Period of communicability.—As long as the ova are discharged in the stools of infected persons, and as long as the cercariae are to be found in the water. The ova hatch into free-swimming forms that are infectious only for the snail; cercariae are short-lived but infected snails give off cercariae for several months. 7. Susceptibility and immunity.—Susceptibility is general. There is no immunity. 8. Prevalence.—No autochthonous cases in the continental United States. Occurs in areas of the West Indies and northern South America; common in the Orient and Africa. CONTROL OF COMMUNICABLE DISEASES 63 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease by symptomatology and microscopical examination of tjhe stools or urine for ova. 2. Isolation: None. 3. Concurrent disinfection: Sanitary disposal of feces and urine. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Important; examination of local waters for infected snails followed by a vigorous cam- paign to eliminate sources of pollution and snails from these waters. B. General measures: 1. Regulation of disposal of sewage. 2. Treatment of the infected persons by sodium antimony tartrate, fouadin, or other trivalent antimony compounds. 3. Education of people in endemic areas regarding method of transmission. School children should be warned not to bathe in infected streams and persons whose occupations re- quire them to wade in infected waters should be cautioned and provided with suitable waterproof garments. Vincent’s Infection (Vincent’s Angina, Ulcerative or Necrotic Stomatitis, Trench Mouth) 1. Recognition of the disease.—Lesions occurring on either the tonsils or pharynx (angina), or the oral mucosa (stomatitis) are characterized by necrosis, pseudomembranous formation, salivation, and a fetid odor. In angina and the more acute forms of stomatitis there is marked pain on swal- lowing, enlarged tender cervical nodes, and slight fever. Acute type of Vincent’s infection is characterized by a rapid onset. The affected gums become acutely inflamed, the interdental papillae edematous with a soft slick appearance, bleeding easily and exquisitely painful. Necrosis of the interdental papillae occurs with subsequent development of characteristic grayish-white pseudomembrane which is easily removed leaving a raw, profusely bleeding surface. Ulcerations may coalesce and progress to adjoining alveolar, palatal, and buccal mucosa, spread toward the buccal sulcus being the more common. A distinctive mixed bacterial flora in- cluding spirochetes, fusiform bacilli, and other organisms characterize this group of diseases. Differential diagnosis should exclude: suppurative periodontitis, diphtheria, mucous patches of syphilis, agranulocytic angina, scurvy, and sprue. 2. Etiological agent.—Complex; underlying and predisposing conditions appar- ently important, if not essential, in development. Fuso-spirochetal flora are present in small numbers on healthy tissue but proliferate rapidly under pathologic conditions. 3. Source of infection.—Discharges from the lesions of infected persons and from carriers often assumed to be source of infection but not yet adequately demonstrated. 4. Mode of transmission.—Direct contact with infected persons or carriers and articles freshly soiled by such persons is often assumed to be source of in- fection, but not yet adequately demonstrated. 5. Incubation period.—Variable and undetermined. 6. Period of communicability.—Not determined but presumed to be as long as the infecting organisms are found in the mouth. Not readily communicable. 7. Susceptibility and immunity.—Susceptibility probably general if predisposing conditions are present. Milder forms of Vincent’s stomatitis seem more prevalent under conditions of depressed vitality, malnutrition, neglected oral hygiene, etc. No immunity known to be acquired. Prevailing pre- disposition, not clearly understood, makes reoccurrence in susceptible individuals likely. 8. Prevalence.—Relatively rare and sporadic in general population. Not uncom- mon among persons of low nutrition and neglected oral hygiene; seemingly more prevalent in children and younger adults than in older adults. May be high at times in segregated populations living under unfavorable or crowded conditions. 64 CONTROL OF COMMUNICABLE DISEASES 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting: On clinical manifesta tions with or without bacteriological confirmation should be reported to school authorities when found among school chil- dren and under conditions of military service should be reported whether as angina or stomatitis. 2. Isolation: None. 3. Concurrent disinfection: All discharges from mouth and nose. 4. Terminal disinfection: None. 5. Quarantine: None. 6. Immunization: None. 7. Investigation of source of infection: Inspection of mouths and throats of other children or adults associated with the patient, at home or in school. Carriers are too common to be worth searching for by culture methods. B. General measures: 1. Encouragement of oral hygiene; correction of abnormal or dis- eased conditions of teeth and gums. 2. Education in matters of nutrition and hygiene. 3. Outbreaks involving small children, especially institutional, war- rant special measures because of the danger of the possible complication of noma. Yaws (Frambesia) 1. Recognition of the disease.—The initial lesion in the form of a granuloma or papules, is located extragenitally, usually on the legs, and is often engrafted upon a preexisting wound or ulcer. In from 1 to 3 months, widespread lesions of the skin develop. The first generalized lesion may be in the form of a furfuraceous desquamation as though the skin had been dusted with flour, but soon characteristic raspberry-like lesions appear. Bone and joint pains are common, and bone lesions are frequently observed. The constitutional symptoms are mild and of little diagnostic value. Among the commonest lesions are those of the soles of the feet, giving rise to the condition known as “crab yaws” because of the difficulty and manner of locomotion. The course of the disease is chronic, and relapses are com- mon. The blood Wassermann reaction and related tests become positive soon after the appearance of the initial lesion and remain positive f0r many years unless affected by treatment. 2. Etiological agent.—Treponema pertenue. 3. Source of infection.—Discharges from skin lesions and mucous membranes. 4. Mode of transmission.—Direct contact with lesions of patient and by nonbiting flies which convey the discharges of infected persons to others. 5. Incubation period.—Three and one-half weeks (experimental) to three or more months. 6. Period of communicability.—As long as the lesions are open and there are moist discharges. 7. Susceptibility and immunity.—There is no racial immunity but Negroes are more commonly affected than whites; children and young people more than adults. Recovery from an attack does not result in immunity to reinfection. It is neither congenital nor hereditary. 8. Prevalence.—Very common in the tropics, especially in Africa, Polynesia, the Philippines, and some parts of the New World. In the West Indies more prevalent in some villages than others. At present not known as indigenous in continental North America. Especially prevalent in the Caribbean area: Jamaica, Haiti, Trinidad, Antigua, and other islands of the Leeward group, and some coastal and valley settlements of Colombia. 9. Methods of control: A. The infected individual, contacts, and environment: 1. Recognition of the disease and reporting. 2. Isolation not practicable. 3. Concurrent disinfection: Protection of all sores and lesions in endemic locality, and disinfection of soiled dressings. 4. Terminal disinfection: None. 5. Quarantine of cases entering noninfected area of tropics. 6. Immunization None. CONTROL OF COMMUNICABLE DISEASES 65 7. Investigation of source of infection: In indigenous areas local surveys of incidence should be made, range of prevalence deter- mined, and cases in early stages sought for, especially in children. B. General measures: 1. Free clinics, laboratory service, and arsenicals for diagnosis and treatment. 2. Information service for physicians, patients, and public. 3. Promotion of adequate personal prophylaxis. 4. Education in schools, clinics, clubs, etc., as to methods of spread, prevention, and treatment. Supplementary List B Diseases of concern to health officers because of their group or epidemic occur- rence and the practicability of their prevention. Botulism. Food infections and poisonings. Pellagra. Botulism 1. Recognition of the disease.—A disease of intoxication, the symptoms of which develop suddenly with gastrointestinal pain, diarrhea or constipation, prostration, and a variety of central nervous system paralyses, the first of which is likely to be an oculo-motor paralysis, all due to the toxin of the particular saprophytic organism. Biological and toxicological tests with laboratory animals may confirm presence of toxin of the botulinus bacillus in the food. 2. Etiological agent.—The toxin produced by the botulinus bacillus (Clostridium botulinum, C. parabotulinum) in foods improperly processed. 3. Source.—Food usually taken uncooked from cans or jars not subjected to adequate heat of sufficient duration or under sufficient pressure during the processing. 4. Mode of transmission.—Only by eating food containing the botulinus toxin. 5. Incubation period.—Symptoms appear almost always within 24 hours after taking the particular food product, possibly longer, the interval being de- termined by the amount of the poisoned food taken and its botulinus toxin content 6. Communicability.—This term does not apply. The disease is not conveyed from man to man, or among animals or men, except as food containing the botulinus toxin is consumed by them. 7. Susceptibility and immunity.—Susceptibility is general. The symptoms de- velop according to the amount of toxin ingested in relation to body weight of the person. Antitoxins conferring passive immunity are of use only after infection is known to have occurred. 8. Prevalence.—Sporadic cases and groups of cases occur in all countries and always in relation to some perishable food product which has been so kept or preserved as to permit the development, under partially anaerobic conditions, of Clostridium botulinum, to the extent of forming the toxin that causes the symptoms. In the United States the disease has in recent years followed most commonly the use, without further or adequate cooking, of home-canned vegetable and meat products. 9. Methods of control: 1. Governmental control by regulation and inspection of commercial proc- essing of canned and preserved foods. 2. Education of housewives and others concerned with home canning of foods in the essentials of safe processing, as to time, pressure, and temperature factors. 3. Education in value of boiling with a small amount of soda, home-canned green and leafy vegetables before serving, and the thorough cooking of sausage and other meats and fish products held for later consumption. 66 CONTROL OF COMMUNICABLE DISEASES 1. Recognition of the disease.—Acute onset, usually with nausea and abdominal pain or distress, with vomiting and diarrhea, prostration, headache, and sometimes fever. Examination of vomitus and feces may reveal the infecting microTorganism, or the poisonous substance. 2. Etiological agent.—A variety of organisms, oftenest of the enteriditis or salmonella, or staphlyococcus groups. A variety of organic and inorganic poisons. 3. Source of infection.—Food recently ingested. 4. Mode of transmission.—In the case of bacterial poisonings, by the transfer of the particular etiological agent by food handlers to the food ingested. Hands unwashed after use of toilet, or hands or arms with furuncles, boils, or other sores are usual means of conveyance of contamination to foods. Food may be contaminated with a rodent strain of the salmonella group by rats or mice. The flesh of some food animals infected with certain salmonella strains may cause severe symptoms. Ingestion of foods to which some poisonous substance was accidentally or intentionally added, or in which a natural but poisonous substance occurs, is a direct cause of food poisoning. 5. Incubation period.—In the case of bacterial infections, may be from a few to 48 hours after ingestion of food. The symptoms may develop almost im- mediately, or several hours after ingestion of bacterial or nonbacterial poisons in the food. 6. Period of communicability.—This term does not apply to these conditions. 7. Susceptibility and immunity.—These do not apply. 8. Prevalence.—Sporadic, but in the main of rather common occurrence, especially in persons taking meals away from home, and in public eating places. 9. Methods of control: 1. All group outbreaks of infections and poisonings attributed to foods should be at once reported to the department of health. 2. Specimens of the foods suspected should be secured and used for lab- oratory examination. 3. The vomitus and feces of patients should be collected for bacteriologi- cal and chemical examination. 4. Persons concerned with the preparation and serving of foods should be brought under observation for medical and bacteriological examina- tion to determine the possible origin, whether from bowel discharges or infections of the skin. 5. Epidemiological inquiries should include particular study of water and milk used by the persons affected. Isolation, quarantine, concurrent and terminal disinfection are not applicable in such cases. Food Infections and Poisonings Pellagra 1. Recognition of the disease.—Pellagra is a general disease brought about by a deficiency of a protective or preventive substance or substances in the diet. Pellagra is characterized by symmetrical erythematous dermatoses on the exposed parts of the head, neck, and extremities, appearing commonly as the spring and summer advance, by gastrointestinal disorders, by glos- sitis, stomatitis, and in the advanced stages by emaciation, lethargy, mental confusion, and deterioration. 2. Etiology.—The cause is the lack of nicotinic acid or closely related compounds in the diet over a prolonged period of months or years. 3. Transmission.—Not communicable. 4. Incubation period.—Term does not apply. The symptoms rarely appear within 3 months after use of a controlled and artificially deficient diet in man. History of deficient diet in human cases is usually one of months or years. 5. Period of communicability.—Term does not apply. 6. Susceptibility and immunity.—Susceptibility is general. There is no immunity. 7. Prevalence.—The disease is endemic where chronic poverty, ignorance in food uses, and unavailability of the pellagra-preventive foods prevail. Indi- vidual cases and institutional cases can be traced to a particular restric- tion by choice or necessity in the pellagra-preventive elements of the diet In the southern States where diets are often seriously deficient in many CONTROL OF COMMUNICABLE DISEASES 67 respects, the incidence of the disease varies with the economic status of individuals and communities. 8. Methods of control: 1. Education in the use of pellagra-preventive articles of diet, particularly liver, lean meats, leafy green vegetables, and milk. 2. Provision of dried brewers’ yeast containing specific pellagra-preven- tive substance, to be distributed by the health or other public authority among persons economically unable to provide pellagra- preventive substance by usual table food. 3. Specific therapy: Nicotinic acid and its nicotinamide are specific. Appendix D Manual of the Medical Department Bureau Circular Letter Y Subject: Form A, Instructions. Reference: (a) Paragraph 3411 of this manual. (a) The Bureau desires that all medical officers and all hospital corpsmen on independent duty bear in mind, when preparing NMS Form A for the month of December that the purpose of the annual census (reverse side of Form A) is threefold: (1) To find the actual number of persons in the naval service who have a history of syphilis. (2) To find the number of all syphilitics in the naval service who actually received treatment during the year. (3) To determine what compounds were given to the persons actually treated during the year. In order to avoid duplication of data each person having custody of health records must take the data only from the health records actually on his custody on December 81 of the year covered by the report and not from the treatment records of the activity. In order to assure uniformly complete, accurate, and progressive health records this Bureau directs all medical officers, pharmacists, and hospital corpsmen on independent duty to make reference to paragraph 2350 of this manual. (b) To clarify further the instructions concerning the preparation of the annual data, the following examples are given: Example No. 1 A person, United States Navy or Marine Corps patient, received the following treatment during the year: January 2, 1937, 1 injection, neoarsphenamine, provocative Kahn. January 10, 1937, to March 20, 1937, 10 injections, neoarsphenamine. January 10, 1937, to March 20, 1937, 10 injections, bismuth salicylate. April 1, 1937, to June 5, 1937, 8 injections, neoarsphenamine. April 1, 1937, to June 5, 1937, 7 injections, bismosol. June 15, 1937, to June 30, 1937, neoarsphenamine, oral, for Vincent’s infection. August 5, 1937, to September 15, 1937, 5 injections, mapharsen. November 1, 1937, to December 22, 1937, 7 injections, tryparsamide. During the year the same person received mercury succinimide, mercury inunctions, and KI in ascending doses. 1 CIRCULAR LETTER Y TTiese data will be reported under paragraph 1 (b) as follows: SYPHILIS U. S. Navy and U. S. M. C. personnel (persons) All others (persons) Arsenicals: Acetarsone Arsphenamine Bismuth-arsphenamine-sulphonate (Bismarsen) o Mapharsen N eoarsphenamine Silver arsphenamine.. Sulpharsphenamine Tryparsamide Heavy metals: Bismuth compounds 1 1 1 Mercury compounds Other treatment: ' Potassium iodide Specific mixture... Number of individual cases treated with an arsenical compound—state disease and compound: Provocative Kahn.. Vincent’s infection, oral, neoarsphenamine 1 0 DISEASES OTHER THAN SYPHILIS It will be noted from the above table that one person received treatment for syphilis during the year, with neoarsphenamine, mapharsen, tryparsamide, bis- muth compounds, mercury compounds, and potassium iodide (KI) in ascending doses. The same person also received treatment during the year with oral applications of neoarsphenamine for Vincent’s infection, and 1 injection of neoarsphenamine for a provocative Kahn (diseases other than syphilis). This person was not recorded twice for neoarsphenamine treatments and twice for treatments with bismuth compounds because he is one person who received treatments for syphilis with neoarsphenamine, and one person who received treatments for syphilis with bismuth compounds (bismuth salicylate and bis- mosol) during the year. Under "Instructions,” Annual Report (reverse side, NMS Form A), it will be noted that this section reads as follows: "When compiling data for the annual report, each activity will include all health records in its custody on December 31.” Paragraph 1—(a) This figure will be obtained by an actual check of health records as of December 31 and is to include all cases in which there is a history of syphilis. Paragraph 1— (b) For the column "U. S. Navy and U. S. M. C. Personnel” obtain data on December 31 from entries in the health records of the persons reported in paragraph 1 (a); for the column "All others” the data will be taken from the treatment records and shall include the actual number of persons other than "U. S. Navy and U. S. M. C.” treated during the year. Example No. 2 A certain tender ship has administered arsenical treatment to the personnel of a destroyer squadron in addition to the administration of treatment to the mem- 2 FORM A—INSTRUCTIONS bers of her crew. If this tender ship includes the total number of persons treated during the year from the destroyer squadron and the total number of persons treated from her crew, then the annual report will be incorrect as the data re- ported under paragraph 1 (b) will be greater than the data reported under para- graph 1 (a) (data of actual number of persons on board on December 31 who have a history of syphilis). The destroyers of this squadron are required, in accordance with instructions, to submit reports for each individual ship. These data will give the Bureau complete information concerning how many persons on each ship have a history of syphilis and how many of these persons having a history of syphilis received treatment during the year. The tender ship will, in accordance with instructions, submit a census of her crew only. Example No. 3 (1) A certain naval hospital during the year has treated service personne from two naval stations in addition to treating service personnel patients con- fined in the hospital for syphilis. The individuals from the two naval stations would report to the hospital on the days of arsenical treatment, receive the treat- ment prescribed, and then return to their respective stations. No admission to the sick list would be made on account of the treatment accorded. In accordance with the instructions, this hospital will not report, in the annual section, the treatments accorded to the individuals from the two naval stations. However, it is the duty of this hospital to furnish complete information to the medical officer of each naval station regarding all treatments accorded, upon the completion of courses of treatment, so that each medical officer can make proper entries in the health records of the individuals concerned. (2) A naval hospital has admitted several service personnel patients during the year for the treatment of syphilis. These individuals are accorded treatment and upon completion of treatment are returned to their respective ships or sta- tions. If the hospital includes, in the annual section, the data of treatments accorded to these patients and the respective ship or station to which the men have returned also includes the data of treatments, a duplication of data will result and the reports from the hospital and the ship or station will be incorrect. Therefore, when compiling the data for the annual report, each hospital will take into consideration only the health records actually in custody on December 31, and will report accordingly. All patients on the sick list in a naval hospital on December 31, and carried over into the next year, will be classed as actually attached on December 31. For the column “All others” (persons other than active service personnel) as Veterans’ Administration patients, supernumeraries, beneficiaries, etc., the data will be taken from the treatment records and shall include the data of the actual number of persons treated during the year. All persons shall be reported regardless of whether the patient has been disposed of prior to December 31, or is continued under treatment on December 31. (c) In order to assure a more complete census the Bureau directs all medical officers and all hospital corpsmen on independent duty who have custody of health records to make notations which will be attached to the health records by memo slips, whether the data for the annual census have or have not been extracted from the health records of persons or patients who are transferred to another ship or station on December 31, or those persons who are transferred on December 31 but who will not arrive at their new ship or station until after December 31. 3 CIRCULAR LETTER Y Strict compliance with this order will assure the medical officer of the ship or station to which the person reports whether the data for the annual census have or have not been extracted from the health record of the person reporting. The term “custody” applies to medical officers of naval transports, who will review the health records of all persons on board on December 31, thus including passengers as well as crew, provided the data for the annual census have not been extracted from the health records by the ship or station from which the passengers reported. 4 Appendix D Manual of the Medical Department Bureau Circular Letter Y Subject: Emergency Oxygen Administration Apparatus. Reference: (a) Paragraph 872 of this manual. (6) Joint Circular Letter Bu. C. & R., L9/P-(9), Bu. M. & S. P3-2(072), of October 5, 1927. (c) Bureau of C. & R. Manual, chap. 28, art. 2815-2821-2822. (d) Service chemicals, U. S. N., 1931, pp. 304-308. (a) The attention of all officers of the Medical Department and hospital corps- men on independent duty is invited to the fact that the Navy-type oxygen rescue breathing apparatus referred to in reference (a) and described in reference (c), is provided with certain attachments whereby the equipment is converted into an inhalator for the emergency administration of oxygen in conjunction with the prone pressure method of artificial respiration. The chief application of the appliance is in the treatment of men who have been overcome in con- nection with fires in a confined space aboard ships, the usual cause being carbon monoxide poisoning. It has come to the notice of the Bureau that a considerable number of medical officers and Hospital Corps men are not aware that this inhalator is available on all vessels having on board the regular Navy-type oxygen breathing apparatus. A detailed description of the equipment is contained in reference (6) under date of October 5, 1927. However, in view of the lapse of time and the possibility that this reference may not be readily available, a description of the four adap- tors, or parts, is presented herewith. (b) Part I: An aluminum face piece that fits tightly over the mouth and nose, provided with an exhalation valve on a 28-inch length of flexible corrugated rubber tube, the outer end of which is fitted with a nickel-plated union to con- nect to the cooler of the rescue breathing apparatus. Part II: A metal cap which fits over the regenerator opening of the rescue breathing apparatus. This cap contains a small mica disk valve which permits the entry of air into the rescue breathing apparatus in case the patient breathes faster than the supply of oxygen. This valve prevents a negative pressure being created in the apparatus. Part III: A metal cap which fits over the small outlet at the bottom of the cooler to which ordinarily the bypass connection between the oxygen cylinder and cooler is connected. Part IV: A flexible copper pipe connection to connect another oxygen cylinder (preferably one of 200 cubic feet capacity) with the bypass outlet connection on the small oxygen cylinder regularly used on the oxygen rescue breathing apparatus. (c) The oxygen rescue breathing apparatus is converted into an inhalator by attaching the above-described adaptors. This is described in detail in references (6) and (d), being illustrated in the last-named reference. Reference (d) has been issued to all vessels of the type provided with rescue breathing apparatus and should, therefore, be available. 1 CIRCULAR LETTER Y As the apparatus is designed, a man breathing normally will take the oxygen as fast as it is released into the breathing bag. If his respiration is very deep and he requires a greater volume than could be supplied by the oxygen feed, sufficient air will be drawn through the check valve (part II) to compensate for the added requirement. If, on the other hand, he is not breathing deeply, and, therefore, not consuming much oxygen, the bag will fill up to a certain point and cut off the supply of oxygen to the bag by means of closure of the automatic admission valve. It is not possible to give a man too much oxygen or to create a partial vacuum in the bag. (d) The method of using the oxygen breathing apparatus adapted as an inha- lator is outlined in references (6) and (d). The importance of not waiting to get the resuscitator before proceeding with manual artificial respiration cannot be too strongly emphasized. The latter should be applied immediately. If the use of the rescue breathing apparatus interferes in any way with manual artificial respiration its use should be suspended. (e) It is directed that the senior medical officer of vessels having on board oxygen rescue apparatus make arrangements through official channels to have this inhalator temporarily set up from time to time and the medical personnel attached to fire and rescue parties familiarized with the principles of operation and the method of use in emergencies. This procedure will also apply to hos- pital corpsmen on independent duty on vessels which are supplied with this equipment. Subject: Heating and Ventilation. References: (a) Heating Ventilation Air Conditioning Guide, chapter 3, 1938, published by American Society of Heating and Ventilating Engineers, 51 Madison Avenue, New York, N. Y. (6) Preventive Medicine and Hygiene, Rosenau, sixth edition, chapter 4. (c) Bureau of Construction and Repair Manual, 1934, chapter 15, available on all naval vessels. Subject: Field and Camp Sanitation. References: (a) Landing Force Manual, U. S. N. (6) Military Preventive Medicine, Dunham, 1938. (c) Essentials of Field Sanitation, Carlisle Barracks, 1935. ( if otherwise, state "no". Date: If "yes" above, state date on which case was pre- viously taken up expressed in numerals. Key: Enter appropriate key letter as defined in paragraph 24U. Specialty: Enter appropriate specialty letter as defined in paragraph 2415* Line 7* - Patient Received From: State name of ship or station from which the patient was received by transfer; if by reason of change of diagnosis, so enter. Hospitals, only, shall indicate by the word "Staff" when the patient is a member of the hospital staff. Indicate when admitted direct to a naval hospital by orders of the Bureau of Naval Person- nel, from sick leave, or from home awaiting discharge or retirement. Indicate if the patient is a straggler or in desertion status. When a case is taken up from a change of diagnosis on the preceding Form F card, enter the phrasr "Change of Diagnosis." Line 8. - Transferred as a Patient to: Use for cases disposed of as TRANSFERRED. The name of the place to which transferred shall be stated. In case of transfer to sick leave, etc., 3 A2-2/EN10(113-33) 80 state. In case of intermediate transfer, the name of the naval vessel to which actually sent for transportation shall be given, not the place to which ultimate transfer is to be made. If such transfer is by commercial trans- portation or Army transport, the words "via commercial transportationn or "via Army transport" shall be inserted after the name of the station or hospital to which the patient is to report. Line 9* - Diagn. Changed (C) To: Enter Navy Nomenclature title of the new diagnosis. Diagn. No.: Use diagnosis number of Navy Nomenclature. On Account of: Eh ter the reason for the change of diagnosis. (Par. 24047?!). Line 10. - AGP: To be completed only when the case is taken up as an ADMITTED CONTRIBUTORY DISABILITY. Diag. No.: Use diagnosis number of Navy Nomenclature. Primary Diagnosis: State the primary diagnosis (Navy Nom- enclature) of which disability reported on Line 4 is a com- plication or sequela. Line 11. - This Card Sent Name of Ship or station preparing the Form Fa card except as in paragraph 2407. This should include active-duty passengers admitted to the sick list as patients of that ship. Line 12. - Remarks: The space provided as Line 12 shall be used for such additional remarks as are required or considered necessary to clarify the report. Circumstances of occurrence for every admission for injuries or poisonings shall be entered as indicated in paragraph 2416. Place of exposure to venereal diseases. The probable place of exposure should be stated on Line 12 when a venereal disease is first reported either as a new admission, "A", or by change of diagnosis, "C" due to error or established. The term "probable place" means the probable geographical location, such as city or town where the exposure occurred. ROSS T. McINTIRE