(restricted) FLIGHT SURGEONS HANDBOOK School of Aviation Medicipe Randolph Field, Texps April 30, 1943 / FLIGHT SURGEON'S HANDBOOK Prepared under the Direction of the Commandant, School of Aviation Medicine, Army Air Forces. 2nd Edition FOREWORD One year has passed since the first edition of the Flight Surgeon’s Handbook came off the press. During this time progress in Aviation Medicine has been great. In attempting to include as much recently acquired knowledge as is possible under wartime restrictions, and also to include material involuntarily omitted from the first edition, the new handbook of necessity has grown in size. There are now a total of eleven chapters and an appendix compared to seven chapters in the origin- al volume. The inclusion of some material may need defense. The chapter on Military Medicine, for example, has been retained and expanded for use by the Flight Surgeon as a Medical Officer. It is a “wartime” inclusion to meet an urgent need for a ready reference to problems which most likely will be met under combat conditions. The same may be said for some other material in the book which has no direct re- lation to Aviation Medicine. Once the emergency is over it will probably be desir- able to delete these subjects from subsequent editions. More references will be found than in the first edition. Some of these are confidential. The Flight Surgeon may investigate them if he has access to a confi- dential file. The subject matter of these references obviously could not be included in this manual. A considerable part of the book’s growth is attributable to constructive criti- cisms submitted by Flight Surgeons and Aviation Medical Examiners on duty with the Army Air Forces all over the world. The Commandant and Facility of the School extend their gratitude to these Medical Officers and hope that the new edition will evoke as much interest. As before blank pages have been included so that the Flight Surgeon may enter amendments when necessary. EUGEN G. REINARTZ, Brigadier General, A.U.S., Commandant. FLIGHT SURGEON’S HANDBOOK Table of Contents CHAPTER 1. GENERAL. Page Paragraph 1. Use 1 2. Purpose 1 3. Preparation 1 CHAPTER 2. THE ARMY AIR FORCES PHYSICIAN. SECTION I. THE AVIATION MEDICAL EXAMINER. Paragraph 4. Eligible Personnel 2 5. Method of Requesting Training for Rating 2 6. Requirements 2 SECTION II. THE FLIGHT SURGEON. Paragraph 7. Eligible Personnel 2 8. Method of Requesting Rating 2 9, Minimum Requirements 2 10. Recommendations of Senior Flight Surgeon 3 11. Physical Examination 3 12. References 3 SECTION III. SUGGESTIONS TO FLIGHT SURGEONS ON FLYING STATUS. Paragraph 13. Equipment 3 14. Prior to Take-off 3 15. In Flight 4 16. Miscellaneous Suggestions 6 17. References 6 CHAPTER 3. THE PHYSICAL EXAMINATION FOR FLYING. SECTION I. THE GENERAL PHYSICAL EXAMINATION. Paragraph IS. The Medical History 7 19. The Medical Examination 7 20. Standards of the Physical Examination for Flying 9 21. Standards of Height, Weight, and Chest Measurements . . 9 22. The Schneider Index 9 23. Vasomotor Instability 11 24. Heart Sounds 11 25. Criteria for the Diagnosis of Common Cardiac Valvular Deformities 11 26. Blood Pressure 17 27. The Electrocardiogram 18 28. Cardiac Radiography 21 29. Examination of the Lungs 26 30. Bones, Joints, Muscles, and Feet 28 31. References 29 SECTION II. EXAMINATION OF THE EYE. Paragraph 32. Technique of the Eye Examination for Flying 30 33. Minimal Visual Requirements of Flying Personnel 42 34. Visual Requirements, All Classes 42 35. Improvised Equipment for Conducting the Eye Examination for Flying 42 36. Primary Differential Diagnostic Points in Nystagmus .... 50 37. Action of Eye Muscles 50 38. Depth Perception Apparatus (Wheel Operated) 53 39. Dark Room Table 53 40. References 57 SECTION HI. EXAMINATION OF EAR, NOSE, AND THROAT. Paragraph 41. Technique of Examination of Ear, Nose, and Throat 58 42. Hearing Requirements, All Classes 65 43. Hearing Tests 65 44. Technique for Taking X-Rays of Sinuses and Mastoids. ... 65 45. References 66 SECTION IV. THE PSYCHOLOGICAL AND NEUROPSYCHIATRIC EXAMINATIC Paragraph 46. General 67 47. Conduct of Examination 67 48. Unfavorable Findings 69 49. The Adaptability Rating for Military Aeronautics 69 50. References 70 SECTION V. THE DENTAL EXAMINATION. Paragraph 51. Notations Used 71 52. Dental Classification 72 53. Standards 72 54. Dental Identification Record 73 55. References 73 EXAMINATION. CHAPTER 4. PROBLEMS IN THE CARE OF THE FLYER SECTION I. SICK CALL AND MEDICAL ATTENDANCE. Paragraph 56. General , 74 57. Flying Pay 74 SECTION II. FLYING FATIGUE. Paragraph 58. Definition 75 59. Symptoms and characteristics 75 60. Prevention 76 61. Treatment 77 62. Conclusion 77 63. References 78 SECTION III. AERO-OTITIS MEDIA. Paragraph 64. Definition 79 65. Dynamics 79 66. Differential Diagnosis 79 67. Prophylaxis 79 68. Treatment 81 69. References 81 SECTION IV. AEROSINUSITIS. Page Paragraph 70. Definition 82 71. Dynamics 82 72. Differential Diagnosis 82 73. Prophylaxis 85 74. Treatment 85 75. References 85 SECTION V. CHANGES IN HEARING PRODUCED BY FLIGHT. Paragraph 76. Factors Affecting Auditory Acuity 86 77. Effect of Noise 86 78. Effects of Changing Barometric Pressure 86 79. Effect of Anoxia 86 80. Effect of Age 86 81. Summary 86 82. References SECTION VI. NIGHT VISION. Paragraph 83. Anatomical and Physiological Considerations 88 84. Summary of Visual Characteristics of Rods and Cones ... 88 85. Practical Applications 89 86. Visibility of Lights at Night 90 87. References 90 SECTION VH. DECOMPRESSION SICKNESS. Paragraph 88. Definition 91 89. Synonyms 91 90. Dynamics 91 91. Symptoms 91 92. Factors Concerned in Production of Symptoms 92 93. Diagnosis 92 94. Treatment 92 95. References , 92 SECTION VIH. AIRSICKNESS. Paragraph 96. Definition 93 97. Etiology 93 98. Symptoms 93 99. Physiological Mechanism 93 100. Incidence 94 101. Prevention and Treatment 94 102. References 95 SECTION IX. INSTRUMENT FLIGHT. Paragraph 103. Definitions 96 104, Bodily Equilibrium 96 105, Sensory Elusions in Flight 96 106, References 96 SECTION X. DRUGS IN RELATION TO FLYING. Paragraph 107. Modifying Factors 98 108. Sulfonamides 98 Page 109. Carbon Monoxide and Other Toxic Fumes 98 110. Arsenicals 98 111. Atabrine 98 112. Use of Drugs in Fatigue 98 113. Use of Drugs in Airsickness 99 114. References 99 SECTION XL THE PSYCHONEUROSES AND PSYCHOTHERAPY. Paragraph 115. General 100 116. Neurasthenia 100 117. Hysteria 101 118. Psychasthenia 101 119. Anxiety State 102 120. Traumatic Neurosis 102 121. Psychotherapy 103 122. References 105 SECTION XH. ANOXIA. Paragraph 123. Definition . 106 124. Symptoms 106 125. Signs 106 126. Therapy 107 127. References 107 CHAPTER 5. PHYSICAL FACTORS OF PHYSIOLOGICAL IMPORTANCE IN FLYING. SECTION I. PHYSICAL CHARACTERISTICS OF THE ATMOSPHERE. Paragraph 128. Composition of the Atmosphere 108 129. Altitude-Pressure Data 108 130. Temperature Conversion Table 108 131. References 108 SECTION H. EXTERNAL AND INTERNAL RESPIRATION. Paragraph 132. Mechanical Factors in Respiratory Gas Exchange 108 133. Gas Laws 113 134. Composition of Pulmonary Alveolar Air 113 135. Formulae for Partial Pressure of Alveolar Oxygen 114 136. Prediction Equations for Alveolar Oxygen Tension 114 137. Carriage of Oxygen ’ Carbon Dioxide in the Body 115 138. Oxygen Dissociation Curve 115 139. References 115 SECTION HI. ANOXIA. Paragraph 140. Equivalent Altitudes Breathing Air and Breathing 100% Oxygen 118 141. Arterial Oxygen Saturation and Degree of Physiological Handicap 118 142. Oxygen Requirements at Altitude 118 143. References 118 SECTION IV. USE OF SUPPLEMENTARY OXYGEN. Paragraph 144. Oxygen Equipment 122 Page 145. Oxygen Duration Data 122 146. References 122 SECTION V. ACCELERATION IN AIRCRAFT. Paragraph 147. Definitions 127 148. Linear Acceleration 129 149. Angular Acceleration 129 150. Radial Acceleration 129 151. References 131 SECTION VI. NOXIOUS GASES IN AIRCRAFT. Paragraph 152. Carbon Monoxide 132 153. Gasoline Fumes 136 154. Hot Oil Fumes 136 155. References 136 CHAPTER 6. MEDICAL TRAINING. SECTION I. MEDICAL DEPARTMENT ENLISTED MEN. Paragraph 156. General 137 157, References 137 SECTION H. AIRCREWS AND COMBAT CREWS Paragraph 158. Objective . 137 159. Scope 137 160. Duration of Instruction 137 161. Method of Instruction 138 162. Program 138 SECTION m. MEDICAL OFFICERS ON DUTY WITH A.A.F. Paragraph 163. Outline of Basic Training 140 164. Didactic Program for Rating as Aviation Medical Examiner 142 165. References 142 CHAPTER 7. SANITATION. SECTION I. SANITARY REPORT. Paragraph 166. Model of Sanitary Report 143 SECTION II. SANITARY ORDER. Paragraph 167. Problem 144 168. Solution 145 SECTION HI. SANITARY DEVICES. Paragraph 169. References for 147 SECTION IV. ABSTRACTS FROM INTERNATIONAL SANITARY CONVENTION FOR AERIAL NAVIGATION (THE HAGUE, APRIL 12, 1933). Paragraph 170. General Reference, Sanitary Regulations on the Care of Page Certain Diseases 147 171. Measures Applicable in the Case of Plague, Cholera, Typhus, and Smallpox 143 172. Measures Applicable in the Case of Yellow Fever 151 173. General Provisions 153 SECTION V. QUARANTINE, INSPECTION AND TREATMENT OF AIRCRAFT Paragraph 174, General 155 175. Nonstop Flights Without Quarantine Restrictions 155 176. Flights with Quarantine Restrictions 155 177. Use of Insecticide 155 178. Dosage for Eliminating Infectious Mosquitoes from Various Types of Military Aircraft 15g 179. Directions for Aerosol Method of Disinsectization 15g 180. Alternate Method of Disinsectization (Pyrethrum method) . 150 181. Form to be Completed After Disinsectization of Aircraft. . 455 182. References 158 CHAPTER 8. ADMINISTRATION. SECTION I. REPORTS. Paragraph 183. Rendered by Station Hospitals or Dispensaries 159 184. Rendered by a Tactical Unit 162 185. Report of Sick and Wounded 165 186. Check System for Forwarding of Reports 165 187. List of Forms Commonly Used, by Number 166 SECTION H. THE FLIGHT SURGEON’S OFFICE. Paragraph 188. Types of Examinations 175 189. Instructions for Completing W.D., A.G.O. Form No. 64 . . . 175 190. Care of Flier Report 178 191. Locator Chart 183 192. Transfer of Records 183 193. Grounding, Relief, Clearance, and Restoration of Flying Personnel 183 194. Procedure in Case of Crash Death 185 195. Reports Following Hospitalization 187 CHAPTER 9. MEDICAL PROPERTY AND SUPPLY. SECTION I. CLASSIFICATION. Paragraph 196. General 188 197. Standard Supplies 188 198. Medical Service and Supply Within the Tactical Units of the Army Air Forces 188 SECTION II. PROCUREMENT. Paragraph 199. Requisitions 189 200. Shipping Ticket 189 201. Purchase Order 189 SECTION HI. PROPERTY RECORD. Page Paragraph 202. Stock Record Cards 190 203. Vouchers 190 204. Memorandum Receipt 190 205. Annual Report 190 SECTION IV. MISCELLANEOUS PROCEDURES. Paragraph 206. Over, Short, and Damaged Report 191 207. Inspection and Inventory Report 191 208. Report of Survey 191 209. Transfer of Property 191 CHAPTER 10. MILITARY MEDICINE. SECTION I. PERIPHERAL CIRCULATORY FAILURE. Paragraph 210. Definition 193 211. Symptoms 193 212. Signs 193 213. Classification of Acute Peripheral Circulatory Failure. . . . 193 214. Principles of Therapy of Peripheral Circulatory Failure, Hematogenic Type 194 215. References 197 SECTION II. BURNS. Paragraph 216. Body Surface 199 217. Classification of Burns 199 218. Object of Treatment 199 219. First Aid Treatment 200 220. Local Treatment 200 221. Chemotherapy of Burns 202 222. Late Therapy of Burns 202 223. Prevention 202 224. References 202 SECTION IH. CRANIOSPINAL INJURIES. Paragraph 225. General 203 226. Signs and Symptoms 203 227. Treatment 204 228. References 204 SECTION IV. CHEMICAL WARFARE. Paragraph 229. Characteristics of Lung Irritants 206 230. Characteristics of Vesicants 207 231. Characteristics of Lacrimators 208 232. Characteristics of Irritant Smokes 209 233. Characteristics of Screening Smokes 210 234. Reference and Training Chart 211 235. References 211 SECTION V. SULFONAMIDE THERAPY. Paragraph 236. General 213 Page 237. Use in Treatment of Gonorrhea 213 238. Use in Hemolytic Streptococcal Infections 213 239. Use in Meningococcal Meningitis 214 240. Use in Purulent Meningitis 214 241. Use in Pneumonia 215 242. lies in Gas Bacillus Infection 215 243. Use in Staphylococcal Infections 216 244. Use in Peritonitis 216 245. Use in Urinary Tract Infections 216 246. Use in Bacillary Dysentery 217 247. Local Use 217 248. Toxic Manifestations 217 249. Laboratory Control of Sulfonamide Therapy 218 250. Regulations on Use of Sulfonamides in Flying Personnel. . 218 251. References 220 SECTION VI. THE VENEREAL DISEASES. Paragraph 252. Prophylaxis 221 253. Gonorrhea 221 254. Syphilis 224 255. Chancroidal Infection 229 256. Lymphogranuloma Venereum 230 257. Granuloma Inguinale 232 258. References 232 SECTION VII. TROPICAL MEDICINE. Paragraph 259. Subject Matter 233 260. Health in the Tropics 233 261. Diet in the Tropics 233 262. Disease in the Tropics 233 263. Effects of Heat 233 264. Plant Poisonings 234 265. Animal Poisonings 234 266. Virus Infections 235 267. Rickettsial Infections 235 268. Bacterial Infections 239 269. Spirochetal Infections 242 270. Protozoal Infections 242 271. Helminthic Infections 258 272. Military Problems 256 273. References 260 SECTION VIH. BLAST INJURY. Paragraph 274. General 262 275. Parts Injured 262 276. References 263 CHAPTER 11. REFERENCE LIBRARIES FOR THE FLIGHT SURGEON. Paragraph 277. The Permanent Library 204 278, The Field Library 205 CHAPTER 12. APPENDIX. Paragraph 279. Some Aspects of Medical Care, Evacuation, and Supply Page with Air Field Units 266 280. Tables of Organization 270 281. Tables of Basic Allowances 270 282. Air Base Group Aid Station Equipment 280 283. Squadron Aid Station Equipment 294 284. Contents of Miscellaneous Kits and Cases 297 285. Formulae of Pharmaceuticals 306 286. Training Channels: Aviation Cadets 306 287. Training Channels: Officers Training in Grade 306 FLIGHT SURGEON’S HANDBOOK List of Illustrations Figure Page 1. Simultaneous carotid arteriogram, jugular phlebogram, apical stethogram, and electrocardiogram 14 2. The normal electrocardiogram 19 3. Fluoroscopic views of the heart: left anterior oblique, anteropos- terior, and right anterior oblique 22 4. Measurements of the heart on the radiograph 23 5. Heterphoria test board 48 6. Diagram of action of individual eye muscles in six cardinal directions from eye front (Peter) 52 7. Diagram showing conjugate (yoke) action of extrinsic ocular muscles in binocular movements (Peter) 52 8. Wheel-controlled depth perception apparatus 54 9. Dark room table (front and partial end view) 55 10. Dark room table (end view) 56 11. Technique of the nasopharyngeal examination 59 12. Technique of irrigating the auditory canal 62 13. Dynamics of aero-otitis media (diagramatic) 80 14. Maxillary sinus in flight 83 15. Frontal sinus in flight 84 16. Composite audiogram demonstrating changes which must be consider- ed in the analysis of the hearing of an airman 87 17. Physical characteristics of the atmosphere 110 18. Mechanics of respiration 112 19. Carriage of oxygen and carbon dioxide in the body 116 20. Oxygen dissociation curve of arterial blood (40 mm. COg pressure) 117 21. Arterial oxygen saturation at various altitudes while breathing air and and while breathing pure oxygen in relation to the degree of phy- siological handicap 120 22. Operating diagram of A-8B oxygen mask and A-9A continuous flow regulator 123 Page 23. Operating diagram of A-9 oxygen mask and A-12 oxygen demand regulator 124 24. Operating diagram of portable (walk-around) cylinder 125 25. Oxygen duration chart using A-8A and A-9A regulator with mask . . 126 26. The relation between velocity, radius of curvature, and force of radial acceleration in g units 128 27. Positive, negative, and transverse acceleration in aircraft 130 28. Effect of carbon monoxide on arterial Hb saturation at various altitudes 133 O 29. Effect of carbon monoxide on the shape of the 0 dissociation curve. . 134 30. Blood saturation and resulting symptoms produced by various concen- trations of carbon monoxide in the inspired air 135 31. Use of the standard Army-Navy plasma 196 32. Geographical distribution of Yellow Fever 236 33. Geographical distribution of Dengue 237 34. Geographical distribution of Typhus Fever 238 35. Geographical distribution of Cholera 240 36. Geographical distribution of Plague 241 37. Geographical distribution of Malaria 243 38. Medical supply chain (AAF tactical units) 269 39. Training channels: aviation cadets SO"7 40. Training channels: officers training in grade 308 FLIGHT SURGEON’S HANDBOOK List of Tables Table Page l. Standards for physical examinations Army Air Forces, (January 1, 1943) 8 II. Heights, weights, and chest measurements at expiration for officers and officer candidates 10 m. Table for scoring the Schneider Index 12 IV. Summary of normal heart sounds 13 V. Terms to be used in describing heart sounds and murmurs 15 VI. Table for calculating rate and systolic index in the electrocardiogram 20 VII. Theoretical transverse diameters of heart silhouette on teleroentgen- ogram for various heights and weights 24 VIE. Prediction for normal cardiac area and transverse diameter on the orthodiagram 25 IX. Mean value of accommodation power 36 X. Minimal visual requirements, flying personnel, by classes (January 1, 1943) 41 XL Eye requirements (all branches, December 3, 1942) 43-46 XII. Primary differential diagnostic points in nystagmus 51 XHI. Action of eye muscles 52 XIV. Hearing requirements, Army Air Forces (January 1, 1943) 63-64 XV. Interpretation of hearing tests 65 XVI. Altitude-pressure table 109 XVH. Temperature conversion table (Centigrade to Fahrenheit) HI XVHI. Equivalent altitudes breathing air and breathing 100% oxygen 119 XIX. Oxygen requirements at altitude 121 XX. The dosage for eliminating infectious mosquitoes from various types of military aircraft 157 XXL Data to be carried on back of Care of Flier Report 180 XXH, Data for Care of Flier Report 182 XXIII. Chemical warfare agents, reference and training chart 212 XXIV. Toxic manifestations of sulfonamides 219 XXV. Treatment schedule, early and latent syphilis 226 XXVI. Medical squadron, air evacuation, transport 267 XXVII. Medical detachments in Army Air Forces 271 Page CHAPTER I GENERAL Paragraphs Use 1 Purpose 2 Preparation 3 1. USE. The “Flight Surgeon’s Handbook” was created by the Faculty of the School of Aviation Medicine primarily for Flight Surgeons and Aviation Medical Examiners on duty with the Army Air Forces who have previously attended the School. It may be found use- ful, however, for all physicians engaged in the ever increasing task of selecting and main- taining flying personnel. 2. PURPOSE. To make readily available to the Aviation Medical Examiner and to the Flight Surgeon the following: a. Tables and normal values of various measurements to which frequent reference must be made in the selection of flying personnel. b. Outlines of diagnostic procedures and techniques which are used frequently in the phy- sical examination for flying. c. Supplements to the Army Regulations which apply to the physical examination for fly- ing. d. Summaries of common problems in the care of the flyer. e. Data, formulae, and tables on physiological aspects of flying to which reference must frequently be made. f. Medical training programs. g. A summary of the procedures to be followed, particularly at the smaller stations of the Army Air Forces, with respect to supply, administration, and sanitation, h. References on each subject which the reader may consult if more details are needed. i. An outline of principles of military medicine and surgery most likely to be encounter- ed in combat. 3. PREPARATION. Although this handbook was prepared by the present Faculty of the School of Aviation Medicine, it can in a measure be regarded as a culmination of the pain- staking efforts of all previous members of the staff and of all physicians and airmen every where who have contributed either directly or indirectly to the progress of Aviation Medi- cine. CHAPTER 2 THE ARMY AIR FORCES PHYSICIAN SECTION I THE AVIATION MEDICAL EXAMINER Paragraphs Eligible personnel 4 Method of requesting training for rating 5 Requirements 6 4. ELIGIBLE PERSONNEL. Any medical officer on active duty, subject to restrictions in part, is eligible for the instruction which is prerequisite for the rating of Aviation Medical Examiner. 5. METHOD OF REQUESTING TRAINING FOR RATING, a. Medical officers on duty with the Ground Forces will make application through channels to the Adjutant General for permission to attend the School of Aviation Medicine. b. Medical officers on duty with the AAF will make application through channels to the Commanding General, AAF, for permission to attend the School. 6. REQUIREMENTS. The applicant must not be over thirty five years of age, should be able to meet the Class 3 standards of par. 3d(3) AR 40-110, should have completed at least three months of previous military duty, and be recommended by his commanding offiC'. is having the professional qualifications, personality, and tact to warrant such asslgm eat. SECTION II THE FLIGHT SURGEON Paragraphs Eligible personnel 7 Method of requesting rating 8 Minimum requirements 9 Recommendations of senior flight surgeon 10 Physical examination 11 References 12 7. ELIGIBLE PERSONNEL. An Aviation Medical Examiner who has served a minimum of one year of active duty with the Army Air Forces after having received such a quali- fication, and who has demonstrated that he possesses required qualifications, may, under such regulations as the CG, AAF prescribes, be rated as “Flight Surgeon”. 8. METHOD OF REQUESTING RATING, Request of an Aviation Medical Examiner for rating as a Flight Surgeon will be initiated by the officer concerned and will be acted up- on by his immediate senior flight surgeon and forwarded through command channels to the Air Surgeon. 9. MINIMUM REQUIREMENTS. The request for rating will certify that the following minimum requirements have been completed by the Aviation Medical Examiner: a. One year’s actual service as an Aviation Medical Examiner, in close contact with flying personnel and actually performing physical examinations for flying. The fact that an officer has been qualified as an Aviation Medical Examiner for a period of one year and has served at an Air Forces station for such a period, is not, in itself, sufficient qualification for such a rating. b. Fifty hours of official flying time in military aircraft. c. He has read and is familiar with the contents of the following War Department Man- uals: (1) TM 1-705 - Physiological Aspects of Flying, and Maintenance of Physical Fitness. (2) TM 1-400 - Theory of Flight. (3) TM 1-231 - Elementary Weather for Pilot Trainees. (4) FM 1-5 - Employment of Aviation of the Army. (5) FM 31-15 - Operations in Snow and Extreme Cold. (6) FM 31-20 - Jungle Warfare. (7) FM 31-25 - Desert Operations. (8) FM 8-35 - Transportation of Sick and Wounded. (9) Outline of Course of Instruction in High Altitude Physiology, Aero Medical Research Unit, Materiel Center, Wright Field, Dayton, Ohio. (10) Such other manuals or texts as may be prescribed from time to time, d. An Aviation Medical Examiner assigned to an AAF unit which departs the continental limits of the United States may be rated as a Flight Surgeon, irrespective of the time he has served as an Aviation Medical Examiner, in accordance with regulations issued by the Commanding General, Army Air Forces. 10. RECOMMENDATIONS OF SENIOR FLIGHT SURGEON. The officer forwarding the request will state whether or not the Aviation Medical Examiner has thoroughly demon- strated necessary professional qualifications, personality, tact, etc., to warrant his being given such a rating. 11. PHYSICAL EXAMINATION. The request will be accompanied by a completed WD AGO Form No. 64 (May 20, 1941), Physical Examination for Flying, on the subject individual. 12. REFERENCES, a. Regulations. (1) AAF Regulation No. 25-5, WD Hq., AAF, June 17, 1942. (2) AR 350-500, Army Air Forces Schools, August 11, 1942 SECTION m SUGGESTIONS TO FLIGHT SURGEONS ON FLYING STATUS Paragraphs Equipment 13 Prior to Take-Off 14 In flight 15 Miscellaneous suggestions 16 References 17 13. EQUIPMENT, a. Always keep personal flying equipment in good condition. Familiar- ize yourself with its proper care. b. It is your responsibility to see that flying equipment is safeguarded. Do not leave your equipment unattended. c. Wear flight clothing only while on the line or while flying unless specifically author- ized to do otherwise. d. Know how to use all personal equipment. This applies particularly to the parachute, the oxygen equipment, the safety belt, radio headset, and clothing. If you are not thorough- ly familiar with their use, ask the pilot or crew chief about them before take-off. e. Unless you are sure of the type of clothing to wear for any specific mission, ask the pilot. T is always extremely cold at high altitudes. Learn how to dress properly for these extreme temperatures. 14. PRIOR TO TAKE-OFF. a. Understand the exact time of take-off. Be there 15 minutes ahead of time. b. Have all equipment adjusted (e.g. your parachute straps) so that you do not cause any delay when you enter the plane. c. Regulations require that someone familiar with the controls enter the plane first. Ordinarily the pilot will get in the ship first. However, the pilot may direct you to get in first so he may check your safety belt and give you instructions, d. When riding in a transport airplane with a senior officer, (e.g. a General Officer), all other officers get aboard first and the General Officer gets aboard when he is ready to depart. If the General Officer walks out with the entire group to the waiting ship, he may elect to go aboard first. Upon landing, the General Officer is the first man to leave the ship. e. An additional map of the proposed route of the flight may frequently be obtained from the operations office, making it possible to practice simple point to point navigation. _f. If there is any equipment in the ship with which you may be concerned, know how to use it. If it is unfamiliar, ask the pilot or crew chief to explain its functioning. Equipment and devices with which familiarity must be established: (1) Safety belt. (2) Control to raise, lower or turn the seat or release the back rest. (Lower seat on landing and take-off to protect your head should the ship nose over). (3) Oxygen mask and regulator. (4) Radio jack for plugging in headset; radio microphone. (5) Control to shift radio to Interphone (if present); control to vary the radio volume. (6) Lighting controls for instrument panel (if riding in a ship with a separate instrument panel). (7) Location of relief tube. (8) Control for opening the canopy or door to cockpit. (9) Emergency release for canopy or door and the location of all regular and emergency exits in large planes. (10) Control on the rudder pedals (to be touched only with permission of the pilot and before take-off) in order to get more room in the cockpit for a long legged man. (11) Fire extinguisher - location, how removed from its rack and how used. (12) On long flights in cold weather, a knowledge of the plane’s heating system is some times very useful. (13) Read WD Circular posted or hanging in each plane. g. Carry plenty of cotton for ear plugs, not only for yourself but for other Air Force personnel. They always expect a Flight Surgeon to have a supply. Plug both ears before take-off. h. Before going on a cross country flight sign “out” at your organization and sign “in” again promptly on your return. J.. If you want to go on a cross country flight, put in your request to the operations offi- cer who will assign both plane and pilot. Many operations officers resent an officer lo- cating a pilot who is willing to make the trip and requesting that this pilot be assigned to a specific trip. j_. Never carry liquor in a plane. It is forbidden by regulations and in case of accident it always causes trouble even though neither the pilot nor passenger has consumed any of it. 15. IN FLIGHT. a. Never touch the controls unless authorized to do so by the pilot. b. Do not get into any position which interferes with the free movement of the controls and do not permit any of your baggage to do so. c. It is dangerous to smoke in airplanes. Do not smoke unless expressly authorized to do so by the pilot. Air currents will frequently blow matches or cigarettes back into the plane when an attempt is made to throw them out. d. If you have a tendency to get airsick, do not eat a large meal immediately before take-off. Keep your eyes on the horizon, do not look at objects near you. Try to get good ventilation (a hand hooked around the edge of a partially opened wind screen will deflect a cool blast in your face). If the pilot will let you fly the ship, it will help. A dose of one of the barbiturates (Nembutal, Seconal, etc.) prior to take-off may prevent sickness if you are just taking a ride. Do not give it to the pilot or anyone else who must remain alert. Cellophane sandwich bags or empty ice cream containers make useful emesis basins. e. If you get sick and regurgitate in the ship, apologies to the pilot are in order, (even if aerobatics caused your fall from grace). In addition, you must either clean the ship yourself or pay the crew chief to clean it. The usual remuneration is a carton of cigar- ettes or its equivalent. _f. Pay close attention to all instructions from the pilot and carry out promptly and exactly all orders he gives. g. Radio. (1) Connect your headset when you enter the plane. (2) Do not at any time talk over your microphone when the radio switch is turned radio' . If you want to talk to the pilot, be sure the switch is turned to “interphone": it is your responsibility to turn it back to “radio" at the end of your conversation. (3) Do not ask unnecessary questions over the Interphone. (4) Never use the Interphone when nearing a field, coming in for a landing or during other maneuvers. (5) Be sure to disconnect your headset before getting up to leave the plane; otherwise it may be damaged. n. Other instructions. 7l) If you use the relief tube, tell the pilot on returning to the ground. He records this on Form 1. The maintenance crew subsequently washes out the tube. (2) Keep your safety belt fastened at all times except when expressly authorized by the pilot to do otherwise. (3) Clear your Eustachian tubes when losing altitude for any reason. Do not go to sleep and awaken with aero-otitls. i. In the combat zone always wear goggles to protect your eyes in case of fire. Be sure the aeronautical first aid kit is present and the jungle kit if applicable. j. Use of parachute. (1) Take good care of your parachute. You may owe your life to it. Never place it pack side down on any surface, because it may absorb moisture. Always place the harness down with the pack side of the parachute up. Do not abuse the harness and do not pull out the rip cord ring. See that the parachute is properly inspected and repack- ed when necessary. If the harness becomes sweaty or damp hang the 'chute up carefully to dry before putting it away. If the pack becomes damp have the chute repacked im- mediately. Let some of the air out of the cushion when flying at high altitudes because the air inside the cushion expands. (2) Whenever you enter an unfamiliar plane, figure out just how you would get out if the need arose. This may save valuable seconds if you have to “bail out" (3) If the pilot tells you to jump do so immediately. You must clear the tail surfaces. If you are in the rear cockpit, dive out head first as far down and out as you can' and somewhat forward. The plane is moving forward and you will not hit the wing even though you dive right at its trailing edge. If possible, the pilot will pull up into a stall in order to slow the plane as much as possible. When this is done, have your safety belt unfastened, the canopy open and your hands and feet braced so that when he gives the signal you can dive forward, down and out as far as possible. Be sure to go head first - a blow on the feet by the tail surfaces is much less dangerous than a blow on the head. Use your arms to get yourself clear of the plane. You can grasp your rip cord ring after you are out of the ship. Always be sure you are well away from the ship before you pull the rip cord ring or you may foul your 'chute in the tail surfaces. If you have jumped from a fast moving plane, wait at least ten seconds before opening your para- chute unless you are near the ground. This will allow you to slow down to terminal velocity (about 125 M.P.H.) and you will not receive such a severe jolt when your ’chute opens. Hang onto the rip cord ring because it is an old Air Forces custom that the drinks are on the man who drops or loses his ring. (4) If your plane is in a spin, jump from the side on which the wing is down. (In a right hand spin, jump over the right hand side.) (5) If shot down in combat do not open your 'chute till near the ground, for the enemy pursuit may machine-gun you. You can tell when you are approaching the ground by the fact that objects look more nearly their usual size and particularly by the fact that the horizon begins to widen out rapidly and you seem to be settling into a bowl. (6) Stop the oscillation of the 'chute as soon as possible after it opens. This is done • by pulling on the riser straps of the parachute. After oscillation has stopped, direction can be controlled somewhat by pulling cautiously on the riser straps on the side in the direction in which you wish to go. You must be careful in doing this maneuver as it causes you to decend more rapidly, by reason of “dumping" the air out of the 'chute. (7) Before jumping from an altitude over 30,000 feet, place the tube from the emergency oxygen bottle in your mouth. If you do not have this supply, take a few deep breaths of the oxygen from your regular supply, then hold your breath and jump. By doing this you can avoid losing consciousness. Do not pull your rip cord until you are below 20,000 feet and if there are enemy pursuit ships in the vicinity do not open the ’chute until near the ground. Keep your goggles on to prevent freezing of your eyes. (8) In landing with a parachute, you will get approximately the jolt or jar you would get in jumping from a height of 10 to 12 feet. Try to land facing the direction you are moving and with your legs slightly bent to take up the shock. Give a sharp pull upward on the riser straps just before landing to decrease the impact. Have the legs relaxed when you land and ease forward to a prone position on the ground. Do not try to get up. In order to prevent being dragged over the ground by wind blowing your parachute, spill the air out of your chute as soon as possible by pulling the bottom riser straps to you until you reach the silk. If the situation warrants, gather in the ’chute and fold it. If you land in the water, have your 'chute straps loosened and slip out of the harness just before you hit the water. This will prevent your being drowned by being fouled in the silk and cords. The seat pad on the chute can be ripped off and used to help keep afloat if you are not wearing other flotation gear. 16. MISCELLANEOUS SUGGESTIONS. a. If a pilot takes you on a trip for your own personal pleasure or business, you should pay his expenses. If you are merely accompanying a pilot on a trip which he would other- wise be making by himself or if it is an official trip, this is not necessary. b. Never criticize a bad landing or a poorly executed aerial maneuver. This is not your function. c. Keep posted on current pilot problems so you can discuss them InteHigently. On the other hand do not pose as an authority on flying problems. Your information about flying is probably as accurate as the Air Force Officer’s information about how to remove a gall bladder. d. Read the current flight regulations which pertain to you. These are on file in the operations office of your home station. e. Don’t ask foolish questions of pilots. If there is something you want to know about flying problems which should probably be known to you, find out by getting a pilot to dis- cuss the subject or ask the crew chief. 17. REFERENCES. a. Reports and Technical Orders. (1) Pinson, E.A., Body Characteristics as Applied to Parachute Jumping - WD AC Materiel Division, Experimental Engineering Section - Serial No. Exp. M-54-670-18, July 13, 1940. (2) Winfield, B.S.O. and Crichton-Miller, C.: Statistical Report on Parachuting, W.A.M 101-37, F.P.R.C. 445, 1942. (3) WD Hq,, AAF Technical Order No. 13-5-19, Parachutes - High-Speed Parachute Jumps, August 17, 1942. b. Manuals. (1) TM 1-705, Physiological Aspects of Flying, 1941. c. Texts. (1) Ruff, S. and Strughold, H.: Grundriss der Luftfahrtmedizin, Leipzig, J. A. Barth, 1939. (2) Von Diringshofen, H.: Medical Guide to Flying Personnel (translated by V. E. Henderson) U. of Toronto Press, 1940. d. Pamphlets. (1) Parachute Sense, Washington, D.C., Training Division, Bureau of Aeronautics, U. S. Navy, 1943. CHAPTER 3 THE PHYSICAL EXAMINATION FOR FLYING SECTION I THE GENERAL EXAMINATION The medical history 18 The medical examination 19 Standards of the physical examination for flying 20 Standards of height, weight, and chest measurements 21 The Schneider Index 22 Vasomotor instability 23 Heart sounds 24 Criteria for the diagnosis of common cardiac valvular deformities 25 Blood pressure 26 The electrocardiogram 27 Cardiac radiography 28 Examination of the lungs 29 Bones, joints, muscles, and feet 30 References 31 Paragraphs 18. THE MEDICAL HISTORY, a. The collection of medical data from applicants for aero- nautical training differs somewhat from the usual clinical history in that its primary pur- pose is to reveal to the examiner any diseases in the past or present which will disqual- ify the applicant for flying training. Details of illnesses which are of interest to the clinician such as mode of onset, probable exciting cause, modifying factors, and the like are of no particular value. To this statement there are a few striking exceptions. In de- ciding whether an applicant did or did not have a disease known to be disqualifying it may be necessary to elicit details. An example is a history of valvular disease of the heart, often too gullibly accepted by the examiner. An applicant will frequently state that he was told he had a “leaky valve” in his heart in childhood. Obviously such a story cannot be accepted as a history of valvular heart disease unless other clinical and laboratory data, collected either in the past or in the present, support this diagnosis. More often than not this proves to have been, on further study, an unexplained (functional) murmur. In this example a record of details would be imperative for reaching a conclusion, and must be included in the history. Other diseases in which details must be obtained because of the possibility of an origin- ally mistaken diagnosis are encephalitis lethargica, paroxysmal tachycardia, malaria, glomerulonephritis, rheumatic fever, renal calculus, epilepsy, and hay fever. b. The use of the phrase “usual childhood diseases” is decried on the original examina- tion. Most often it means that the medical officer has simply neglected to question the applicant about them. This may result in overlooking a disease like scarlet fever, com- plicated by otitis media, nephritis, or cardiac valvular disease, historical facts which would make the subsequent physical examination infinitely easier and more precise. Childhood diseases should be listed but the exact date of each need not be given, the time being indicated simply as “in childhood” (under 12 years of age). c. Many applicants will have learned before the examination about disqualifying factors. Considerableingenuitymust be used in eliciting a history from these individuals, and resort to circumvention often must be made. d. The family history in general is of value in strengthening such past or present diagnoses in the applicant as rheumatic fever, tuberculosis, or mental disease. Other remote details, are in general, of little value. e. The psychological interview can conveniently be carried out at the same time that the medical history is ascertained. 19. THE MEDICAL EXAMINATION. The usual defects are sought in the extremities, heart, lungs, viscera, and genitourinary system that may interfere with flying. Some of EXAMINATIONS OF AVIATION CADET APPLICANTS AND AVIATION CADETS KING IN GRADE OFFICER CANDIDATE SCHOOL EXAMINATIONS AND REEXAMINATIONS FOR FLYING RATINGS APPOINTMENT AUS AVIATION CADET APPLICANTS AVIATION CADETS AIR CREW GROUND DUTY REPORTING FOR DUTY COMMISSION AIR CREW GROUND DUTY ADMINISTRATIVE AIRPLANE PILOT SERVICE PILOT LIAISON PILOT AIRCRAFT OBSERVER TECHNICAL OBSERVER NOH-RATED OBSERVER COMBAT CREW ENLISTED VARIOUS BRANCHES AIR CREW CLASSIFICATION CENTER GROUND DUTY TECHNICAL SCHOOL AIR CREW GROUND DUTY INDIVIDUALS ELIGIBLE ENLISTED MAN OR CIVILIAN ENLISTED MAN OR CIVILIAN AVIATION CADET AVIATION CADET AVIATION CADET AVIATION CADET COMMISSIONED OFFICER COMMISSIONED OFFICER ENLISTED MAN COWISSIONED OFFICER ENLISTED MAN OR CIVILIAN COMMISSIONED OFFICER ENLISTED MAN OR CIVILIAN COMMISSIONED OFFICER ENLISTED MAN O'R CIVILIAN COMMISSIONED OFFICER COWISSIOHEO OFFICER (RATED) COMMISSIONED OFFICER NON- RATEO BRANCHES OTHER THAH AIR ENLISTED MAN ENLISTED MAN OR CIVILIAN TYPE OF TRAINING OR RATING PILOT NAVIGATOR BOMBARDIER ENGINEERING METEOROLOGY PHOTOGRAPHY COMMUNICATIONS ARMAMENT PILOT BOMBARDIER ENGINEERING METEOROLOGY PHOTOGRAPHY COMMUNICATIONS ARMAMENT NAVIGATOR BOMBARDIER ENGINEERING METEOROLOGY PHOTOGRAPHY COMMUNICATIONS ARMAMENT NAVIGATOR BOMBARDIER ENGINEERING METEOROLOGY PHOTOGRAPHY COMMUNICATIONS ARMAMENT ADMINISTRATIVE SENIOR PILOT COWARD PILOT SERVICE PILOT LIAISON PILOT AIRCRAFT OBSERVER OBSERVER NOH-RATED OBSERVER GUNNER ENGINEER RADIOMAN VARIABLE DESIGNATED PURPOSE OF EXAMINATION TRAINING AS AVIATION CADET (TAC) AIR CREW AVIATION CADET (TAC) 6R. DUTY ENGINEERING ETC. REPORTING FOR DUTY (A/C) AIR CREW REPORTING FOR DUTY (A/C) GROUND DUTY ENGINEERING COMMISSION AND FLYING RATING PILOT, ETC. COMMISSION ENGINEERING OFFICER GRADE. PILOT, ETC. OFFICER TRAINING IN GRADE, ENGINEERING ETC. OFFICER CANDIDATE SCHOOL ADMINISTRATIVE AS INDICATED REEXAMINATION AS SERVICE PILOT APPOINTMENT OR REEXAMINATION PILOT APPOINTMENT OR REEXAMINATION AS AIRCRAFT OBSERVER APPOIHTMEHT OR REEXAMINATION AS TECHNICAL OBSERVER HOH-RATED OBSERVER COMBAT CREW GUNNER. ETC. APPOINTMENT AUS FORMS USED 6H 63 6B 63 FINAL TYPE 63 FINAL TYPE 6B 63 63 FINAL TYPE ORIG. EXAM. FINAL TYPE ORIG. EXAM. FINAL TYPE ORIG. EXAM. FINAL TYPE ORIG. EXAM. FINAL TYPE 6B " 63 FINAL TYPE COPIES ACCOMPLISHED 2 ?OAL. 1 DISQUAL. 2 QUAL. 1 DISQUAL. 3 QUAL. 2 DISQUAL. 3 QUAL. 2 DISQUAL. 3 QUAL. 2 DISQUAL. 3 QUAL. 2 DISQUAL. 3 QUAL. 2 DISQUAL. 3 QUAL. 2 DISQUAL. 2 COPIES ALL EXAMINATIONS EXAMINATIONS 3 COPIES ALL EXAMINATIONS 3 COPIES ALL EXAMINATIONS 3 COPIES ALL EXAMINATIONS 3 COPIES ALL EXAMINATIONS 3 COPIES ALL EXAMINATIONS 2 COPIES ALL EXAMINATIONS 3 COPIES ALL EXAMINATIONS EXAMINER ANY MEDICAL OFFICER ANY MEDICAL OFFICER FLIGHT SURGEON AVN. MED. EXAM- OFFICER FLIGHT SURGEON AVN. MED. EXAM. ANY MEDICAL OFFICER FLIGHT SURGEON OFFICER ANY MEDICAL OFFICER FLIGHT SURGEON AVN. MED. EXAM. FLIGHT SURGEON FLIGHT SURGEON FLIGHT SURGEON FLIGHT SURGEON FLIGHT SURGEON FLIGHT SURGEON ANY MEDICAL OFFICER DISPOSITION OF FORMS QUALIFIED DUPLICATE AIR SURGEON DISQUALIFIED AIR SURGEON QUALIFIED ORIG. - S.C. DUPLICATE AIR SURGEON DISQUALIFIED AIR SURGEON ALL COPIES TO TRAINING CENTER SURGEON ALL COPIES TO TECHNICAL TRAINING CENTER) SURGEON ALL COPIES TO TRAINING CENTER SURGEON ALL COPIES TO TECHNICAL TRAINING CENTER SURGEON ALL COPIES TO AVIATION CADET SECTION. HQ., ALL COPIES TO AVIATION CADET SECTION. HQ., ALL COPIES TO CONVENING AUTHORITY ALL COPIES PROCEEDINGS THRU COMMAND CHANNELS OTHER EXAM. AIR SURGEON APPL. FOR APPT. ALL COPIES PROCEEDINGS THRU COMMAND CHANNELS OTHER EXAM. AIR SURGEON APPL. FOR APPT. ALL COPIES WITH BOARD PROCEEDINGS THRU COMMAND CHANNELS OTHER EXAM. AIR SURGEON ALL COPIES TO AVIATION CADET SECTION. HQ.. AAF OTHER EXAM- AIR SURGEON All COPIES TO AIR SURGEON ALL COPIES TO AIR SURGEON ALL COPIES TO SENIOR FLIGHT SURGEON OF EXAMINING STATION AS DESIGNATED BY AUTHORITY REQUESTING EXAMINATION REVIEWING AUTHORITY MEDICAL OFFICER OF EXAMINING BOARD MEDICAL OFFICER OF EXAMINING BOARD TRAININ6CENTER SURGEON TECHNICAL TRAINING CENTER SURGEON TRAINING CENTER SURGEON TECHNICAL TRAINING CENTER SURGEON THE AIR SURGEON THE AIR SURGEON SENIOR SURGEON OF EXAMINING STATION THE AIR SURGEON THE AIR SURGEON THE AIR SURGEON THE AIR SURGEON THE AIR SURGEON THE AIR SURGEON SENIOR FLIGHT SURGEON OF EXAMINING STATION AS DESIGNATED BY ADJUTANT GENERAL PHYSICAL STANDARDS (WITH TXCEPTIOHS AS NOTED SEEOW) CL. 1 AR BO-105 PI LOT-BOMB- CL. 1 NAVIGATOR CL. 2 AR BO-105 PI LOT-BOMB. CL. 1 NAVIGATOR CL- 2 AR BO-105 CL. I AR BO-105 AR BO-105 AR BO-IIO CL. 1-2-3 CL. 1-2-3 AR BO-IIO CL. 1-2 AR BO-IIO CL. 1-2-3 AR BO-IIO CL. 1-2-3 AR BO-IIO CL. 1 MODIFIED AR BO-105 AGE OF INDIVIDUALS EXAMINED 18-26 INCL. METEOROLOGY IB - 30 INCL. ALL OTHERS 18 - 26 INCL- IB - 27} METEOROLOGY ILL OTHERS DEPENDENT ON AGE ENTERING DEPENDENT ON AGE ENTERING TRAINING 18-26 INCL. METEOROLOGY IB - 30 INCL- ALL OTHERS 18 - 26 INCL. IB - B5 INCL- IB - 6B IB - 6B IB - 6B 18 - 6B IB - 6B IB - 6B IS - 6B IS - SB HEIGHT WEIGHT sf s| PILOT 6B" - 76" 60" - 78" 6B" - 76" 60" - 78- PILOT 6B* - 76- NON-PILOT 60* - 76- 60* - 78- 60- - 78- 6B- - 76- FIGHTER PILOT 160 LBS.)8**' 6B- - 76* 6B- - 76- 170 LBS. MAX- 60- - 76* 6B- - 76- 60- - 76- GUNNER 60- - 72- OTHERS 80- - 76- GUNNER ISO LBS. MAX. SO* - 78- VISUAL ACUITY 20/20 BILAT. UNCORRECTED NEAR VISION Jl 20/100 BILAT. CORRECTED TO 20/20-20/30 IR BO-110 CL. 1 NAVIGATOR AR BO-110 CL- 2 20/100 Bl LAT. CORRECTED TO 20/20-20/30 PI LOT-BOMB. AR BO-IIO CL. 1 NAVIGATOR AR BO-IIO CL. 2 20/100 BILAT. CORRECTED TO 20/20-20/30 20/20 BILAT. UNCORRECTED 20/100 31 LAT. CORRECTED 20/20-20/30 20/200 BILAT. CORRECTED TO 20/BO BILAT. *CL«°i-2-3 AR BO-IIO CL. 1-2-3 CL. 1-2 CU 1 CL. 1-2-3 CL. 1-2-3 “JV10 DEPENDENT ON BRANCH COLOR VISION 751 ISM IMARA OR AOC BOON DISTINGUISH TRUE RED AND TRUE GREEN 754 1 SHI KARA OR AOC BOON OR COLOR "SAFE* DISTINGUISH TRUE RED AND TRUE GREEN 754 ISHIMARA OR COLOR "SAFE" DISTINGUISH TRUE RED AND TRUE GREEN 754 ISHIHARA OR AOC BOOK DISTINGUISH TRUE RED AND TRUE GREEN DISTINGUISH TRUE RED AND 754 ISHIHARA APPL. FOR APPT. 754 ISHIHARA APPL. FOR A(*PT. 794 ISHIHARA ORIG. EXAM. 754 ISHIHARA "°T °"E 754 ISHIHARA OR AOC BOOK DISTINGUISH TRUE RED AND TRUE GREEN DISTINGUISH TRUE RED AND TRUE GREEN X-RAY AMO BLOOD SEROLOGY IF FACILITIES IF FACILITIES AVAILABLE «s YES YES YES YES YES TES AS INDICATED ORIG. EXAM. ORIG. EXAM. ORIG. EXAM. NO NO NO YES OPHTHALMOSCOPIC OR REFRACTION NO REFRACTION INDICATED NO NO NO YES "° NO )RI6. EXAM. NO NO ORIG. EXAM. ONLY NO NO "° NO TABLE I - STANDARDS FOR PHYSICAL EXAMINATIONS ARMY AIR FORCES JANUARY I, 1943 the special procedures used are elaborated in following paragraphs 22, 24 to 30. In addition, an attempt is made to evaluate the emotional stability of the applicant by the ob- servation of certain physical signs which constitute the syndrome called “vasomotor instability’’ (see par. 23), and to evaluate his intelligence by the facility with which he follows simple directions (see par. 30). 20. STANDARDS OF THE PHYSICAL EXAMINATION FOR FLYING. (See Table I), a. The general physical requirements for classes 1, 2, and 3 are the same. These classes differ only in the eye and ear requirements. (See Tables X and XIV) b. Applicants for the W.A.A.F.imust meet the class 1 or class 2 standards. The origin- al and two copies of the examination are sent direct to the Air Surgeon. The physical ex- amination must be completed in all cases, and all defects described in detail. c. Class 1 or class 2 standards apply to rated Flight Officers and to rated Glider Pilots. 21. STANDARDS OF HEIGHT, WEIGHT, AND CHEST MEASUREMENTS. (See Table H). 22. THE SCHNEIDER INDEX, a. Definition. The Schneider Index is a numerical score derived from changes in the pulse rate and blood pressure caused by changes in posture and by exercise. (It is not a test of circulatory efficiency). Individual and psychogenic factors, fatigue, lack of condition, fever, recent ingestion of a large meal, and recent exercise may materially affect the score. The index has three important functions: (1) In original selection, the individual with signs of “vasomotor instability” and psy- chological evidence of inadaptability to military aeronautics may show a repeatedly low score. (2) In original selection the test will occasionally detect postural hypotension or ortho- static syncope. (3) In flying personnel, all of whom know the relation of the Schneider Index to physical fitness, it is of value because it serves as a stimulus to the examinee for the main- tenance of this fitness. b. Technique. ~(1) Subject reclines with eyes closed until pulse becomes stabilized; this usually re- quires 5 minutes; care should be taken to avoid disturbing or exciting influences, (2) Heart rate is counted for 20 seconds. When two consecutive 20-second counts are the same, this is multiplied by 3 and recorded. (3) The systolic pressure is taken by auscultation and recorded. Take two or three readings to be certain. (4) The subject then rises and stands for 2 minutes to allow the pulse to assume a uni- form rate. When two consecutive 15-second counts are the same, multiply by 4 and record. This is the normal standing rate. (5) The systolic pressure is taken as before and recorded. (6) Timed by a stop watch, the subject steps upon a stool 18-1/2 inches high five times in 15 seconds. To make this uniform the subject stands with one foot on the stool at the count one. This foot remains on the stool and is not brought to the floor again un- til after count five. At each “up” count he brings the other foot onto the stool 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 return and record. In com- puting this return, count from the end of the 15 seconds of exercise to the beginning of the first normal 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, according to d. below. (10) Enter history of case, including amount of sleep, amount of smoking, kind of work (outdoor or indoor or sedentary, etc.), time since last meal, and any personal worries or pathological condition which might affect the subject. b. Precautions. The index should not be taken within 2 hours after a meal. The amount of "habitual exercise, smoking, and sleep (which affect the index materially) should be OFFICERS AND OFFICER CANDIDATES, AAF, WD, AGO, FORM 64 OR 63 WEIGHTS ACCORDING TO AGE TABLE II Height in Inches 18 - 20 21 - 25 26 - 30 31 - 35 Min. Chest at Expiration Min. Stand. Max. Min. Stand. Max. Min. Stand, Max. Min. Stand. Max. 60 105 117 146 108 120 150 110 122 153 110 125 157 29 61 105> 119 _M2 110 122 153 112 124 155 112 127 159 29 1/4 62 109 121 .151 112 124 155 113 126 153 113 129 161 29 1/2 _J>3 112 124 [211 113 126 158 115 128 160 115 131 164 29 3/4 u _H4_ 127 159 Ul_ 128 160 118 131 164 118 134 168 30 _65 117 130 163 119 132 165 121 135 169 121 138 173 30 66 120 122 166 122 136 170 125 139 174 125 142 178 30 1/4 . 67 . 123 137 171 126 140 175 129 143 179 129 146 183 30 l/2 68 127 141 176 130 144 180 132 147 184 132 150 188 30 3/4 . 69 130 145 181 133 148 185 136 151 189 136 154 193 31 70 ... 134 U9 186 137 152 190 139 155 194 139 153 198 31 1/4 71 138 153 191 140 156 195 143 159 199 143 162 203 31 3/4 72 ...Ml 157 196 145 161 201 148 164 20$ 148 167 209 32 1/4 _Z3 U5 161 201 149 166 208 152 169 211 152 172 215 32 3/4 74 UB 165 206 154 171 214 157 174 218 157 177 221 33 1/2 -21 152 169 211 158 176 220 161 179 224 161 182 228 34 1/4 76 156 173 _216 163 181 226 166 184 230 166 187 234 34 3/4 77 159 177 221 167 186 232 170 189 236 170 192 240 35 1/4 78 163 181 226 172 191 239 175 194 242 175 197 246 35 3/4 Height in Inches 36 - 40 41 - 45 46 - 50 51-64 Min. Chest at Expiration Min. Stand. Max. Min. Stand. Max. Min. Stand. Max. Min. Stand. Max. 60 110 128 160 110 131 164 lio 133 166 lio 135 169 29 61 112 130 163 112 133 166 112 135 169 112 137 171 29 1/4 62 113 132 165 113 135 169 113 137 171 113 139 174 29 l/2 63 115 134 163 115 137 171 115 139 174 115 U1 176 29 3/4 64 118 137 171 118 140 175 118 142 178 118 144 180 30 _ 65 121 141 176 121 144 180 121 146 183 121 148 185 - 30 66 -125 145 181 1 ..125 148 185 125 150 183 125 152 190 30 l/4 67 129 149 136 129 152 190 129 154 193 129 156 195 30 1/2 68 132 153 191 132 156 195 132 158 198 132 160 200 30 3/4 69 136 157 196 136 160 200 136 162 203 136 164 205 31 70 139 161 201 .129 J 164 205 139 166 208 139 168 210 31 1/4 71 . M3 165 206 143 168 210 143 170 213 143 172 215 31 3/4 72 148 170 213 148 173 216 148 175 219 148 177 221 32 1/4 23 .152.... 175 219 152 178 223 152 180 225 152 182 228 32 3/4 _Z4 157 180 225 157 183 229 157 185 231 157 137 234 33 1/2 73 161 185 231 161 188 235 161 190 238 161 192 240 34 1/4 - 76 166 190 238 166 193 241 166 195 244 166 197 246 34 3/4 77 170 195 244 170 198 248 170 200 250 170 202 253 35 1/4 78 175 200 250 175 203 254 175 205 256 175 207 259 35 3/4 NOTE: 1. The weight for each height for the age group 26-30 is the ideal one to maintain thereafter. For age after this age group a minimal allowance of not more than 10 per cent below ideal will be acceptable. 2. A candidate whose weight falls at the extremes of either the minimum or maximum range is acceptable only when he is obviously active, of firm musculature, and evidently vigorous and healthy. 3. A minimum chest expansion of 2 inches will be required. U- For flying training no candidate will be considered whose weight is above 200 pounds. taken into consideration in interpreting the findings. The presence of intercurrent mild respiratory infections (colds, etc.) may also materially lower the index. There are sever- al common sources of error in the test: (1) In the performance of the exercise, one foot is placed on the stool at the start. It is kept there until the completion of the last count when both feet are placed on the floor. (2) The pulse should be counted for the 15 seconds period that immediately follows the exercise. In order that this count may begin precisely at the end of the exercise period, the examiner should grasp the subject’s wrist either at the beginning of the exercise period, or just before the exercise is completed, (3) If the blood pressure is varying a good deal while making several readings, it would seem most desirable to take an average of several determinations. c. Interpretation. A candidate will never be disqualified on the index alone, but an in- dex persistently less than 8 means a poor pulse response to exercise and posture, a cause for which should be sought by the examiner. d. Scoring. (See Table in). 23. VASOMOTOR INSTABILITY, a. Definition. The term is used to describe a group of signs probably resulting from unusual activity of the sympathetic nervous system, or im- balance of the autonomic nervous system, in response to an emotional stimulus. In the case of original applicants the emotional stimulus is the strange environment of the Flight Surgeon’s office. The manifestations listed below are probably present in some degree in all individuals depending upon the intensity of the emotional stimulus. If it is persist- ently present in marked degree in the original applicant for flying training he is disqual- ified. The reason for this is that these individuals show a variable degree of psychomotor tension. When confronted by the strange environment of the airplane cockpit and exposed to the additional uncertainty of loss of reference to the ground, they do not learn to fly or learn to fly with difficulty because of the tenseness associated with these emotional stimuli, b. Manifestations. ~(1) Labile pulse, often rapid. (2) Labile blood pressure; frequently high systolic. (3) Persistently low Schneider Index. (4) Cold, clammy, cyanotic, mottled extremities (excessive vasoconstriction). (5) Palmar, plantar, and axillary sweating. (6) Tremors of hands, closed eyelids, muscles of face, and lips. 24. HEART SOUNDS, a. Normal heart sounds, Table IV and Figure I. b. Terms to be used in describing heart sounds and murmurs, Table V. 25. CRITERIA FOR THE DIAGNOSIS OF COMMON CARDIAC VALVULAR DEFORMITIES.: a. Aortic Insufficiency. The diagnosis should be made only in the presence of a charac- teristic murmur. The signs are: (1) Diastolic murmur, blowing or musical in quality, and of a pitch higher than that of the usual first heart sound. It may be very faint, often better heard with the ear directly applied to the chest than with the stethoscope. It is loudest (a) in the third or fourth interspace at the left border of the sternum, or (b) over the sternum itself at this level, of (c) in the second or third interspace at the right border of the sternum, or (d) rarely at other sites. The murmur is best heard with a relatively slow heart rate, with the breath held in expiration and with the patient erect or bent for- ward. (2) Enlargement of the heart, mainly of the left ventricle. (3) Collapsing (Corrigan) pulse. (4) Large pulse pressure, with lowered diastolic and elevated systolic pressure. This sign, as well as the collapsing (Corrigan) pulse, may be absent when there is accom- panying stenosis of the orifice. * From Nomenclature and Criteria for Diagnosis of Diseases of the Heart, 4th Ed., 1940. B. Pulse rate increase on standing A. Reclining pulse rate 1 ( -p- 0-10 beats n-is beats »-26beatsz7-34be9ls 3512 heals Points Points Points Points, Points Points 5060 j 3 3 3 2 10 61 -70 j 3 3 2 10 —1 71 _80 2 3 2 0 | —1 |—2 St — 90 | 2 1 —1 —2 — 3 91 100 J 0 1 0 —2 —3 1 —3 ioi_ no ...( —i 0 —1 -3 —3 j —3 D.Puke rate increase immediately after exercise C. Standing pulse rate 010 beats n-20 beats 21-30 beats 31-40 beats 4k>o beats Points, Points, Points Points Points Points «0_70 3 3 3 i 2 1 0 1 71 _ SO 3 3 2 1 0 0 St _ 90 . „ 2 3 2 1 1 0—1 91 _ tOO 1 2 I 0 —I —2 101_lt0 1 1 0 —1 1 —2 — 3 111_120 0 1 — 1 —2 —3 —3 121-130 0 0 — 2' 1—3 —3 | -3 131-140 —1 0 — 3 —3 i —3 1—3 1 : E. Return of pulse rate to stan _ ding normal after exercise F. Systolic pressure standing compared 'with, rpdinni^^^ Seconds Points Changteinmm Points R|se a 8 or more 3 Riseof 2-7 2 0-30 31 60 01 — 90 3 2 1 91 — IZO , 0 After 120:2-10 heats above normal — 1 rail of 2-5 0 FaHof on-more —1 After I2o;n-3obeate above normal -2 TABLE m TABLE IV. - SUMMARY OF NORMAL HEART SOUNDS SOUND FIRST SECOND THIRD FOURTH Origin From each ven- tricle: (1) Muscular (2) Valvular (3) Vascular (ba- sal vessels) and (4) Auricular (see 4th heart sound) compo- nents. From both ven- tricles: (5) Contact with chest wall Closure of semi- lunar valves Vibration of ven- tricular walls, valves, and chor- dae tendineae as a result of sud- den rush of blood into ventricles in early diastole (1) Tension and con- traction of auricular walls (2) Flow of blood through A-V orifices (3) Distention of ven- tricles (4) Friction of auricles against other struc tures Components (1) Isometric phase (compo- nents 1, 2 ' and 5 above) (2) Ejection phase (component 3 above) (1) Aortic (2) Pulmonic Three groups re- sulting from; (1) Auricular con- traction (2) Distention of ventricles (3) Incomplete clo- sure of A-V valves (same as auricular compo- nent of first sound) Auditory char- acteristics (1) Prolonged (2) Low pitch (3) Variable in- tensity (4) Heard best at apex (1) Short (2) High pitch (3) Variable in- tensity; relation of A2 to P2 changes with age (4) Heard best at base (1) Short (2) Low pitch (3) Low intensity- best heard in adolescents and in youth (4) Heard best in left lateral supine position at apex (1) Each group short (2) Lowest pitch (3) Usually inaudible (recorded best in mesocardiac area. Heard in this area in A-V block). Graphic relations E.K.G. Just after peak of R (auricular component pre- cedes peak of R wave) End of T wave 0.14 to 0.16 sec. after end of T wave Variable relation to P wave (0.08 to 0.30 sec. after beginning) Jugular Phlebo- gram Before rise of C wave 0.11 sec. before peak of V wave Lowest portion of descending limb of V wave Usually afer the rise of the A wave Carotid Arterio- gram .04 to .10 sec. before rise of carotid pulse Incisura (dicro- tic notch) 0.14 to 0.16 sec. after incisura Physio- logic varia- tions due to Cardiac factors (1) Rate of rise of intraventri- cular pressure (2) Duration of P-R interval (1) Relative intra- aortic and intra- pulmonic pres- sures (2) Differences in pressure be- tween chamber and vessels Suddenness of ven- tricular filling Increased venous return to the heart Extra cardiac factors Common to all. Variations in intensity due to va.rations in thickness of thoracic wall, shape of chest, size of lungs, etc. SIMULTANEOUS CAROTID ARTERIOGRAM JUGULAR PHLEBOGRAM APICAL STETHOGRAM AND ELECTROCARDIOGRAM. FIGURE 1 TABLE V. TERMS TO BE USED IN DESCRIBING HEART SOUNDS AND MURMURS (TERMS IN CAPITALS PREFERRED) * HEART SOUNDS INTENSITY PITCH QUALITY DURATION TIME NORMAL FAINT Weak Distant Muffled HIGH NORMAL SHARP Snapping Valvular NORMAL SHORT LOUD Accentuated Increased ABSENT Replaced by a mur- mur LOW BOOMING Muscular SPLIT RINGING Metallic Bell-like Tambour HoHow PROLONGED MURMURS FAINT Soft HIGH BLOWING SHORT SYSTOLIC MODERATE MEDIUM HARSH Rough Coarse MODERATE EARLY SYS- TOLIC LOUD LOW MUSICAL RUMBLING CRESCENDO DECRESCENDO LONG LATE SYS- TOLIC DIASTOLIC EARLY DIA- STOLIC MID-DIA- STOLIC PRESYSTOLIC (Late Dia- stolic) ♦From Nomenclature and Criteria for Diagnosis of Diseases of the Heart, 4th Edition, 1939. b. Aortic stenosis. The diagnosis of aortic stenosis should be made with caution if the murmur of aortic insufficiency is absent. However, it is not unusual for aortic stenosis to exist without aortic insufficiency. Syncope is a common symptom. The signs are: (1) Loud, harsh systolic murmur in the second right interspace close to the sternum, usually transmitted upward. (2) Systolic thrill, best felt in the second right interspace close to the sternum. It is elicited more readily with the breath held in expiration and the patient bending forward. (3) Anacrotic pulse, with slow rise and broad summit. (4) Faint or absent aortic second sound. (5) Enlargement of the heart, especially of left ventricle. (6) Low systolic and small pulse pressure. c. Mitral insufficiency. Not all precordial and apical systolic murmurs denote mitral valvular deformity. Sometimes the murmur is evidence of incompetence of the valve ring resulting from myocardial disease. Occasionally it is due to a congenital anomaly or may be of pulmonary or other extracardiac origin. With a history of rheumatic infection and especially when associated with murmurs due to disease of other valves or with cardiac enlargement, the murmur is likely to indicate mitral valve deformity with insufficiency. The systolic murmur of mitral insufficiency may be inconstant or of variable intensity during the period of observation. The signs are (1) Systolic murmur, best heard at or just outside the region of the cardiac apex, either following or merging with the first heart sound and usually transmitted to the left ax- illa. Its quality may be blowing, harsh or musical, with relatively high pitch. A sy- stolic thrill is occasionally palpable. (2) Enlargement of the heart may be slight and recognizable only on radiography, but without it deformity of the mitral valve should not be diagnosed. d. Mitral stenosis. The diagnosis should be made only in the presence of a characteris- tic murmur. In some cases of aortic insufficiency the diastolic murmur at the apex (Austin Flint murmur) cannot be differentiated by its characteristics from that due to organic mitral stenosis. If aortic insufficiency is of rheumatic etiology, a rumbling diastolic murmur at the apex is .likely to be due to mitral stenosis. If there is a sharp first heart sound, the diagnosis of mitral stenosis is more probable. If, on the other hand, the aortic insufficien- cy is syphilitic, it is fair to assume that the mitral valve is anatomically intact and that it is a Flint murmur which is heard. Often the final differentiation can only be made radiographically, whereby enlargement of the left auricle or the right ventricle, or both, should be demonstrable if the murmur is due to mitral stenosis. The signs are: (1) The characteristic murmur of mitral stenosis is a low-pitched, diastolic rumble, localized at the cardiac apex with or without presystolic accentuation. In the presence of auricular fibrillation it is often heard only during early diastole, becomes faint or may disappear completely. It can sometimes be heard only with the patient lying on his back or left side and is almost always louder in these positions than when erect. Acceleration of the heart rate by exercise will frequently make definite a murmur which is otherwise inaudible. (2) Accentuated, snapping first sound at the apex. The presence of such a sound, to- gether with the murmur of mitral insufficiency, should arouse suspicion of narrowing of the mitral orifice. (3) Accentuated secondsound at the pulmonic area. (4) Enlargement of left auricle best observed radiologically in the right oblique position.** (5) Enlargement of the right ventricle and pulmonary artery observed radiologically.** (6) Right axis deviation of the QRS group of the electrocardiogram especially with notched, broad P waves. **When these radiologic phenomena are present in well-marked degree, along with the murmur of mitral insufficiency, the presence of mitral stenosis may be sus- pected. 26. BLOOD PRESSURE, a. Blood pressure determinations.***(1) The blood pressu'0 equipment to be used, whether mercurial or anaeroid, should be in good condition an. calibrated at yearly intervals. In the mercurial type the level of the mercury at rest should be exactly at the zero mark. The small air vent at the top of the glass tubing must always be patent to prevent lag in the instrument. The appartus must be on a level sur- face, for tilting gives rise to errors of considerable magnitude. All valves and rubber parts should be free from leakage. The armlet for an adult should be 12 to 13 cm. wide and 23 cm. long. The cloth covering should be of inextensible material of such nature that an even pressure is exerted throughout the width of the cuff, it should extend as a band 15 cm. wide for 60 cm. beyond the edge of the rubber cuff, and taper gradually for an additional 30 cm. For measuring blood presuure in the leg, the rubber bag should be 15 cm. wide, and its covering 17 cm. wide ana 120 cm. long, (2) The patient should be comfortably seated or in a sitting position, with the arms slightly flexed and the whole forearm supported on a smooth surface at the level of the heart. If readings are taken in any other position, a notation of that fact should be made, The patient should be allowed time to recover from any recent exercise or excitement. The arm used should be free of constricting clothing. (3) A completely deflated cuff should be applied snugly and evenly around the arm with the lower edge about 1 inch above the antecubital space, and with the rubber bag applied over the inner aspect of the arm. The cuff should be of such type and applied in such manner that inflation causes neither bulging or displacement. (4) The stethoscope should be placed over the previously palpated brachial artery in the antecubital space, not in contact with the cuff, and held in place with a minimum of pressure on the skin. The hand may be pronated or supinated, depending upon which position yields the clearest brachial pulse. (5) In the determination of the systolic pressure only the auscultatory method is to be used. The cuff should be rapidly inflated, then slowly deflated at a rate of 2 to 3 mm of Hg per second. The level at which the first sound regularly appears should be con- sidered the systolic pressure. (6) In the determination of the diastolic pressure, with continued deflation of the cuff, the point at which the sounds suddenly become dull and muffled should be known as the diastolic pressure. (7) With premature beats the higher systolic pressures of the beats which terminate compensatory pauses should be-ignored. With auricular fibrillation only approxima- tions of the systolic and diastolic pressures can be made. It is recommended that sy- stolic pressure be calculated as an average of the highest pressure at which sounds come through and the pressure at which the sound for each beat is detectable. The dia- stolic pressure is obtained by taking the average of several readings. With pulsus alternans both systolic pressures should be recorded. In hypertensive subjects care must be exerted to avoid errors that may be introduced by the zone of silence occasion- ally encountered between systolic and diastolic pressure, known as the auscultatory gap. b. Blood pressure requirements (see AR 40-105, par. 36f and 39e and f, AR 40-110, par. 20e(l)). (1) Air Crew training (TAC-pilot, bombardier, or navigator - Form AGO, WD No. 64) Systolic - 100 minimum 134 maximum Diastolic- 89 maximum (2) Ground duty training (armament, meteorology, communications, engineering, photo- graphy - Form AGO, WD, No. 63). (a) Less than 25 years of age. Systolic - 100 minimum 139 maximum Diastolic- 89 maximum (b) Over 25 years of age. Systolic - 100 minimum 149 maximum Diastolic- 94 maximum ***Modified from Standardization of Blood Pressure Readings (J.A.M.A., 113:249, 1939). (3) Other applicants for flying training (officer training in grade, liaison pilot), (a) Same as for Air Crew training, par. 22b. (1), (4) Other flying personnel (civilian flying instructor; rated and non-rated observer, combat crew (enlisted); annual, semi-annual, and special examinations on rated flying personnel). (a) 25 years of age or under. Systolic - 100 minimum 140 maximum Diastolic- 94 maximum (b) Over 25 years of age. Systolic - 100 minimum 149 maximum Diastolic- 94 maximum 27. THE ELECTROCARDIOGRAM, a. Criteria for the Normal Standard Leads (Figure 2). The normal electrocardiogram consists of a group of summits and depressions. There may be as many as 7 of these (P, Ta, Q, R, S, T, and U), but the P, R, and T are always present, normally. The P wave and Ta wave comprise the auricular complex. The ventricular complex consists of initial (QRS) and final (RS - T and T) deflections. (1) Auricular Complex. The P wave results from electrical excitation or depolariza- tion of the auricular muscle. In the normal it is upright in leads I and II and is not more than 0.25 or less than 0.05 millivolt in height. Its width, at its base, it 0.1 second or less. It is rounded or pointed, and often notched. The electrocardiogram is said to display a high voltage P wave if this deflection is more than 0.25 mv. in any standard lead, and a low voltage P wave if this deflection is less than 0.05 mv. in all three stand- ard leads. The Ta wave is a gradual depression occurring immediately after the P wave which usually is slight and rarely exceeds 0.1 mv. It represents electrical recovery or re- polarization of the auricular muscle. (2) Ventricular complex. The initial ventricular deflections, Q, R, and S, are written during electrical excitation or depolarization of the ventricular muscle. The Q wave may be normally absent. It is an initial downward ventricular deflection which is neither slurred nor splintered, and which has a maximum absolute and rela- tive size in the three leads as follows: Lead Absolute size in millivolts Percent of largest QBS deflection in the 3 leads I 0.20 15% n 0.25 20% m 0.30 25% These criteria are not applicable in any lead to curves showing a high voltage of QRS, or in leads II and III if there is right deviation of the electrical axis. A normal R wave is an upward deflection varying in size from 0.15 to 2.0. mv. It is not unusually slurred, notched, or splintered. A normal S wave is a depression preceded by a summit. It does not exceed 0.6 mv. in depth, and is not unusually slurred, splintered, or notched. When any QRS deflection in the 3 leads, measured in either direction from the base- line, exceeds 2.0 mv., the electrocardiogram is said to show high voltage of QRS or simply high voltage. When the largest QRS deflection is less than 0.5 mv., similarly measured, the curve is said to show low voltage. The final ventricular deflections, S-T and T, are written during electrical recovery or repolarization of the ventricular muscle. THE NORMAL ELECTROCARDIOGRAM TABLE VI. - Table for calculating rate and the systolic index (Q - - R) in the electrocardiogram. R - R is the cycle length or the distance between 2 R waves. R - R in 0.04 Sec. Rate per Minute R - R in 0.04 Sec. Rate per Minute Vr - R in Sec. ~VR - R in Sec. 10.00 150 0.633 20.50 73 0.906 10.50 143 O.64.8 21.00 71 0.917 11.00 136 0.663 21.50 70 0.927 11.50 130 0.678 22.00 68 0.938 12.00 125 0.693 22.50 67 0.949 12.50 120 0.707 23.00 65 0.959 13.00 115 0.721 23.50 64 0.970 13.50 111 0.735 24.00 62 0.980 14.00 107 0.743 24.50 61 0.990 14-50 103 0.762 25.00 60 1.000 15.00 100 0.775 25.50 59 1.010 15.50 97 0,787 26.00 58 1.020 16.00 94 0.800 26.50 57 1.030 16.50 91 0.812 27.00 56 1.039 17.00 88 0.825 27.50 55 1.049 17.50 86 0.837 28.00 54 1.058 18.00 83 0.849 28.50 53 1.068 18.50 81 0.860 29.00 52 1.077 19.00 79 0.872 29.50 51 1.086 19.50 77 0.883 30.00 50 1.095 20.00 75 0.894 1 The normal S-T (R-T, RS-T) segment is that portion of the curve between the end of QRS and the beginning of T. It is not displaced at its origin by more than 0.1 mv. in either direction from the baseline. It usually inclines upward slightly as it approaches the T wave. The normal T wave is upright in leads I and II. Occasionally it may be inverted in leads II and III, especially in hyposthenic subjects when sitting, but becomes upright in lead II or in leads II and III when the electrocardiogram is recorded with these subjects recumbent. The normal T wave varies in size from 0.1 to 0.5 mv. The electrocardiogram is said to show a high voltage T wave if this deflection is more than 0.5 mv. in any stand- ard lead, and a low voltage T wave if this deflection is less than 0.1 mv. in the three standard leads. The U wave is a small deflection which occurs inconstantly after the T wave. It is normally upright. (3) Intervals. The P-R (P-Q) Interval is measured from the beginning of the P wave to the beginning of QRS. Its normal value is 0.12 to 0.20 sec. in adults. It is an index of auriculoventricular conduction. It normally gets shorter as the rate gets faster. The QRS interval is measured from the beginning to the end of QRS. It represents the duration of excitation of the ventricular muscle. In adults it is normally 0.1 sec. or less. The Q-T interval (Table VI) is measured from the beginning of QRS to the end of the T wave. It normally gets shorter as the heart rate gets faster. A correction for rate is expressed in the systolic index, K, which is the Q-T interval in seconds divided by the square root of the cycle length (K = Q-TTr - R). In normal subjects K has a max- imum value of 0.4 in males, and 0.44 in females. b. Criteria for the normal precordial leads. (1) Technique. Lead IV F is the preferred chest lead. The exploring electrode should be circular, less than 3 cm in diameter, and placed at the outer border of the apex of the heart as determined by palpation. It the apex beat cannot be located satisfactorily, the electrode may be placed in the fifth intercostal space just lateral to the left midclavicular line. The indifferent electrode is placed on the left leg. Galvanometer connections are made in such a way that relative positivity of the explor- ing or apical electrode is represented by an upward deflection in the finished record. One method by which this can be done is to connect the left leg wire to the exploring electrode and the left arm wire to the left leg. The lead switch is turned to lead III. The sensitivity of the recording device should be so adjusted that a potential difference of one millivolt causes a deflection of one centimeter as in the standard leads. Any re- duction in sensitivity made necessary by very large deflections should be clearly indi- cated on the curve, preferably by photographying the standardization. (2) Criteria. Data on the normal deflections in lead IV F of male subjects are limited. Tentatively the following values in tenths of a millivolt (millimeters at normal sensi-> tivity of the string) may be used for the range of normal deflections: P Q R_ _S_ T_ S-T Min. -1.0 0 3.0 1.0 0.5 -0.5 Max. 1.5 3.0 30.0 35.0 13.0 2.0 c. When electrocardiogram is required. In the annual or special examination for flying arTelectrocardiogram will be made on all rated Air Corps personnel who have reached 40 years of age. In addition it may be used in any examination when such diagnostic aid is needed. In applicants for commission it is to be recorded routinely if the applicant is 50 years of age or over, or if his pulse rate is 50 beats per minute or less. 28. CARDIAC RADIOGRAPHY. The principal methods of examining the heart radiograph- ically are: fluoroscopy, teleroentgenography, orthodiagraphy, kymoroentgenography, and angiography. In general, the fluoroscopic method is perhaps the best because good ob- FIGURE 3. MEASUREMENTS OF THE HEART ON THE RADIOGRAPH TRANVERSE BROAD DIAMETER DIAMETER _LONG (OBLIQUE) AORTIC WIDTH DIAMETER FIGURE 4 TART ,F1 VTT - Theoretical Traunm DianHn of Heart Silhouette Table for Determining the Per Cent. Donation x xxxjxjxj »xx. (or Various Heights and Weights from Average T. D. of Heart HEIGHT Minus Av’fe Plus ft'O* I" i“ 8" 4* ft- «- 7* ft" ft- io- ii- 4-.-1 «-p »•[ 4-] *ft* ao% 1»* 10% »% % »% 10% 15% 20% 28% 100 mm 101 " 102 “ 103 " 104 " 83 85 87 88 90 85 86 88 90 92 86 88 90 92 93 87 89 91 93 95 89 91 92 94 96 90 92 94 96 98 92 93 95 97 99 95 97 99 101 100 102 Refer to faper entitled “A Study of the Transverse Diameter of the Heart Sil- houette with Prediction Table Based on the Teleoroentffenofram" presented to the Association of Life Insurance Medi- cal Directors of America by Dr. Harry E. Unfericider of the Equitable Life Assurance Society, and Dr. Charles P. Clark, of the Mutual Benefit Life In- surance Company. (1038) 75 76 77 77 78 80 81 82 82 83 85 86 87 88 88 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 no in 112 113 114 115 116 117 118 120 120 121 122 124 125 125 126 128 129 130 105 •' 106 '■ 107 “ 108 “ 109 “ 92 94 95 97 99 93 95 97 99 101 95 97 99 100 102 % 98 100 102 104 98 100 102 104 106 99 101 103 105 107 101 103 105 107 109 103 104 106 108 no 104 106 108 no 112 106 108 no 112 114 in 113 ns 117 79 80 80 81 82 84 85 86 86 87 89 90 91 92 93 95 95 96 97 98 100 101 102 103 104 105 106 107 108 109 no 111 112 113 114 116 117 118 119 120 121 122 123 124 125 126 127 128 130 131 131 133 134 135 136 110 “ 111 " 112 “ 113 “ 114 " 101 103 105 106 108 102 104 106 108 no 104 106 108 110 112 106 108 no 112 114 108 109 111 113 115 109 111 113 115 117 in 113 115 117 U9 113 115 117 119 121 114 116 118 121 123 116 118 120 123 125 118 120 122 124 126 119 121 124 126 128 121 123 125 128 130 125 127 129 132 129 131 133 133 135 137 83 83 84 85 86 88 89 90 90 91 94 94 95 96 97 99 100 101 102 103 105 105 106 107 108 no 111 112 113 114 116 117 118 119 120 121 122 123 124 125 127 128 129 130 131 132 133 134 136 137 138 139 140 141 M3 115 “ 116 “ 117 “ 118 “ 119 “ 110 112 114 116 118 112 114 116 118 120 114 116 118 120 122 116 118 120 122 124 117 120 122 124 126 119 121 124 126 128 121 123 125 128 130 123 125 127 129 132 125 127 129 131 134 127 129 131 133 136 129 131 133 135 138 130 133 135 137 140 132 134 137 139 142 134 136 139 141 143 136 138 141 143 145 138 140 143 145 147 140 142 144 147 149 141 144 146 149 151 146 148 151 153 86 87 88 89 89 92 93 94 94 95 98 99 99 100 101 104 104 105 106 107 109 no 111 112 113 115 116 117 118 119 121 122 123 124 125 127 128 129 130 131 132 133 135 136 137 138 139 140 142 143 144 145 146 148 149 120 '' 121 “ 122 '• 123 " 124 “ 120 122 124 126 128 122 124 126 128 130 124 126 128 130 132 126 128 130 132 134 128 130 132 134 137 130 132 134 136 139 132 134 136 139 141 134 136 138 141 143 136 138 140 143 145 138 140 143 145 147 140 142 145 147 149 142 144 147 149 152 144 145 149 151 154 146 148 151 153 156 148 150 153 155 158 ISO 152 155 157 160 152 154 157 160 162 154 156 159 162 164 156 159 161 164 166 90 91 92 72 93 96 97 98 98 99 102 103 104 105 105 108 109 no 111 112 114 115 1)6 117 118 120 121 122 123 124 126 127 128 129 130 132 133 134 135 136 138 139 140 141 143 144 145 146 148 149 150 151 153 154 155 125 “ 126 “ 127 “ 128 " 129 “ 130 132 134 136 139 132 134 137 139 141 134 137 139 141 143 137 139 141 143 146 139 141 143 146 148 141 143 146 148 150 143 145 148 150 152 145 148 150 152 155 147 150 152 155 157 150 152 154 157 159 152 154 157 159 162 154 156 159 161 164 156 159 161 164 166 158 161 163 166 169 160 163 166 168 171 163 165 168 171 173 $ 170 173 176 167 170 172 175 178 169 172 175 177 180 94 95 95 96 97 100 101 102 102 103 106 107 108 109 no 113 113 114 115 116 119 120 121 122 123 125 126 127 128 129 131 132 133 134 135 138 139 140 HI 142 144 145 146 147 148 150 151 152 154 155 156 158 159 160 161 130 " 131 “ 132 “ 133 “ 134 M 141 143 145 147 150 143 145 148 150 152 145 148 150 152 155 148 150 152 155 157 150 152 155 157 160 152 155 157 160 162 155 157 160 162 164 157 160 162 165 167 160 162 164 167 169 162 164 167 169 172 164 167 169 172 174 167 169 172 174 177 169 172 174 177 179 171 174 177 179 182 174 176 179 182 184 176 179 181 184 187 178 181 184 187 189 181 183 186 189 192 183 186 189 192 194 98 98 99 100 lot 104 105 106 106 107 111 111 112 113 114 117 118 119 120 121 124 124 125 126 127 130 131 132 133 134 137 138 139 140 141 143 144 145 146 147 150 151 152 153 154 156 157 158 160 161 163 164 165 166 168 135 “ 136 “ 137 “ 138 '■ 139 “ 152 154 156 159 161 154 157 159 161 164 157 159 162 164 166 159 162 164 167 169 162 164 167 169 172 164 167 169 172 174 167 169 172 174 177 169 172 175 177 180 172 175 177 180 182 175 177 180 182 185 177 180 182 185 188 180 182 185 188 190 182 185 188 190 193 185 187 190 193 196 187 190 193 196 198 190 193 195 198 201 192 195 198 201 204 195 198 201 204 206 197 200 203 206 209 101 102 103 104 104 108 109 no no in ns 116 116 117 118 122 122 123 124 125 128 129 130 131 132 135 136 137 138 139 142 143 144 145 146 149 150 151 152 153 155 156 158 159 160 162 163 164 166 167 169 170 171 173 174 140 " 141 “ 142 ■' 143 “ 144 " 163 166 168 170 173 166 168 171 173 176 169 171 174 176 178 171 174 176 179 181 174 177 179 182 184 177 179 182 184 187 180 182 185 187 190 182 185 188 190 193 185 188 190 193 196 188 190 193 196 199 190 193 196 199 201 193 196 199 202 204 196 199 202 204 207 199 201 204 207 210 201 204 207 210 213 204 207 210 213 216 207 210 213 216 219 209 212 216 219 222 212 215 218 221 224 105 106 107 107 108 112 113 114 114 115 119 120 121 122 122 126 127 128 129 130 133 134 135 136 137 140 14! 142 143 144 147 148 149 150 151 154 155 156 157 158 161 162 163 164 166 168 169 170 172 173 175 176 178 179 180 145 “ 146 '■ 147 '• 148 " 149 “ 175 178 180 182 185 178 ISO 183 185 188 181 183 186 188 191 184 186 189 192 194 187 189 192 195 197 190 192 195 198 200 193 195 198 201 203 196 198 201 204 206 198 201 204 207 210 201 204 207 210 213 204 207 210 213 216 207 210 213 216 219 210 213 216 219 2 22 213 216 219 222 225 216 219 222 225 228 219 222 225 228 231 222 225 228 231 234 225 228 231 234 237 228 231 234 237 240 109 no no in 112 116 117 118 118 119 123 124 125 126 127 131 131 132 133 134 138 139 140 141 142 145 146 147 148 149 152 153 154 155 156 160 161 162 163 164 167 168 169 170 171 174 175 176 178 179 181 183 184 185 186 150 “ 151 " 152 " 153 “ 154 " 187 190 192 195 198 191 193 196 198 201 194 196 199 201 204 197 199 202 205 207 200 203 205 208 211 203 206 208 211 214 206 209 212 214 217 209 212 215 218 221 212 215 218 221 224 215 218 221 224 227 219 222 224 227 230 222 225 228 231 234 225 228 231 234 237 228 231 234 237 240 231 234 237 240 244 234 237 241 244 247 237 241 244 247 250 240 244 247 250 253 243 247 250 253 257 113 113 114 115 116 120 121 122 122 123 128 128 129 130 131 135 136 137 138 139 143 143 144 145 146 150 151 152 153 154 158 159 160 161 162 165 166 167 168 169 173 174 175 176 177 180 181 182 184 185 188 189 190 191 193 155 “ 156 " 157 " 158 " 159 " 200 203 206 207 210 210 213 216 213 216 219 217 220 222 225 220 223 226 229 224 227 229 232 235 227 230 233 236 239 230 233 236 239 242 233 236 239 243 246 237 240 243 246 249 240 243 246 249 253 243 247 250 253 256 247 250 253 256 260 250 254 257 260 263 253 257 260 263 267 257 260 263 267 270 260 264 267 270 274 116 117 118 119 119 124 125 126 126 127 132 133 133 134 135 140 140 141 142 143 147 148 149 150 151 155 156 157 158 159 163 164 165 166 167 171 172 173 174 175 178 179 181 182 183 186 187 188 190 191 194 195 196 198 199 160 - 161 " 162 “ 163 " 164 “ 245 249 252 255 259 256 259 262 259 263 266 269 273 263 266 270 273 276 266 270 273 277 280 270 273 277 280 284 274 277 280 284 287 277 281 284 288 291 120 121 122 122 123 128 129 130 130 131 136 137 138 139 139 144 145 146 147 148 152 153 154 155 156 160 161 162 163 164 168 169 170 171 172 176 177 178 179 180 184 185 186 187 189 192 193 194 196 197 200 201 *03 204 205 TABLE VUL* - Prediction for Normal Cardiac Area and Transverse Diameter Predicted T-D = +0.1004 x A — 0.1041 X H + 0.8179 x W + 95.8625 I JL n Stature Transverse Diameter, Weight -\ Transverse Diameter, Cm. In. / Sq. Cm. Mm. Kg. Pounds Sq. Cm. Mm. 150 59 66.7 66.74 50 110 17.00 40.90 351 60 67.57 66.55 61 112.2 17.34 41.71 J52 68.44 66.36 52 114.4 17.68 42.53 353 69.31 66.16 53 116.6 18.02 43.35 154 61 70.18 65.97 54 118.8 18.36 44.17 35o 71.05 65.77 55 121 18.70 44.98 156 71.92 65.58 56 123.2 19.04 45.80 157 62 72.79 65.39 57 125.4 19.38 46.62 158 73.66 65.19 58 127.6 19.72 47.44 159 63 74.53 65.00 59 129.8 20.06 48.26 160 75.40 64.80 60 132 20.40 49.07 161 76.27 64.61 61 134.2 20.74 49.89 162 64 77.14 64.42 62 136.4 21.08 60.71 163 78.01 64.22 63 138.6 21.42 61.63 164 65 78.88 64.03 64 140.8 21.76 52.36 166 79.75 63.83 65 143 22.10 63.16 166 80.62 63.64 66 145.2 22.44 63.96 167 66 81.49 63.45 67 147.4 22.78 64.80 168 82.36 63.25 68 149.6 23.12 55.62 169 67 83.23 63.06 60 151.8 23.46 66.44 170 84.10 62.86 70 154 23.80 67.26 171 84.97 62.67 71 156.2 24.14 58.07 172 85.84 62.47 72 158.4 24.48 68.89 173 68 86.71 62.28 73 160.6 24.82 59.71 174 87.58 62.00 74 162.8 25.16 60.52 175 69 88.45 61.89 75 165 25.60 61.84 176 89.32 61.70 76 167.2 25.84 62.16 177 70 90.19 61.50 77 169.4 26.18 62.98 178 91.06 61.31 78 171.6 26.52 63.80 179 91.98 61.12 79 173.8 26.86 61.61 180 71 92.80 60.92 80 176 27.20 65.43 181 93.67 60.73 81 178.2 27.54 66.25 182 94.64 60.53 82 180.4 27.88 67.07 183 72 95.41 60.34 88 182.6 28.22 67.89 184 96.28 60.15 84 184.8 28.66 68.70 186 73 97.15 59.95 85 187 28.90 69.52 186 98.02 59.76 86 189.2 29.24 70.34 187 98.89 59.56 87 191.4 29.58 71.16 188 74 99.76 59.37 88 193.6 29.92 71.96 180 100.63 59.18 89 195.8 30.26 72.79 190 101.50 68.98 90 198 30.60 73.61 101 75 102.37 58.79 91 200.2 30.94 74.43 102 103.24 58.59 92 202.4 31.28 75.25 193 76 104.11 58.40 93 204.6 31.62 76.06 194 104.98 58.21 94 206.8 31.90 76.88 195 105.85 58.01 95 209 32.30 77.70 196 77 106.72 67.82 96 211.2 32.64 78.52 197 107.50 67.62 97 213.4 32.98 79.34 198 78 106.46 67.43 98 215.6 33.32 80.15 199 109.39 67.23 99 217.8 33.66 80.97 200 79 110.20 67.04 100 220 34.00 81.79 To find normal transverse diameter for a given individual, add T-D figure for stature to T-D figure for weight and to this total add i mm. for every decade of age; e. g., height, 6 feet; Weight, 187 pounds; age, 50 = 134.86 mm. T-D or 60.34 + 69.52 + 5. * The figures of this table are valid for orthodiagrams and for male subjects. The hearts of female subjects of same stature, weight and age are slightly smaller in size. From P. C. Hodges and J. A. E. Eystcr: Arch, of Int. Med. 1926, 37; 711-7x3. lique views may be obtained (Figure 3),the degreeof motion of separate chambers and vessels may be observed, and minor degrees of enlargement not ordinarily manifested in the usual measurements may be detected. The usual measurements made on the cardiac silhouette of a teleroentgenogram (2 meter plate) or on orthodiagram are shown in Figure 4. If the “area” of the cardiac shadow is desired, it is measured first by completing its superior and inferior borders, by conjecture, and then by determining the area of the ovoid thus formed with a plani- meter. The transverse diameter is the most widely used measurement '(Figure 4). When cal- culated on the teleroentgenogram, it may be compared to the predicted normal for the height and weight of that individual (Table VII), determined on radiographs made in mid- inspiration. A deviation of ten per cent from this prediction is likely to be abnormal. In making the normal table, the authors measured the heights of their subjects with shoes on, and the weights Included all clothing except coat and vest. Corrections must be made for this, because heights and weights in the Army are determined with the subject com- pletely unclothed. When the transverse diameter is measured on an orthodiagram made during quiet res- piration, a different prediction table must be used. (Table VIH). The prediction from this table is based on height, weight, age, and sex. A deviation of more than 1 cm from this prediction is regarded as abnormal. The normal cardiac area on the orthodiagram can also be predicted from this table. The width of the aorta can be measured in several ways, the most common being the one shown in Figure 4 in which the greatest distances between the midline and the later- al borders of the shadow of this vessel on either side are summated. In male adults this measurement normally does not exceed 7 cm. For the technique of making a teleroentgenogram, see TM 8-240. 29. EXAMINATION OF THE LUNGS. (AR 40-105 Section XH and AR 40-110, par. 20d) a. Tuberculosis. This diagnosis will usually be based on roentgenographic findings. The pathogenic phase in which a given lesion presents itself should be differentiated since such knowledge is helpful in selection for military duty as well as in prognosis and treatment. (1) Primary Phase (2) Reinfection Phase (a) Site of Initial Lesion A single parenchymal lesion (occas- ionally multiple) usually in the lower or mid-lung field and involvement of one or more hilar lymph nodes. A parenchymal focus usually in upper third of the lung without gross involvement of the hilar lymph nodes. (b) Pathological Lesion Exudative pneumonic lesion proceed- ing to caseation, both in the pulmonary lesions and in the involved hilar nodes. Heals by fibrotic encapsulation of caseous foci with or without calcifica- tion. 1. Exudative pneumonic lesion with caseation and liquefaction necrosis in center. 2. Productive pneumonic lesion - a true tubercle with a caseous center. 3. Mixed lesions of 1 and 2; usually one or the other predominates. Heals by resorption, fibrosis, and occasionally calcification. (c) Early Appearance on Roentgenogram A patch of mottled or rounded homo- genous clouding associated with density of enlarged hilar nodes, which cause the 1. Exudative - diffuse shadow of uneven density with hazy, irregular borders gradually fading into surround 26 mediastinal border to appear wider than normal, or sometimes a localized rounded bulge is seen. In adults the enlargement of the hilar nodes is not as prominent as in children. ing normal densities. 2. Productive - Round or irregular shadows of uniform density which are sharply delineated from surrounding normal shadows. 3. Mixed - any combination of the above. (d) Late Appearance or Roentgenogram May not be evident in adults, or may appear in the healed stage as a calcified pulmonary focus (Ghon tubercle) and calci- fied nodes. More often only the calcified nodes are visualized. NOTE: These apparently calcified lesions often are still partly caseous and harbor viable tubercle bacilli. Usually they re- main quiescent after adolescence, but large lesions or those not uniformly calcified are potential sources of future disease . 1. Exudative - changes more rapid, definite and extensive. Excavation de- noted by rarefaction within the shadows of the various infiltrations. 2. Productive - same changes may occur- but are likely to be less rapid and less extensive. 3. Mixed - changes depend on which type is predominant. Healing of all types is indicated by gradual fading of shadows about the periphery. Fibrosis often appears as stellate densities radiating from the central round lesions or as wiry streak- like sharply defined lines radiating in a fan-like manner from the hilum toward the periphery. Healing by calcification is infrequent. Early exudative lesions may resorb completely. b. Quantitative classification (National Tuberculosis Association). (1) Minimal. Slight lesions without demonstrable excavation confined to a small part of one or both lungs. The total extent of the lesions, regardless of distribution, shall not exceed the equivalent of the volume of lung tissue which lies above the second chondrosternal junction and the spine of the fourth or body of the fifth thoracic verte- bra on one side. NOTE: Early and minimal tuberculosis are not synonymous terms. Early tuberculosis may be extensive and minimal tuberculosis may be of long duration. (2) Moderately advanced. One or both lungs may be involved, but the total extent of the lesions shaH not exceed the following limits: (a) Slight disseminated lesions which may extend through not more than the volume of one lung, or the equivalent of this in both lungs, (b) Dense and confluent lesions which may extend through not more than the equivalent of one-third the volume of one lung, (c) Any gradation within the above limits, (d) Total diameter of cavities, if present, estimated not to exceed 4 cm. (3) Far advanced. Lesions more extensive than moderately advanced. c. Method of Interpretation of Chest Roentgenograms. (1) Technique employed (TM 8-240, pp. 150-155) (a) Posture - scapula out of pulmonary, field. (b) Phase of Respiration - note blurring due to movements of ribs, diaphragm, heart or blood vessels. (c) Proper centering of x-ray tube - Improper centering or rotation of patient pro- jects image of mediastinum to one side. With proper centering the spinous processes of the upper thoracic vertebrae should be in a vertical line which falls midway be- tween sternal ends of the clavicles. (2) Technical quality (TM 8-240, pp. 66 to 73) (a) Artefacts. (b) Overpenetration. Small pulmonary lesions not seen. (c) Underpenetration. General fogginess, no contrast in details. (3) Order of Examination. (a) Densities of soft tissues - breast, nipple shadows, neck, etc. (b) Bony frame work - ribs, clavicles and size of intercostal spaces. (c) Trachea - position, course and size. (d) Cardiovascular silhouette (see par. 28) (e) Diaphragms and costophrenic sinuses - position, contour, adhesions. (f) Lung fields. 1. Hilar and truncal shadows. 2. Pulmonary parenchyma, d. Standards. (1) For candidates for commission - See AB 40-105, October 14, 1942, par. 35. (2) For candidates for enlistment - see MR 1-9, March 15, 1942, par. 55-59. (3) For original applicants for flying training - as for candidates for commission (see AR 40-110, December 3, 1942, par. 20d). 30. BONES, JOINTS, MUSCLES, AND FEET. a. Exercises. The applicant will be put through a series of movements which will bring into action the various joints and muscles of the body. The examiner should give the commands for these exercises in concise easily understood language but should not demonstrate them to the applicant. This enables the Flight Surgeon to evaluate the ap- plicant’s intelligence. The elbows should be brought firmly to the sides of the body and the forearms extended to the front, palms of the hands uppermost; extend and flex each finger separately; bring the tips of the thumbs to the base of the little fingers; 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 forearms 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 to 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 shoulder, 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. 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). Take the position of “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;making a standing jumpas far as possible and repeat it several times; run the length of the room several times, b. Pes planus. Changes in the arches of the foot may be marked but if they have occurred slowly they may cause no symptoms. A slight change rapidly evolved may, on the other hand, cause acute symptoms. (1) Classification. It has been customary in accordance with AR 40-100, November 16, 1942, to describe pes planus as being first, second or third degree depending upon the extent of the anatomical deformity. By usage first degree pes planus has come to mean lowering of the longitudinal arch; second degree means that in addition to the lowered arch there is a beginning bulge of the medial border with some bowing of the tendon of Achilles; and third degree indicates complete disappearance of the longitudinal arch, inward rotation of the astragalus with bulging of the inner border, bowing of Achilles tendon, abduction, and variable degrees of rigidity. This amount of deformity, espec- ially lowering of the longitudinal arch, does not necessarily parallel the severity of the symptoms, and that weakness of the foot may be marked when there is slight or no deformity. (2) Examination. The examination should include inspection for (a) lowering of the longitudinal arch, (b) abduction, (c) bowing of Achilles' tendon, (d) weakness of the feet on exercise (see par. 29a.), (e) spasticity and rigidity determined by manipulation, (f) the line of weight bearing, (g) bulging of the medial aspect of the foot, (h) callosi- ties. The most common symptoms of weak foot are aching principally along the medi- al border of the foot, with variable degrees of stiffness, aching in the calf, and symp- toms of low back strain. In general these symptoms are brought on or exaggerated by use of the foot. (3) Requirements. A “flat foot” is disqualifying for commission or for flying training if it accompanied by symptoms of weak foot or when the foot is weak on test. If there is eversion, and bulging of the astragalus this is disqualifying in itself despite the ab- sence of symptoms. In terms of the classification of pes planus given above this last means that asymptomatic first or second degree pes planus is qualifying but that asym- ptomatic third degree pes planus is disqualifying. 31. REFERENCES. a. Regulations. (1) AR 40-100 (November 16, 1942) (2) AR 40-105 (October 14, 1942) (3) AR 40-110 (December 3, 1942) b. Articles. (1) Schneider, E.C.; A Cardiovascular Rating as a Measure of Physical Fatigue and Efficiency, J.A.M.A. 74:1507, 1920. (2) Fellows, H.H.; Serial Chest Roentgenograms of 3179 Office Employees, 1926-38, J. Ind. Hyg. and Toxicol, 22:157, 1940. (3) Hodges, P.C., and Eyster, J.A.E.: Estimation of Transverse Cardiac Diameter in Man, Arch, Int. Med., 37:711, 1926. (4) Ungerleider, H.E., and Clark, C.P.; A Study of the Transverse Diameter of the Heart Silhouette with Prediction Tables Based on the Teleroentgenogram, Am. Heart J. 17:92, 1939. c. Manuals. (1) TM 8-240, Roentgenographic Technicians, July 3, 1941. (2) TM 8-305, Notes on Cardiology in Aviation Medicine, November 12, 1940. d. Texts and Pamphlets. (1) Nomenclature and Criteria for Diagnosis of Diseases of the Heart, by the Criteria Committee of the N.Y. Heart Association, 4th Ed., New York, 1940. (2) Standardization of Blood Pressure Readings, American Heart Association, New York, 1939, (also see J.A.M.A. 113:294, 1939). (3) Examination of the Heart, American Heart Association, New York, 1940. (4) Diagnostic Standards and Classification of Tuberculosis, National Tuberculosis Association, New York, 1940. (5) Amber son, J.B.; Chest X-ray Interpretation, National Tuberculosis Association, New York, 1941. (6) Roesler, H.; Clinical Roentgenology of the Cardiovascular System, Baltimore, Charles C. Thomas, 1937. (7) Manual of Clinical and Laboratory Procedures, Third (N,Y.U) Medical Division, Bellevue Hospital, New York, 1941. (8) Orias, O. and Braun-Menendez, E.; The Heart Sounds in Normal and Pathological Conditions, New York, Oxford University Press, 1939. SECTION n EXAMINATION OF THE EYE Paragraphs Technique of the eye examination for flying 32 Minimal visual requirements of flying personnel by classes 33 Eye requirements (all branches) 34 Improvised equipment for conducting the eye examination for flying 35 Primary differential diagnostic points in nystagmus 36 Action of eye muscles 37 Depth perception appartus (wheel operated) 38 Dark Room table 39 References 40 32, TECHNIQUE OF THE EYE EXAMINATION FOR FLYING, a. Visual Acuity. (1) Equipment. The standard Snellen test charts or the self-illuminated test cabinets as issued will be used in the determination of visual acuity. The use of a satisfactory projector with screen in a dark room is authorized when available. Where the test letters are printed upon white cardboard the chart should be iUuminated by a 100-watt daylight Mazda lamp placed 4 feet above and in front of it, and this lamp should be so screened or shaded that no direct light from it falls upon the eyes of the examinee. The test chart or cabinet must be installed in a room of such dimensions that a space of exactly 20 feet is availabl e from the examinee to the test chart. The windows of the room should be equipped with shades or shutters so that extraneous sources of light in front of and to the sides of the examinee may be excluded. For the purpose of screen- ing the eye not being examined an opaque card of suitable dimensions is necessary. Such a screen may be devised by cutting a disk from cardboard, approximately 2-1/2 inches in diameter with a handle projecting from one side. (2) Procedure. Immediately upon entering the room the examinee is seated in a chair directly facing the Snellen chart and exactly 20 feet away from it. The test should be- gin promptly in order to prevent memorizing the test letters. The examiner, using the opaque card or disk, screens the left eye of the examinee, and directs him to read as many rows of the illuminated letters as possible, beginning with those of a larger size, as for example the 20/50 row. When the maximum acuity of the right eye has been ob- tained, the left eye is tested in the same manner, the right being screened. The smallest row of letters read correctly determines the fraction used in recording visual acuity, the numerator of the fraction being the distance in feet from the eyes of the examinee to the test chart, and the denominator being the size type of the smallest row read. The number of letters read correctly in the next smaller line or row is added to the fraction following the plus sign, for example, visual acuity R.E. 20/20 plus 3; L.E. 20/20 plus 5. In instances where visual acuity is reduced below 20/20, the fraction, when reduced, does not represent the actual visual efficiency. Assuming an acuity of 20/20 to be normal or 100 per cent, the following table gives the percentage of visual efficiency corresponding to the Snellen notations for visual acuity at 20 feet: Snellen notation Percent- Snellen notation Percent- Snellen notation Percent- for distance: age of vi- for distance: age of vi- for distance: age of vi- sual effi- sual effi- sual effi- ciency; ciency: ciency: 20/20 - 100.0 20/50 - 76.5 20/120 - 40.9 20/25 - 95.7 20/60 - 69.9 20/140 - 34.2 20/30 - 91.5 20/70 - 64.0 20/160 - 28.6 20/35 - 87.5 20/80 - 58.5 20/180 - 23.9 20/40 - 83.6 20/90 - 53.4 20/200 - 20.0 20/45 - - 80.0 20/100 - - 48.9 On examination, when the examinee habitually wears correction for distant vision, the acuity for each eye uncorrected and corrected should be determined and recorded, also the prescription worn should be noted on WD AGO Form No. 64, at the first examina- iaUy lowering of the longitudinal arch, does not necessarily parallel the severity of the symptoms, and that weakness of the foot may be marked when there is slight or no deformity. (2) Examination. The examination should include inspection for (a) lowering of the longitudinal arch, (b) abduction, (c) bowing of Achilles’ tendon, (d) weakness of the feet on exercise (see par. 29a.), (e) spasticity and rigidity determined by manipulation, (f) the line of weight bearing, (g) bulging of the medial aspect of the foot, (h) callosi- ties. The most common symptoms of weak foot are aching principally along the medi- al border of the foot, with variable degrees of stiffness, aching in the calf, and symp- toms of low back strain. In general these symptoms are brought on or exaggerated by use of the foot. (3) Requirements. A “flat foot” is disqualifying for commission or for flying training if it accompanied by symptoms of weak foot or when the foot is weak on test. If there is eversion, and bulging of the astragalus this is disqualifying in itself despite the ab- sence of symptoms. In terms of the classification of pes planus given above this last means that asymptomatic first or second degree pes planus is qualifying but that asynv ptomatic third degree pes planus is disqualifying. 31. REFERENCES. a. Regulations. (1) AR 40-100 (November 16, 1942) (2) AR 40-105 (October 14, 1942) (3) AR 40-110 (December 3, 1942) b. Articles. (1) Schneider, E.C.; A Cardiovascular Rating as a Measure of Physical Fatigue and Efficiency, J.A.M.A. 74:1507, 1920. (2) Fellows, H.H.; Serial Chest Roentgenograms of 3179 Office Employees, 1926-38, J. Ind. Hyg. and Toxicol, 22:157, 1940. (3) Hodges, P.C., and Eyster, J.A.E.: Estimation of Transverse Cardiac Diameter in Man, Arch, Int. Med., 37:711, 1926. (4) Ungerleider, H.E., and Clark, C.P.; A Study of the Transverse Diameter of the Heart Silhouette with Prediction Tables Based on the Teleroentgenogram, Am. Heart J. 17:92, 1939. c. Manuals. (1) TM 8-240, Roentgenographic Technicians, July 3, 1941, (2) TM 8-305, Notes on Cardiology in Aviation Medicine, November 12, 1940. d. Texts and Pamphlets. _(1) Nomenclature and Criteria for Diagnosis of Diseases of the Heart, by the Criteria Committee of the N.Y. Heart Association, 4th Ed., New York, 1940. (2) Standardization of Blood Pressure Readings, American Heart Association, New York, 1939, (also see J.A.M.A. 113:294, 1939). (3) Examination of the Heart, American Heart Association, New York, 1940. (4) Diagnostic Standards and Classification of Tuberculosis, National Tuberculosis Association, New York, 1940, (5) Amber son, J.B.; Chest X-ray Interpretation, National Tuberculosis Association, New York, 1941. (6) Roesler, H.; Clinical Roentgenology of the Cardiovascular System, Baltimore, Charles C. Thomas, 1937. (7) Manual of Clinical and Laboratory Procedures, Third (N,Y.U) Medical Division, Bellevue Hospital, New York, 1941. (8) Orias, O. and Braun-Menendez, E.; The Heart Sounds in Normal and Pathological Conditions, New York, Oxford University Press, 1939. SECTION n EXAMINATION OF THE EYE Paragraphs Technique of the eye examination for flying 32 Minimal visual requirements of flying personnel by classes 33 Eye requirements (all branches) 34 Improvised equipment for conducting the eye examination for flying 35 Primary differential diagnostic points in nystagmus 36 Action of eye muscles 37 Depth perception appartus (wheel operated) 38 Dark Room table 39 References 40 32. TECHNIQUE OF THE EYE EXAMINATION FOR FLYING, a. Visual Acuity. (1) Equipment. The standard SneHen test charts or the self-Illuminated test cabinets as issued will be used in the determination of visual acuity. The use of a satisfactory projector with screen in a dark room is authorized when available. Where the test letters are printed upon white cardboard the chart should be Hluminated by a 100-watt daylight Mazda lamp placed 4 feet above and in front of it, and this lamp should be so screened or shaded that no direct light from it falls upon the eyes of the examinee. The test chart or cabinet must be installed in a room of such dimensions that a space of exactly 20 feet is availabl e from the examinee to the test chart. The windows of the room should be equipped with shades or shutters so that extraneous sources of light in front of and to the sides of the examinee may be excluded. For the purpose of screen' ing the eye not being examined an opaque card of suitable dimensions is necessary. Such a screen may be devised by cutting a disk from cardboard, approximately 2-1/2 inches in diameter with a handle projecting from one side. (2) Procedure. Immediately upon entering the room the examinee is seated in a chair directly facing the Snellen chart and exactly 20 feet away from it. The test should be- gin promptly in order to prevent memorizing the test letters. The examiner, using the opaque card or disk, screens the left eye of the examinee, and directs him to read as many rows of the illuminated letters as possible, beginning with those of a larger size, as for example the 20/50 row. When the maximum acuity of the right eye has been ob- tained, the left eye is tested in the same manner, the right being screened. The smaHest row of letters read correctly determines the fraction used in recording visual acuity, the numerator of the fraction being the distance in feet from the eyes of the examinee to the test chart, and the denominator being the size type of the smaHest row read. The number of letters read correctly in the next smaller line or row is added to the fraction following the plus sign, for example, visual acuity R.E. 20/20 plus 3; L.E. 20/20 plus 5, In instances where visual acuity is reduced below 20/20, the fraction, when reduced, does not represent the actual visual efficiency. Assuming an acuity of 20/20 to be normal or 100 per cent, the following table gives the percentage of visual efficiency corresponding to the Snellen notations for visual acuity at 20 feet: Snellen notation Percent- Snellen notation Percent- Snellen notation Percent- for distance: age of vi- for distance: age of vi- for distance: age of vi- sual effi- sual effi- sual effi- ciency: ciency; ciency: 20/20 - 100.0 20/50 - - • - 76.5 20/120 - 40.9 20/25 - 95.7 20/60 ■ - 69.9 20/140 - 34.2 20/30 - 91.5 20/70 • - 64.0 20/160 - 28.6 20/35 - 87.5 20/80 • - 58.5 20/180 - 23.9 20/40 - 83.6 20/90 ■ - 53.4 20/200 - 20.0 20/45 - 80.0 20/100 • - 48.9 On examination, when the examinee habitually wears correction for distant vision, the acuity for each eye uncorrected and corrected should be determined and recorded, also the prescription worn should be noted on WD AGO Form No. 64, at the first examina- tion after such prescription has been obtained, or after any change is made in a for- mer correction. (3) Precautions. Every possible safeguard is thrown around the test to prevent memor- izing the charts. Examinees awaiting their visual acuity test are not permitted to re- main 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 line, screening all others, and will have the examinee name them. The examinee will not be allowed to reduce the palpebral fissure to a narrow slit, but must read with his lids open to the natural position. The pupils should be examined to make certain that no miotic has been instilled in order to cause a con- traction. Such a procedure markedly improves the vision of an ametrope while effects of the drug continue. A bright light in front of or above, so situated that it shines dir- ectly into the eyes of the examinee, is not allowable. Such a light, by causing the con- traction of the pupils, may result in an apparent improvement in visual acuity. The eye not being examined is to be screened completely from the letters while the other is be- ing tested. b. Visual Acuity at 13 inches. (1) Equipment. Standard Jaeger cards which may be calibrated in Snellen system or Jaeger system of notation. Snellen .37 m = J-l/2 .50 m = J - 1 .62 m = J - 2 .75 m = J - 3 (2) Procedure. The examinee stands with his back to a source of light so that the card is well illuminated. Each eye is tested separately. The card is held level with the eye at a distance of 13 inches. The examinee reads a line of a paragraph with the smallest visible print, “j-1-13”, J-2-13” is recorded for each eye. (3) Precautions. Illumination should be sufficient; artificiallllght may be used. To prevent memory replacing visual acuity in testing the second eye, reading of the lower line of same paragraph may be requested of the examinee. Cards with different texts may be used for the same purpose. The use of squinting, miotics or glasses are not allowed in measuring unconnected near visual acuity. If glasses are worn, near visual acuity is measured without and again with glasses (corrected), the Jaeger type read re- corded in each case, together with the prescription for each eye. c. Depth perception at 6 meters. (1) Equipment. The standard depth perception apparatus as issued is fixed in a position immediately beneath the Snellen test chart or cabinet where it will receive overhead illumination, or the standard depth perception apparatus modified for indirect instead of overhead illumination is authorized. Care should be taken that the apaaratus is fixed in position so that when the movable rod is on the zero marking, both rods will be the same distance from the examinee, and the apparatus at about the same level of the eyes of the examinee when seated. Extraneous light should be excluded. (2) Procedure. On the original examination particularly, the operation of the apparatus should be explained at close range to the examinee, and the necessity of accuracy, pre- cision, and promptness emphasized. The examinee is seated in the chair 20 feet in front of the rear screen of the apparatus, as in the determination of visual acuity; the window in the front screen is occluded (as by the examiner standing before it) and the movable rod is widely separated from the fixed rod, being placed either in front of or behind it. The examinee is then directed, after the examiner has stepped aside, to adjust the movable rod by manipulating the cords attached to it, so that it appears to be exactly alongside the fixed rod. When this is accomplished the procedure is re- peated, a notation being made of the distance in millimeters the movable rod is away from the zero marking. If the results of the individual trials are approximately the same, five trials will be sufficient. If, however, they are widely variant ten trials may be given. The average error in millimeters is then determined and recorded. (3) 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 fixed and is now allowed to move from one side to the other. The exam- inee will not be allowed to pull the rods back and forth the full length of the apparatus as this gives information as to the length of the box. The rods should be adjusted promptly by the examinee as the time element is an Important factor. Care will be taken by the examiner: (a) To avoid casting a shadow on the background. (b) To avoid so placing the hands as to give the examinee information as to his error. (c) To avoid any facial expression from which the examinee might gain information as to the result of his efforts. (d) To remove the cord from the examinee's hands while separating the rods prelim - inary to each trial so that the examinee will not be able to judge the distance the rods have been separated by the length of cord that has slipped through his fingers. (e) To cover the window of the front screen of the apparatus while the examiner is placing the movable rod prior to each trial. d. Heterophoria at 6 meters. *"(1) Equipment. A phorometer trial frame equipped with a pair of multiple Maddox rods and a pair of Risley rotary prisms, or a hand phorometer; a spotlight approximately 1 centimeter in diameter (as a component of the illuminated test cabinet, or a muscle lamp) and a suitable monocular screen such as used in the determination of visual acuity. If the phorometer trial frame is not available, the trial frame, Maddox rod, and prisms from the standard trial lens case may be used satisfactorily, but the proce- dure is somewhat more tedious and time consuming. (Also see paragraph 34). (2) Procedure. Before beginning the test the examinee's sighting or fixing eye is de- termined. For this purpose a blank card approximately 13 by 20 centimeters with a 1.5-centimeter round hole in the center is employed. The examinee, seated, facing the spotlight 6 meters away, grasps the card by the short sides with both hands. While fixing on the spotlight, 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 by screening the eyes alternately, while the card is held steady, the eye which fixes the light can be determined. This is the fixing (or sighting) eye; (a) With phorometer trial frame. Having determined the sighting eye, the phorometer is adjusted closely in front of the examinee's eyes, is leveled, and is adjusted for interpupillary distance. One of the multiple Maddox rods is swung into position be- fore 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 nonsighting eye to give a vertical line of light. The rotary prism is adjusted also before the non-sight- ing eye for the measurement of lateral deviation; that is, with the zero mark verti- cal, and set 4 or 5 prism diopters off the zero mark. This gives enough deflection at the first reading to determine whether an examinee has been coached to say the line passes through the light. The opaque disk is moved from one eye to the other a few times to ascertain that 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 fur- ther darkening of the room may be necessary to render it clearly visible. When the examinee sees the line with one eye and the light with the other, the ex- aminer holds the card or screen in front of the nonfixing 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 should see the line and be able to locate it with reference to the light. After one or two such exposures he will say that the line is to the right or the left of the light, or possibly through it. He is instructed to grasp the milled head that rotates the prism and turn it to shift the line directly into the light. To en- able him to do this, the screen is removed from in front of 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 each time he sees it when the screen is removed. The number of prism diopters necessary to do this is read from the scale of the ro- tary prism. This is entered on the record as esophoria if the prism is base out (displaced temporally) and exophoria if the prism is base in (displaced nasally). For the measurement of hyperphoria the Maddox rod before the nonfixlng eye is re- adjusted before the same eye to measure vertical deviation; that is, with the zero marking out and set 1 or 2 diopters off the zero mark. 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. Whether it is right or left hyperphoria is determined by the position of the prism. If it is base down it is hyperphoria of that eye (i.e., the eye before which it is located). If it is base up it is hyperphoria of the other eye. (b) With spectacle trial frame. Use the Maddox rod and prisms from trial lens case. Adjust the spectacle trial frame on the examinee so that it is comfortably worn and the cells properly placed as to interpuplllary distance. For determining an imbalance in the horizontal meridian, that is, exophoria or eso- phoria, place the Maddox rod in the cell before the nonsighting eye so that the axis of the rod is horizontal. Direct the examinee to fix upon the spot of light, and for a few seconds at a time alternately cover and uncover the nonfixing eye, allowing the fixing eye to maintain fixation constantly. If orthophoria exists, the visual lines of the nonfixing eye will not deviate and the vertical line of light will be seen as passing through or bisecting the spotlight. If the line of light is seen on the same side (homonymous diplopia) of the examinee as the Maddox rod is placed (for example, the Maddox rod before the left eye and the line is seen to the left), the qualitative diagnosis of esophoria is made, and in order to make a quantitative determination a prism must be used base out. Homonymous diplopia indicates esophoria, the amount of which is estimated by the use of a prism before the nonflxing eye with base out or toward the temporal side. A weak prism, base out, that is, of one diopter, is placed before the nonfixing eye, and the procedure of covering and uncovering the nonfixing eye is repeated. It will be found that perhaps the line of light has moved nearer the spot of light but still does not pass through it. The prism is replaced by a stronger one until the line of light passes through the spot of light, and the strength of the prism vised indicates the amount of esophoria in prism diopters. If the line of light is seen on the opposite side, as for example, the Maddox rod is before the left eye and the line is seen to the right (crossed diplopia) then a qualita- tive diagnosis of exophoria is made. A crossed diplopia indicates exophoria, the amount of which is estimated by the use of a prism before the nonfixing eye with base in or toward the nasal side. The procedure is the same as with esophoria ex- cept that the prism is used base in. The strength of the prism used to cause the line of light to pass through the spot of light Indicates the amount of exophoria in prism diopters. Hyperphoria is used as a diagnostic term where a deviation of one of the visual lines on the vertical meridian exists and the designation is made as to right or left, depending upon which of the visual lines is the higher, or which tends to deviate up- ward in comparison with its feHow. For the measurement of hyperphoria the Maddox rod is adjusted before the nonfixing eye with its axis vertical, hence the line of light is seen as horizontal. The nonfixing eye is alternately covered and uncovered, and if the line of light is seen passing through the spot of light there is no hyperphoria. If the line of light is seen below the spot of light, there is a hyperphoria of the eye behind the Maddox rod, and the strength of prism, base down, before the eye which causes the line to pass through or bisect the spot of light represents the deviation in prism diopters. If the line of light is seen above the spotlight a hyperphoria of the opposite eye is indicated, and the strength of prism base up before the eye be- hind the Maddox rod represents the amount of deviation in prism diopters. (3) Precautions. The Maddox rod and the measuring prism are always used together before the nonfixing eye. The test gives an Inaccurate result if the examinee is per- mitted to see the line for a longer time than is allowed by the momentary exposures described above. !, Power of divergence. '(1) Equipment. Phonometer trial frame; 1 centimeter spotlight or muscle lamp at 6 meters distance; or if phonometer trial frame is not available, spectacle trial frame and prisms from trial lens case. (2) Procedure. The examinee is seated facing the spotlight 20 feet (6 meters) away as in the determination of heterophoria at 6 meters. A rotary prism of the phonometer trial frame is adjusted before one eye with the milled head exactly vertical and the prism set at the zero marking. The examinee is directed to fix upon the spot of light and the examiner slowly rotates the prism base in. As the prism is rotated in this manner the spotlight, as seen by the examinee, will eventually blur and then separate into two distinct spots of light. The number of prism diopters which causes the light definitely to blur, or the maximum strength prism, base in, which he is able to over- come by divergence is the measurement of his power of divergence in prism diopters and is so recorded. Where the phorometer trial frame is not available, the prisms from the trial lens case may be used, base in, one after another, beginning with the weakest and replacing by stronger prisms, until diplopia occurs. (3) Precautions. Examiners are cautioned that the prism strength which causes the first actual diplopia exceeds the examinee’s diverging power, f. Red lens test. (1) Equipment. Spectacle trial frame; red lens from trial lens case or large spectac- les made up with a large red lens on one side only; small light such as ophthalmoscope without head; metric rule or tape. (2) Procedure. The examinee is seated in the dark room and the spectacle trial frame is adjusted in place. The red lens from the trial lens case is placed in one of the cells of the trial frame, and the small lamp is held directly in front of his eyes 75 centimeters away and at the same level of his eyes. The presence or absence of diplopia in this position (primary) is noted. The light is then slowly moved from this position toward the examinee's right through a distance of 50 centimeters in the horizontal plane. In the same manner the light is moved in the remaining five cardinal directions and the presence or absence of diplopia noted in these meridians. Diplopia should not occur in any meridian within 50 centimeters from the primary position, which approximately limits the field of binocular fixation. Where diplopia does occur within 27.30 centimeters of the primary position (approximately 20°) a more accurate determination will be made upon a blackboard or wall. The examinee with the spectacle trial frame and red lens before one eye is seated before the wall so that his eyes are exactly 75 centimeters from it, a point marked on the wall at the same level of his eyes and in the median line; from this point the light is moved outward in the six cardinal directions and the exact point where diplopia occurs is marked on the wall. The exact distance from the primary point to the point where diplopia first occurs will be measured in centimeters and from the following table the angle in degrees may be determined: Degrees Distance from pri- mary point in cm. Degrees Distance from pri- mary point In cm. 1 - 1.31 19 - - - - - 25.82 2--- - - 2.62 20 27. 30 3 - - _ 3.93 21 - - 28.79 4 - - - 5.24 22 30.30 5----- . . 6.56 23 31.84 6 - 7.88 24 33.39 7 - - ------ 9.21 25 34.97 8 - - ------10.64 26 36.58 9 - - - - - -11.88 27 - - - - 38.21 10 - - - - - -13.22 28 39.88 11----- - - 14.58 29 41.57 12 - - 15.95 30 43.30 13 17.32 31 ------- 45.07 14 18.70 32 46.87 15----- 20.09 33 . - 48.71 16 - . -21.50 34 50.59 17 22.93 35 ------- 52.52 18 ----- -24.37 Where diplopia is found within 27.30 centimeters, notation should be made as to wheth- er it is crossed, homonymous, or vertical. When the light is seen on the same side as the red lens is worn, the diplopia is homonymous; crossed when seen on the opposite side. Where diplopia may be suspected and the examinee coached to deny its presence, a prism of 3 or 4 diopters may be placed either base up or down in one of the cells of the trial frame, and if diplopia is still denied, the statement is obviously untrue. The prism may be alternately replaced by a weak spherical lens (minus .12) In order to confuse the examinee. (3) Precautions. The head of the examinee must remain fixed while the light is being moved, no tilting or rotation of the face being permitted, g. Inspection of the eyes. Observation of the eyes and adnexa is conducted throughout the entire examination. In addition a careful objective examination employing special methods is indicated on all examinations to determine any evidence of past or present ab- normality, disease, or defect. (1) Equipment. Plus spherical lenses (from trial lens case) with suitable Illumination as required for oblique illumination; the hand slit lamp and the binocular loupe when available; Ophthalmoscope, preferably electric. (2) Procedure. On the original examination the inspection of the eyes is not completed until the ophthalmoscope is used in the examination of the cornea, anterior chamber, iris and lens. This examination should be particularly thorough, as evidence of pre- vious injury or disease may be found which may not be obtained in the history taken. The following conditions should be borne in mind and noted: (a) Changes from the normal position of the globes, as changes in the direction of the visual axes (squint) exophthalmos and enophthalmos. (b) Lids: Ptosis, blepharitis, trichiasis, entropion, ectropion, symblepharon, chala- zion, and hordeolum. (c) Lacrimal apparatus; Dacryocystitis, acute and chronic, dacryoadenitis, imperfect drainage or epiphora from any cause. (d) Conjunctiva and sclera; The lids are to be everted and the palpebral conjunctiva and fornices exposed. The following are to be noted: conjunctivitis, acute and chronic evidence of trachoma, contractures, cicatrices, circumcorneal injection, evidences of episcleritis or sclerttis, and chalklike meibomian concretions. (e) Cornea: Keratitis, opacities, vascularization, pterygium, deposits on posterior surface, anterior synechia, post-traumatic irregularity of corneal surface or retain- ed foreign bodies. (f) Pupils; Note size, shape, inequality, direct and consensual reactions to light, and reaction to accommodation. (g) Iris: Synechiae, anterior and posterior, evidence of past or present iritis, congen- ital anomalies, traumatic sequelae, and minute pigmented neoplasms. (h) Anterior chamber; Abnormality in depth and any evidence of alteration in normal character of aqueous humor, retained foreign bodies. (i) Lens: Opacities and anomalies. (j) Intraocular tension; Taken by palpation and recorded as normal, increased, or decreased. When there is a question of increased intraocular tension the tonometer will be used and results recorded with the type of tonometer employed being stated. (3) Interpretation of findings. Distinction should be made between defects considered as being of a temporary or of a permanent nature, and notation made as to interference with function. Any evidence of acute inflammation of the eye or adnexa is temporarily disqualifying. A small chalazion which is non-irritating and does not interfere with the normal function of the lid is not dlsqualifying but will be recorded. A hordeolum should be considered as a temporary disqualifying condition but the possibility of error of re- fraction being an etiological factor should be considered. Corneal opacities, which in no way interfere with vision are not disqualifying but will be recorded as to size, posi- tion, and density (example: “irregularly round nebula 3 mm. in diameter, 4 mm. within limbus at 6 o’clock”). An inactive pterygium that does not encroach more than one millimeter upon the cornea is of no significance, but one that is definitely progressive, as evidenced by marked vascularity and thick elevated head, temporarily disqualifies, and its removal is indicated even though it barely encroaches on the cornea. Any evi- dent increase or decrease in intraocular tension disqualifies. Actual nystagmus dis- qualifies, but nystagmoid movements which are noted only at extreme limits of the normal ocular movements are of no significance and must be differentiated from a true nystagmus. If anisocoria exists, further attention will be given to visual fields (form), pupillary reaction to light, serology, and history of syphilis. Abnormal pupillary re- action is disqualifying if caused by organic disease. Any defect, disease, or abnorma- lity that materially interferes with the normal ocular function disqualifies for all three classes. Evidence of past or present iritis should be given particular attention, because of the frequent possibility of rheumatic, syphilitic or focal infectious background, h. Accommodation. (1) Equipment. The Prince rule; a small millimeter rule; a card with several rows of small letters; the Thorne rule when available. (2) Procedure. Accommodation is measured from the anterior focus of the eye which is about 15.7 millimeters in front of the cornea. Using the millimeter rule, a pencil mark is made on each side of the examinee’s nose 15.7 millimeters in front of the right and the 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 horizontally and extends direct- ly to the front, edge up. The card of test letters is held not more than 5 centimeters 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 that he begins to read the letters correctly, and the point of 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 is repeated, using a different line of letters. (3) Precautions. Care must be taken that the examinee is seated with his back to a window and that the card is illuminated by good daylight. The letters on the test card are read aloud. The same line of letters is not used for testing both eyes. The size of the letters on the card should be that of Jaeger type No. 1 (Snellen 0,5 cm. or 50 cm.) and the Jaeger card may be used as test letters provided the Jaeger No. 1 type only is used. The card is first held within 5 centimeters from the eye and slowly carried away from it. It is important that the test card be clean and legible. (See par. 35f). (4) Interpretation of findings. The appended table gives the mean values oi accommo- dation in diopters from 18 to 50 years of age. These values have been computed on the basis of emmetropic individuals. Accommodation may be considered as within normal limits provided it is not more than 3 diopters below the mean for the examinee’s eye. Before an examinee is disqualified his accommodation must be taken on three succes- sive days and an aver age. of the three findings determined. Low accommodative power may be indicative of accumulative fatigue, staleness, or of a debilitating condition either of a transient or permanent nature. For classes 2 and 3, examinees are quali- fied with accommodation below 2 diopters regardless of age, provided they actually wear their correction for near vision while flying and their correction while worn enables them to read Jaeger-1 test letters at 20 inches (50 cm.). Table IX - ACCOMMODATION (DUANE) Age Minimum Average Age Minimum Average Age Minimum Average Allowable Allowable Allowable 18 . ... 8.9 . . 11.9 27. 30. . . 7.1 19 . . . . 8.7 . . 11.7 28. . . . 6.4 . . . 9.4 37. . . 3.8 . . . . 6.8 20 . ... 8.5 . . 11.5 29. . . . 6.2 . . . 9.2 38. . . .3.5 . . . 21 . . . . 8.2 . . 11.2 30. . . . 5.9 . . . . 8.9 39. . .3.2 . . . . . 6.2 22 . ... 7.9 . . 10.9 31. . . . 5.6 . . . 8.6 40. . . . 2.9 . . . . . 5.9 23 . . . . 7.6 . . 10.6 32. . . . 5.3 . . . . 8.3 45. 24 . . 7 4 10 4 33. 5.0 . . 8 0 50. 25 . ... 7.2 . . 10.2 34. . . . 4.7 . . . . 7.7 26 . ... 6.9 . . 9.9 35. . . . 4.3 . . . 7.3 i. Power of Convergence. “(1) Near point of convergence (PcB). (a) Equipment. The Prince rule or a rule graduated in millimeters at least 30 cent- imeters long; a pin with a white head 2 millimeters in diameter. (b) Procedure. The distance to the near point is computed from the base line connect ing the centers of rotation of the eyes. The end of the Prince rule is placed, edge up, at a mark on the right side of the nose, 11.5 millimeters in front of the cornea. The white-headed pin is held 33 centimeters 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 by the ex- aminer fixing his gaze upon the examinee’s glabella, thus observing both eyes at once. The instant one is observed to swing outward or fails to follow the pinhead, 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 ob- tained. To this reading 25 millimeters are added, which will give approximately the distance from the near point of convergence to the base line (PcB). (c) 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. The pin should be carried in toward the nose at a moderate speed. Frequent repetition usually tires the muscles and gives erroneous findings. The near point of convergence, unlike the near point of accommodation, varies little with age. (2) Interpupillary distance (Pd). (a) Equipment. A millimeter rule. (b) 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 examin- nee’s nose in line with his pupils, as close to the two eyes as possible. The exami- ner 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. (3) For Classes 1 and 2 the distance from the baesllne to the near point of convergence (PcB) must not exceed the interpupillary distance (Pd) by more than 25 mm. Test is omitted in Class 3 . j. Central color vision. %1) Equipment. The Ishihara or American Optical Company books of Pseudo-Isochro- matic plates for testing color vision defects and either a set of Holmgren yarns or the School of Aviation Medicine (S.A.M.) color test lantern. (2) Procedure. The purpose of the test is to determine into which of four groups the applicant belongs. These are: (a) normal color perception; (b) defective color percep- tion but considered “safe for aircrew” duty; (c) defective color perception, “unsafe for aircrew” duty who can “distinguish pure red and pure green V(d) disqualified for all flying duty. All applicants are first examined by reading the Ishihara or A.O.C. plates. They should be exposed only in daylight (not bright sunlight) and only three to four seconds per plate should be allowed. Persons with normal color perception and mental alert- ness can easily read the plates in that length of time. Instructions accompanying the test are to be followed strictly. A.O.C. plates Nos. 39, 40, 43, and 44 are not used and may be removed. If no plates are incorrectly interpreted the candidate is considered to have normal color perception and no further color test is given. If he misses more than 25% of the plates he is considered unsafe for air crew and is disqualified. If he misses 25% of the plates or less he is given an adjunct test with the S.A.M. lantern or Holmgren yarns. Adjunct Test with S.A.M. lantern: (a) The examinee is given an ordinary writing pad and pencil, told to write his name, the date and series 1 at the top of the page, (b) He is then seated in a dark room 15 to 20 minutes to permit dark adaptation. (c) A small light (a well shaded standard 7.5 watt light) is turned on above and behind him. This gives barely enough light to write without disturbing the test itself. (d) The examinee is instructed by the examiner as follows: “You will see a total of 18 different colored lights. As each light is shown, I will call out a number. These numbers are not in sequence. You are to write the number on the pad and next to it the color you believe that light to be. It is unnecessary to qualify the color as being light or dark, merely state the name of the color. Five seconds will be allowed for each one.” (e) The examiner who holds the instrument stands 20 feet away (the examiner can safely be any trained and alert enlisted man.) He reads the numbers seen in the mirror' at the top of the instrument which is directed at the individual tested, or the middle of the group if more than one is being tested. The disks can be turned so that all the numbers are read as they come. No filter is used for the first series and the one-quarter inch aperture is used at all times. A different starting point is used each time. (f) After the first series has been run the examinee is instructed to turn the page over and write on the top, Series 2. The neutral filter is then interposed, which dup- licates the effect of haze, rain, etc., quite closely. The entire procedure is repeated. (g) The papers are then collected immediately and the written record compared to a key. This should be done by an officer, but a trained enlisted man will be able to do this equally well. (h) CAUTION: The examiner must ascertain that the batteries in the lantern are fully charged before each test, and that the colors are clearly perceptible. (i) When the S.A.M. lantern is not available the Holmgren test wools will be employed and the test will be conducted in accordance with instructions contained in Section XVHI TM 8-300. (3) Precuations. The Ishihara and Stillings plates and the skeins of yarn should be kept in darkness when not actually in use. Care must be taken that the plates and skeins of yarn do not become soiled or stained in handling. Where memorizing the plates may be suspected, plates involving tracing of a tract will be of particular value. The small numerals giving the plates numbers should be covered with an opaque card. The exam- ination must be conducted in daylight, preferably a north light. (4) Interpretation. (a) Applicants for appointment as commissioned officers in the Army of the United States will be required to meet the basic requirements of AR 40-105. (b) Applicants for flying training who correctly interpret all the plates of the test books mentioned above will be recorded as having “normal” central color vision (corresponds to first group - 31j_(2)a. above). (c) Applicants for flying training who incorrectly interpret 1 to 25% of the plates in the color vision books will be recorded as “misses 3 A.O.” or “misses 3 Ish.” referring to the number of plates missed and the book used. (d) Those who correctly interpret less than 75% of the plates in the test books will be recorded as “fails Ishihara” or “fails A.O.” and are disqualified for any type of flying training. (e) Aviation cadets undergoing classification and personnel, commissioned or enlist- ed, undergoing flying training in grade who are found to have defective binocular central color perception, as indicated by having incorrectly interpreted more than 25% of the plates of the color test book, will be subjected to further color vision tests, as directed by the Commanding General, AAF (as outlined under j Adjunct Test with S.A.M. lantern above.) Applicants who are considered “unsafe ’ will be recommended for elimination from further flying training. k. Field of vision for form. Peripheral vision for form will be determined by the use of the confrontation test on all examinations. (1) Equipment. A 1 cm. white sphere with a black wire handle of appropriate length or, if not available, an ordinary wooden applicator may be substituted as a handle. (2) Procedure. The examiner faces the examinee about two feet away. He instructs the examinee to close his left eye and fix his right eye on the examiner’s left eye. (The examiner’s right eye being closed). He brings in from the periphery a white ball 1 cm. In diameter on the end of a dark wire. The examinee states when he first sees the object. If it is brought in from the periphery at a point midway between the exam- iner and the examinee they should both see the object at the same time. This is true in all meridians except directly temporal. In that meridian the test object should be brought out slowly from a position peripherally and behind the examinee until he sees the object. This is necessary because of the fact that the visual field extends to 90 degrees at the temporal side and the examinee should see the object when it is brought forward to a point corresponding to the 90 degree tangent from the eye. (3) Precautions. The test object should be approximately 1 cm. in diameter and should be attached to a slender blac k rod of such a length that the hand is not seen in moving it. The eye being examined must not be permitted to shift fixation. The test object must be clean and wen-illuminated. (4) Interpretation. The normal field for form extends temporally 90° or more; super- iorly 50°; nasaHy 55°; interiorly 65°. Any contraction of the visual field for form of 15° or more in any meridian disqualifies for flying unless the contraction is the result of the anatomic conformation of the examinee’s face. Other pathological changes of the visual field disqualify for flying (scotomata, nasal contraction, etc.). If scotomata are suspected, they wiH be mapped on a tangent screen at 75 cm. Scotomata other than the normal blind spot are disqualifying. This standard applies to all three classes. The test is then repeated for the left eye. Should any abnormality be detected, the more detailed examination with a perimeter is indicated. Any apparent scotomata should be outlined with the perimeter or on the blackboard or tangent screen at 75 cent- imeters. 1. Summary of steps in refraction. (1) Cycloplegla is obtained by using 5% homatropine, instilling 2 drops at 5-minute intervals and waiting about an hour. (2) The examinee should be seated comfortably with the trial frame or phorometer ad- justed so that: (a) The visual axis is in the center of the lens aperture. (b) The lenses are near the point 15.7 mm. anterior to the cornea. (c) The lenses are in a plane at right angles to the visual axis (tilting of spherical lenses Induces cylindrical effect). (3) The working lens (preferably a + 1.50) is inserted in the back cell of the trial frame or phorometer. The examiner should be seated comfortably so that his eye is the pro- per distance from the eye of the examinee. (66 cm. or 27 inches if + 1.50 working lens is used). This distance should be determined in relation to the examiner’s reach. (4) It is considered good practice to cover one of the examinee’s eyes. (5) If complete cycloplegla has been obtained, it is safe to have the examinee fix on the examiner’s forehead above the retinoscope. If, however, as is often the case, cyclo- plegla is not complete, it is safer to have the examinee look just past the examiner’s head and fix on an object 20 feet away. In this way the tendency of the examinee to ac- commodate for the near point is avoided. Retinoscopy of the patient’s right eye with the examiner’s right eye and of the patient’s left eye with the examiner’s left eye is then done. It is important that the object fixed be seen just past the examiner’s head, as this enables retinoscopy of the portion of the retina near the macula, and will give a more accurate reading than retinoscopy of an area farther away from the visual axis. (6) The character of the light reflex is noted. (a) Color. While by no means an absolute rule, in general, a pearly white color sug- gests an error of more than + or - one diopter. If the reflex is orange, it suggests less than a + or - one diopter error. The dull red central portion of the reflex should be noted as the end point is approached. This dull red central reflex moves “with” while the peripheral portion of the light reflex moves‘against’.’ The dull red central reflex not more than 2 mm. in diameter is the diagnostic portion of the reflex. The peripheral portion should be ignored. (b) Shape of light reflex. If the reflex is round or nearly so, it indicates a single plus or minus spherical correction. If the reflex is oval, there is generally a small cy- lindrical error with axis the same as the greatest diameter of the oval. If a “band” is seen, this usually indicates the presence of astigmatism in that eye and the axis of the correcting cylinder is the same as the axis of the “band”. (c) Direction of motion. Motion of the reflex in the same direction as the move- ment of the retinoscope light is called a “with” movement. In this instance, plus lenses are used to reach the end point. If the light reflex moves opposite to the mo- tion of the retinoscope light, it is called an “against” motion and minus lenses are used. (d) Speed of movement. As the end point is aproached, the speed of the light reflex increases so the retinoscope must be rotated much more slowly. Failure to observe this will occasionally result in underestimation of errors. (7) Spherical lenses are generally used in neutralizing the movement of the light re- flex. It should be remembered that a spherical lens may be considered as being com- posed of two equal cylindrical lenses combined at right angles. In using a spherical lens, properly centered, one of these two cylindrical components is neutralized at a time. It is easier to use than two cylinders, or than a sphere and a cylinder, because slight deviations of axis may cause some confusion. However, the use, by experienced refractionists, of a sphere to neutralize the weaker meridian, with a cylinder added'Uo neutralize the stronger meridian, will be found very useful. It should not be attempted by beginners. (8) If the retinoscope is always rotated about its long axis, the meridian of the eye be- ing refracted will be corrected by a cylinder placed in the same axis as the retinoscope handle. For example, if the handle of the retinoscope is vertical, rotation of the head around this vertical axis causes the beam of light to move from side to side. The direc- tion of motion of the light reflex is horizontal and is observed to be either “with” or “against”. If the motion is “with”, plus lenses are added until it is noted that there is an “against” motion of the central portion of the reflex. This is the end point for prac- tical purposes. This then neutralizes a cylinder whose axis is at 90°. (The same as the axis of the retinoscope handle). The handle should be then turned 90° and the value of the cylinder at 180° determined. (9) The working lens is now removed and the formula obtained by the use of the two cylinders found above should be placed before the eye. (10) If cycloplegia has been complete, the findings on retinoscopy should be the same as the lens with which the patient can see best under cycloplegia. m. Ophthalmoscopic examination. The examination of the media and fundi of the eyes routinely follows refraction on the original examination, while the pupil is widely dilated and accommodation completely relaxed. (1) Equipment. Ophthalmoscope, preferably electric, and in instances where cyclople- gia and mydriasis have not been induced for purposes of refraction, 5 percent homatro- pine solution or 4 percent euphthalmin solution. The latter solution has the advantage of having a transient effect and is particularly desirable for use in the examination of individuals past 40 years of age. (2) Procedure. The examination should be conducted in the dark room and with pupils dilated. Where homatropine has not already been used, the euphthalmin solution may be instilled, one drop every 10 minutes until dilatation occurs. The direct method of ophthalmoscopy ’should be employed routinely and the indirect method utilized when circumstances permit and the examiner is familiar with its technique. The examiner should wear his correction for ametropia. The fundus of each eye is examined thor- oughly and any abnormality of the disk, the blood vessels, the retina, and the choroid noted. By the interposition of plus spherical lenses in the aperture of the ophthalmo- scope,the media, the lens, and the iris may be examined. (3) Precautions. In the examination of the macular region the illumination of the oph- thalmoscope should be reduced and the exposure made as brief as possible. The exa- minee should be advised to wear smoked lenses until the effects of the mydriatic have disappeared. The use of a miotic, as eserine salicylate, 1/2 percent solution, one drop in each eye repeated once after 10 minutes, is advisable upon completion of the exam- ination. (4) Interpretation of findings. Any abnormality, as may be discovered by the ophthal- moscopic examination, that materially interferes with the normal ocular function dis- qualifies for all three classes, Attention is invited to the fact that pathological con- CLASS 1 2 3 VISUAL ACUITY 20/20 20/4.0 CORRECTIBLE TO 20/20 20/100 CORRECTIBLE TO 20/20 DEPTH PERCEPTION 30 MAXIMUM 35 MAXIMUM WITH CORRECTION OMITTED HETEROPHORIA ESO 10 MAXIMUM 12 MAXIMUM EXO 5 MAXIMUM 7 MAXIMUM HIPER 1 MAXIMUM 2 MAXIMUM PRISM DIVERGENCE 3 TO 15, INCLUSIVE. P.D. MUST EQUAL OR EXCEED ESO OMITTED RED LENS TEST NO DIPLOPIA OR SUPPRESSION WITHIN 50 CM. OMITTED ROUTINELY COMMAND & SERVICE PILOTS: NO DIPLOPIA WITHIN 27.3 CM. POWER OF CONVERGENCE PcB MUST NOT TEXCEED Pd BY MORE THAN 25 MM. OMITTED ACCOMMODATION —NOT" LESSTEHTHIHIRDH FOR AGE (SEE TABLE IX) GLASS I STANDARDS OR J-l AT 50 CM. WITH CORRECTION COLOR VISION ORIGINAL EXAMINATION: ERRORS IN ISHIHARA OR A.O. MAY NOT EXCEED 25% SUBSEQUENT EXAMINATIONS; ADJUNCTIVE TEST WHEN ERRORS EXCEED 25% FIELD OF FORM CONTRACTION OF 15° OR MORE IN ANY MERIDIAN DISQUALIFIES. SCOTOMATA DISQUALIFY. (NORMAL LIMITS OF FIELD: UP 50° , TEMPORALLY 90° , DOWN 65° , NASALLY 55°) REFRACTION (WHEN INDICATED) ORIGINAL EXAMINATION; NOT MORE THAN 1.5 D IN ANY MERIDIAN; NOT MORE THAN 0.5 D CYLINDER. TABLE X. MINIMAL VISUAL REQUIREMENTS, FLYING PERSONNEL, BY CLASSES (APRIL 30, 19A3). 41 ditions of the retina and choroid are most frequently indicative of extraocular or sy- stemic disease. Particular attention should be paid to the ophthalmoscopic examina- tion of individuals past midlife, where arteriosclerosis may be suspected or where there is a history of rheumatic or of focal infection as dental foci and chronic disease of the nasal accessory sinuses. Repeated ophthalmoscopic examination is indicated following head injury with fracture, concussion, or period of unconsciousness other than momentary. Any abnormality found is to be classified and described accurately, and where possible substantiated by subjective findings (visual field defects, reduction in visual acuity, etc.). Lenticular opacities should be described as to appearance, location, and interference with function. 33. MINIMAL VISUAL REQUIREMENTS FOR FLYING PERSONNEL See Table X. 34. VISUAL REQUIREMENTS; ALL BRANCHES. See Table XI 35. IMPROVISED EQUIPMENT FOR CONDUCTING THE EYE EXAMINATION FOR FLY- ING. Under present wartime conditions it is often necessary to conduct physical ex- aminations without the use of regular equipment. While this is not desirable, it may at times be necessary to improvise such equipment, a. Visual acuity. For testing visual acuity a card of Snellen Test letters may be used if procurable. This should be illuminated by 7-10 ft. candles of light. This will be ob- tained by use of a 100-watt daylight lamp placed about 4 ft. above and 4 ft. in front of the chart. The lamp must be shaded so that none of the light from the lamp passes directly to the examinee s eyes. If no test card is available one can be made. Each letter should subtend an angle of 5 minutes. Each portion of the letter should subtend an angle of 1 minute. One minute angles are subtended by lines of the following widths of the indicated dis- tances: 200 ft. - 18.3 m m 100 ft. - 9.1 m m 70 ft. - 6.4 m m 50 ft. - 4.6 m m 40 ft. - 3.7 m m 30 ft. - 2.7 m m 25 ft. - 2.3 m m 20 ft. - 1,8 m m 15 ft. - 1.4 m m b. Depth Perception. The Howard-Dolman Depth Perception apparatus can be built by a local carpenter or metal worker (see Figure 8). If fluorescent lighting is not available, the box may be left open on top and illuminated by a reflector placed above the apparatus in such a way that no light is permitted to go directly back to the examinee (100 watt light 4 ft. above and in front of the instrument). The illumination of the apparatus must be chiefly direct against the white background at the back of the box. The rods must be evenly illuminated and should show no variation in light intensity as they are moved back and forth. This may be assisted by painting the rods with a good grade of very flat black paint. c. Heterophoria Tests. (1) Muscle Test Light. If no test cabinet is available which has the regulation sized (1-1/2 cm) spot of light, a flashlight head can be covered with adhesive tape leaving only a hole this size through which light can emerge. If an American Optical Co. Projecto-Chart is available it can be modified to give this type of spot also. The hole now in the slide is too large and it projects too large a spot of light on the screen. If a hole is drilled in the slide 3/4 mm. in diameter (using a dental drill) placed 1/2 inch beyond the present hole in the slide, a very satisfactory spotlight will be project- ed on the screen. It will be approximately 1 cm. in diameter and will be found most satisfactory for muscle balance testing. A Maddox rod can be made by placing a glass Aviation Cadet Applicants (when facilities for "64" exam not available) Aviation Cadet at Classification Center Air Crew Pilot, Bombar- dier, Navigator Ground Duty Armament, Heterology, Ehgineering, Photography, etc. Pilot, Bombardier, Bombardier-Navigator Navigator Student Officers Visual Acuity 20/20 20/100 corr. to 20/20 in one eye and 20/30 in other. No organic disease 20/20 20/40 corn, to 20/20 by glasses worn while fly- ing 20/20 Depth perception Not required Not required 30 mm Defective depth perception may be waived 30 mm Heterophoria 6 M Not required Not required Class 1 Defective muscle balance may be waived Class 1 Color vision Pseudo-isochro- matic plates 75% to 100% correct Recognize vivid red and vivid green Pseudo-isochro- matic plates 75% to 100% correct or less than 75% correct and color 'Safe' ty SAM lantern or Holm- gren yarn. Same as pilot and bombardier' Same as pilot and bombardier Refraction Only if indi- cated If indicated by defective visual acuity, etc. Only if indicated If visual acuity- less than 20/20 Only if Indicated Jaeger Req. J-l-13 J-l-13 J-l-13 J-l-13 J-l-13 Form 64 63 64 64 64 TABLE II. - ETE REQUIREMENTS ( APRIL 30, 1943 ) 43 Applicants for En- listment MR 1-9 Commission in Regular Army, except Medical Department, Chaplain, JAGD Commission in Regular Amy in Medical Depart- ment, Chaplain, JAGD only Commission in 0RC, all branches NG, and for Federal recognition Visual Acuity General military ser- vice in all arms and services: 20/200 each eye correctible to 20//+0 in either eye / no organic disease. Limited services 20/400 bilateral correctible to 20/40 in each eye, or non-progressive blindness in one eye with 20/100 correctible to 20/20 in other eye. 20/40 correctible to 20/20 in one eye and 20/30 in the other 20/100 in each eye correctible to 20/20 in one eye and 20/30 in the other when no organic disease exists. 2-/100 in each eye correctible to 20/20 in one eye and 20/30 in the other Depth Perception Not required Not required Not required Not required Color vision Not required Distinguish vivid red and vidid green Distinguish vivid red and vivid green Distinguish vivid red and vivid green Refraction Not required Not required if vision satisfactory Not required if vision satisfactory No*t required if visual acuity satisfactory TABLE II. - EIE REQUIREMENTS (APRIL 30, 1943) (CONT'D) 44 Flying Personnel Civilian Flying Instructors Combat Crews Aircraft Observer Non-Rated and Technical Observer Control Tower Operator Visual Acuity Class 1 - 20/20 Class 2 - 20/A0 corn, to 20/20 Class 3 - 20/100 corr. to 20/20 20/50 corr. to 20/20 bilateral 20/20 - If already trained, local C.O. can give waiver for 20/4.C corr. 20/20 bilateral 20/20 20/100 corr. to 20/20 bilateral Vision corr, to 20/2C bilateral Depth Perception Class 1 - 30 mm Class 2 - 35 nun Class 3 - not done except for Command pilots - 35 nun 35 mm 30 mm If al- ready trained, local C.O. can give waiver to 35 mm 30 mm Not required Not required Heterophoria 6 M Class 1) See mini- Class 2) mal visual Class 3) requirements Table X Class 2 Class 1 - If already trained, local C.O. can give waiver to Class 2 Class 1 Class 3 Not required Color vision Pseudo-Isochromatic plates 75$ to 100$ correct. Pseudo-Isochromatic plates 75% to 100% correct. Pseudo-Isochro- matic plates 75% to 100$ correct. Pseudo-Isochromatic plates 75% to 100$ correct. Pseudo-Isochromatic plates 75$ to 100$ correct. Recognition without con- fusion of true red and true green Refraction Only if indicated Only if indicated Only if indi- cated Only if indicated Only if indicated Only if indi- cated TABLE XI. - ETE REQUIREMENTS (APRIL 30, 19A3) (CONT’D) 45 Applicants for West Point Liaison Pilot Service Pilot Parachute Troops Visual Acuity 20/30 bilateral corr. to 20/20 bilateral 20/A0 corr. to 20/20 bilateral 20/100 corr. to 20/20 bilateral 20/AO uncorr. bilateral Depth Perception Not required 35 m.m. Class 1, 2, or 3 Not required Heterophoria 6 M Disqualified by Eso. more than 10 diopters; Exo. more than 5 diopters; Hyper, more than 1 diopter Class 1 and 2 Class 1, 2, or 3 Not tested Color vision Distinguish pure red and pure green Pseudo-Isochromatic plates 75$ to 100$ correct. Pseudo-Isochromatic plates 75$ to 100$ correct. Recognize pure red and pure green Refraction If indicated - Disqual- ified if board feels error excessive. Dis- qualified by more than 2 D in any meridian or myopia more than .75 any meridian Only if indicated Only if indicated If indicated TABLE XI. - EIE REQUIREMENTS (APRIL 30, 1943) stirring rod over a hole in a card, so that no light can reach the eye around the outside of the stirring rod. This rod, placed before the eye, will give a satisfactory line of light at right angles to its long axis. A chart is made on a piece of cardboard or wall board approximately one meter square. In the center of the cardboard a hole 1/2 to 1 cm. in diameter is cut. Lines are then drawn on the board as shown in the accompanying sketch, “Heterophoria Test Board” (Figure 5). A light is now placed behind the hole in the center of the board at the end of the 20 ft. dark room. This end of the room is then dimly illuminated so the examinee can see the lines on the board from 20 ft. away. The Maddox rod, constructed from the stirring rod, is placed before the non-fixing eye and the applicant sees a line of light and a dot of light as with the regular test. The number of lines that the line of light is displaced from the dot gives the number of prism diopters of Heterophoria which the patient has in that position. The test will give an inaccurate result if an occluder is not used to cover and uncover the non-fixing eye at several second intervals. This method is recommended only if no phonometer or trial lens case is available. (2) Trial lens case. If a trial lens case is available, this method is better than the above mentioned test. The trial lens frame is placed on the examinee with the Maddox rod in place before the non-fixing eye. A 1/2 to 1 cm. spotlight is turned on at the end of the 20 ft. dark room. Loose prisms are then inserted into the trial frame until the line of light bisects the spot of light. (Interruption of the vision of the non-sighting eye with an occluder is essential). The amount of phoria is equal to the prism strength re- quired to place the line of light through the dot of light. Prism divergence may also be estimated with the use of loose prisms, but this me- thod is recommended only if a phonometer is not available. Any existing phorias are first determined using loose prisms. The examinee is directed to fix the muscle light with both eyes. A 3 D loose prism is placed base in before one eye (if esophoria) of more than 3D exists, the power of the loose prism must equal the amount of esopho- ria). The examinee is qualified for Class 1 or 2 if he can overcome diplopia through divergence. If he is unable to overcome a prism of this strength, a prism is selected the power of which is 2 D (or 1 D less than the existing esophoria). If the examinee is able to overcome a prism of this strength, a 1 D prism base in is superimposed on the first, thus creating a combined prism of at least 3 D. Care must be taken not to in- terrupt vision in superimposing the second prism. If the examinee is able to overcome the combined prism, he is qualified. A combined prism of a strength of 15 D,is placed base in before one eye. If the ex- aminee is able to overcome diplopia, he is disqualified for class 1 or 2. A quicker method of determining the phorias with loose prisms consists in using a prism table to determine the power of a prism rotated base in or out in the following manner: The sighting eye is determined in the usual way. The trial frame is carefully ad- justed to the examinee’s face. Special care should be taken to see that the frame is level. The Maddox rod is placed in the posterior fixed cell of the frame before the non-sighting eye. Prisms are placed in the anterior rotating cell. Vertial phorias. Place a 2 D prism base 180° (or 5 D prism if vertical phoria ex - ceeds 2 D). Instruct examinee to rotate prism by turning the adjustment screw on the trial frame until the light streak bisects the point of light. The position of the base of the prism is noted on the degree scale of the trial frame, as well as its relation to the horizontal base line, whether base up or down. If the marker at the base of the prism is brought to rest off the degree scale, reverse the prism in the cell of the trial frame. Vertical equivalents are determined from the table of “Vertical Equivalents of Obliqu- ely Placed Prisms,’’below. VERTICAL EQUIVALENTS OF OBLIQUELY PLACED PRISMS 2 Diopters Prism 0° - 0 diopter -180° 14° - 0.5 diopter - 166° 30° - 1.0 diopter -150° 48° - 1.5 diopter -132° 5 Diopters Prism 0° - 0 diopter - 180° 6° - 0.5 diopter - 174° ISP - 1.0 diopter - 168° 18°- 1.5 diopter - 162° HETEROPHORIA TEST BOARD LINES ABOUT ICM WIDE. SPA'CED 6 CM FROM CENTER OF HOLE TO CENTER OF FIRST LINE IN EACH DIRECTION LINES 6 CM APART - (CENTER TO CENTER) (BY PLACING AN ARROW BELOW THE BOARD IT CAN BE USED AS A TEST TO DETERMINE PRISMATIC POWER AT 20 FEET EACH LINE THE ARROW IS DISPLACED REPRESENTS I PRISM DIOPTER.) FIGURE 5 VERTICAL EQUIVALENTS OF OBLIQUELY PLACED PRISMS (CONTD.) 2 Diopters Prism 30° - 2.C dionters - 90° 5 Diopters Prism 24° - 2.0 diopters - 156° 3CP - 2.5 diopters - 150° - 3.0 diopters - 143° 44° - 3.5 diopters - 136° 5SP - 4.0 diopters - 127° 64° - 4.5 diopters - 116° 9CP - 5.0 diopters - 90° Horizontal phorias. Place a 5 D prism base 90° (or a 10 D prism if phoria exceeds 5D.) Instruct the examinee to rotate the prism until the vertical streak bisects the point of light. Note the position of the base of the prism on the degree scale of the trial frame, as well as its position in relation to the vertical, whether base in or out. If the marker at the base of the prism is brought to rest off the degree scale, reverse the prism in its cell and repeat. Horizontal equivalents are determined from the table, “Horizontal Equivalents of Obliquely Placed Prisms.” Thus, if an examinee were being checked for his horizontal phoria and turned a 5 diopter prism base out to 60° (prism before left eye), he would have referring to the table below) an esophoria of 2.5 diopters. HORIZONTAL EQUIVALENTS OF OBLIQUELY PLACED PRISMS 5 Diopter Prism 90° - 0 diopter - 90° 84° - 0.5 diopter - 96° 78° - 1.0 diopter - 102° 72° - 1.5 diopter - 108° 66° - 2.0 diopters - 114° 60° - 2.5 diopters - 120° 53° - 3.0 diopters- 127° 46° - 3.5 diopters- 134° 37° - 4.0 diopters - 141° 26° - 4.5 diopters - 154° 0° - 5.0 diopters- 180° 10 Diopter Prism 90° - 0 diopter - 90° 87° - 0.5 diopter - 93° 84° - 1.0 diopter - 96° 78° - 2.0 diopters - 102° 72° - 3.0 diopters - 108° 66° - 4.0 diopters - 114° 60° - 5.0 diopters - 120° 53° - 6.0 diopters - 127° 46° - 7.0 diopters- 134° 37° - 8.0 diopters - 141° 26° - 9.0 diopters - 154° 0° - 10.0 diopters- 180° d. Red lens test. An improvised lens for this test can be made from a tail light lens ground smooth and mounted in one side of a pair of large sun glass frames. The other lens is entirely removed from the sun glasses. This gives a large, unobstructed field of vision and even if other equipment is available, will be found most satisfactory, e. Power of Convergence. The angle of convergence need no longer be calculated ac- cording to existing regulation. A candidate may be qualified on the relation of the PcB and Pd alone. If PcB minus Pd = 25 mm or less, the candidate may be qualified. In the absence of a Prince Rule, the PcB and pupillary distance may be accurately mea- sured with an ordinary ruler graduated in centimeters or inches. A centimeter rule may be used in exactly the same manner as a Prince rule, and the angle similarly computed. If an inch ruler is used, the PcB and Pd expressed in centimeters are obtained by mul- tiplying the distances in inches by the factor 2.54. f. Accommodation. (1) The accommodative power may be easily determined even if no Prince Rule is available. An ordinary Jaeger card, used in lieu of the usual mounted type card, is carried away from the eye until the J-l type is correctly read by the examinee. The distance from the anterior focus of the eye (15.7 mm. in front of the cornea) to the point at which the type is first read is measured and noted. One of the following formulae is used to determine accommodative power in diopters: 40 = Power in diopters Inches 100 = Power in diopters CM A substitute for the Prince Rule is easily constructed by pasting on a centimeter or inch ruler a scale graduated in diopters according to the following table. In conducting the examination the zero end of the rule is placed at the anterior focus of the eye (15.7 mm. in front of the cornea). CM Diopters Inches 5.0 = 20.0 D = 2 5.5 18.0 D 2 1/8 6.3 16.0 D 2 1/2 6.7 15.0 D 2 5/8 7.1 14.0 D 2 13/16 7.7 13.0 D 3 8.3 12.0 D 3 1/4 9.1 11.0 D 3 9/16 10 10.0 D 3 15/16 10.5 9.5 D v 4 1/8 11.1 9.0 D 4 3/8 11.8 8.5 D 4 5/8 12.5 8.0 D 4 7/8 13.3 7.5 D 5 3/16 14.3 7.0 D 5 5/8 15.4 6.5 D 6 1/8 16.7 6.0 D 6 5/8 18.2 5.5 D 7 1/8 20 5.0 D 7 7/8 22.2 4.5 D 8 11/16 25 4.0 D 9 13/16 28.6 3.5 D 11 5/16 33.3 3.0 D 13 1/8 40 2.5 D 15 11/16 44.4 2.25 D 17 1/2 50 2.0 D 19 11/16 66.7 1.5 D 26 5/16 100 1 D 39 3/8 (2) The approximate additional lens power required for near vision in older pilots is listed as follows: Age Reading Diets 13 Inches mce Desired 16 inches 45 + 1,00 + .50 50 + 1.50 + 1.00 55 + 2.25 + 1.75 60 + 3.00 + 2.50 36, PRIMARY DIFFERENTIAL DIAGNOSTIC POINTS IN NYSTAGMUS. See Table XU 37. ACTION OF EYE MUSCLES. See Table XIII and Figures 6 and 7. TABLE III- PRIMARY DIFFERENTIAL DIAGNOSTIC POINTS IN NYSTAGMUS Visual Acuity Slow and quick Component Occurs only in extreme positions Occurs in any position Accompanied by vertigo, nausea, vomiting, past pointing, etc. Physiological Nystagmus Not diagnostic Yes Yes No No Ocular Nystagmus Much im- paired central vision No No When attempt- ing to see ob- jects No Nystagmoid movements due to extra ocular muscle paralysis Not diagnostic As a rule Only in ex- treme posi- tion in field of action of paralyzed muscle No No Central nystag- mus (lesion of C. N. S.) Not diagnostic As a rule, but not al- ways No Yes Not as a rule Labyrinthine Nystagmus Not diagnostic Yes No Yes Yes TABLE xm. - ACTION OF EYE MUSCLES - (PETER) Tables of Primary and Subsidiary Actions of Individual Ocular Muscles Muscle Primary Action Subsidiary Action Internal Rectus Internal Rotation None External Rectus External Rotation None Superior Rectus* Elevation Internal Rotation, Intorsion Inferior Rectus Depression Internal Rotation, Extorsion Superior Oblique Intorsion Depression, Exter- nal Rotation Inferior Oblique Extorsion Elevation, External Rotation FIGURE 6. - DIAGRAM OF ACTION OF INDIVIDUAL EYE MUSCLES IN SIX CARDINAL DIRECTIONS FROM EYE FRONT - (PETER) (Facing the patient) FIGURE 7. - DIAGRAM SHOWING CONJUGATE (YOKE) ACTION OF EX- TRINSIC OCULAR MUSCLES IN BINOCULAR MOVEMENTS - (PETER) 38. A WHEEL-CONTROLLED DEPTH PERCEPTION APPARATUS. (See Figure 8). The apparatus described below wiU be found of value in that the use of the ordinary ad- justment cords is eliminated and in the convenience of having scale at the examiner’s end of the eye lane. Floor construction. Measurements, 12 Inches x 32 inches. Fixed rod placed 20 inches behind front end of box. Movable rod is fixed in a wooden block, which slides in a groove made of metal or wooden strips. Block is moved by light airplane cable passing through a pulley system, as indicated in the diagram. Rods are 11 inches long, 1 cm in diameter and 64 mm apart, painted flat black. Millimeter scale, 150 - 0 - 150 mm, is placed alongside the movable rod. Roof construction. Illumination is providecfby two light tubes, preferably 24 inches daylight fluorescent, fixed to the roof of the box. Tubes should be placed as far forward as possible and in the long axis of the box, in order to provide uniform illumination upon the rods. Rear screen. Covered with white unglazed paper. Wheel construction. Solid round wheel affixed to wall in position convenient to the examinee’s chair. The chair is placed in position directly in front of the depth percep- tion apparatus. The lower cable is wound several times about the hub of the wheel, and passes around a wheel fixed to the wall behind the examinee’s chair. Reading scale. A millimeter scale is affixed to the wall beneath the upper cable. Rod positions are indicated by a marker attached to the cable. The scale is concealed from the examinee by placing it behind his chair or by placing it in a deeply gropved block. 39. DARK ROOM TABLE. Plans for a control cabinet for use in the eye room for con- ducting examinations for flying are appended (Figures 9 and 10). This table has switches on it to control all electrical equipment used, including over- head light, projecto-chart, depth perception apparatus, muscle test spot light, and trans- former switch for ophthalmoscope and retinoscope. The bottom switch on the panel controls the input to the transformer which is located inside the table. The transformer is reached through the small door at the end of the table, as shown, and the cord to the instrument is brought out through the hole adjacent to the door. The four other switches are connected to four single outlets in the back of the cabinet. In this way, the table can be connected to drop cords which, in turn, are connected to the items of electrical equipment to be controHed. If it is desired at a later date to change the equipment or to add other items, it is only necessary to pull out the plug and insert the plug attached to the new item. By attaching in this fashion, the table can be made movable for a distance of three or four feet, which has been found to be very convenient when doing refractions. When the vision test cabinet with eight button control box is in use, this box can be mounted directly on the face of the table as shown. When a reading scale on the wall near the examinee is being used in depth perception tests, this wall light may be wired so it will turn on when the depth perception apparatus is turned on. The trial lenses are removed in the tray from the box in which they usually are issued. This tray is set into the frame formed of one-quarter rounds. Since this frame is on a sloping surface, the lenses are easily seen with the examiner either sitting or standing. The lenses are illuminated by either a small night light or a flexible neck lamp attached to the tables. This light does not interfere with retinoscopy. When not in use, the lenses are covered by a towel. The shelf on the table is wide enough to use in filling out forms or recording refrac- tion findings. The drawer holds Jaeger cards, flashlight, ophthalmoscope, retinoscope, occluder, card for determination of sighting eye, blank forms, and other equipment. The table should be made of plywood to be of light weight and mounted on large size casters so that it can be freely moved. APPARATUS IN PLACE LEFT WALL REMOVED RODS: II INCHES LONG, SEPARATED BY 64MM. center to center j 10 mm. In diameter FIGURE 8 DARK ROOM CONTROL AND EQUIPMENT CABINET. FRONT AND PARTIAL END VIEW. FIGURE 9 55 DARK ROOM CONTROL * EQUIPMENT CABINET. END VIEW TO BE MADE OF NATURAL FINISH VARNISHED PLYWOOD. ELECTRICAL WIRING TO BE DONE TO MEET REQUIREMENTS OF STANDARD ELECTRICAL SAFETY CODES. FIGURE 10 56 40. REFERENCES. a. Manuals. (1) TM 8-300 “Notes on Eye, Ear, Nose, and Throat in Aviation Medicine,” November 26, 1940. b. Regulations. (1) AR 40-105 (October 14, 1942). (2) AR 40-110 (December 3, 1942). (3) MR 1-9 (October 15, 1942), Cl (January 22, 1943), C2 (February 23, 1943). c. Letters. (1) War Department, Hq., A.A.F., Washington, Office of the Air Surgeon, June 16, 1942 Subject: “Determination of Central Color Perception Efficiency.” d. Texts. (1) Peter, Luther C.: The Extra Ocular Muscles, Philadelphia, Lea & Febiger, 1936. (2) Duke-Elder, W. S.: Textbook of Ophthalmology, Vols. I, II, in, St. Louis, C. V. Mosby Co., 1933. (3) Traquair, H. M.: Clinical Perimetry, St. Louis, C. V. Mosby Co., 1938. (4) Duane, A., Fuchs’s Textbook of Ophthalmology, Philadelphia and London, J. B. Lippincott Co., 1917. SECTION m EXAMINATION OF EAR, NOSE AND THROAT Paragraphs Technique of examination of ear, nose, and throat 41 Hearing requirements, all classes 42 Hearing tests 43 Technique for taking X-rays of sinuses and mastoids 44 References 45 41. TECHNIQUE OF EXAMINATION OF EAR, NOSE AND THROAT, a. Nose and Throat. (1) Equipment: Head mirror, lamp, nasal speculum, nasopharyngeal and laryngeal mirror. (2) Methods of Examination. A complete examination by reflected light, will be made of the anterior and posterior nares, the mouth, the pharynx, nasopharynx and the larynx. When considered necessary the use of special instruments, transillumination and stu- dies by X-ray will be employed. (a) Mouth and oro-pharynx. The mouth is ordinarily examined by reflected light using the head mirror and tongue blade. The examination may be performed by flash- light held to illuminate the mouth and oro-pharynx directly. (b) Nose. The nasal speculum and head mirror are used for examination of the an- terior nare . When the speculum is not available suitably fashioned wire loops may be used to dilate the nares. Though usually not satisfactory, the electric otoscope battery handle with the nasal speculum attached may be utilized. In some instances the nasopharyngoscope may be used. (c) Nasopharynx. The examination is best performed with the reflected light of the head mirror and the nasopharyngeal mirror. The usual difficulties encountered with this technique are thick tongue and tense soft palate. Instructing the examinee to con- centrate on breathing or to pant rhythmically will usually relax the tongue, which may then be firmly depressed with the tongue blade into the floor of the mouth. The soft palate may remain tensed and retracted but when the examinee is asked to try to breathe through the nose, the soft palate will relax and drop down toward the fauces and an adequate entry for the mirror will be presented. Instruments may be firmly but gently applied against the mucous membrane of the palate and pharynx but these tissues can rarely be irritated by recurrent contact without eliciting the gag reflex. It is therefore necessary to insert the mirror into the nasopharynx without touching the base of the tongue, soft palate or posterior pharyngeal wall. The instrument may be steadied by resting the handle against the angle of the open mouth or the lower bi- cuspid teeth which serve as a fulcrum or rest for an otherwise tremulous hand. (Figure 11). In some instances it will be necessary to apply topical anesthesia to the soft palate and pharynx and use a soft palate retractor. A rubber catheter may be passed through the nose, recovered in the oropharynx and brought out through the mouth. Traction applied to the two presenting ends, will adequately elevate the soft palate for the pre- sentation of the mirror in the nasopharynx. Though rarely necessary, digital palpa- tion may be employed. When practicable and available, the nasopharyngoscope, which is actually an infant cystoscope, may be inserted through the nares and the nasopharynx examined under the tiny lenses of this instrument. The application of this instrument entails the same difficulties as cystoscopy and requires some familiarity with its use for accurate interpretation. (d) The hypopharynx, larynx and esophagus. Indirect observation with a large mirror is usually employed for this examination. The tongue is extruded and grasped between the thumb and index finger while the mirror is inserted into the mouth and applied gently but firmly against the soft palate with the mirror face directed toward the larynx. The base of the tongue, epiglottis, pyriform sinuses, the glottis and contents, and the mouth of the esophagus may be examined in this manner. In some instances the tongue may be depressed by a tongue blade into the floor of the mouth and the mirror used in a fashion as previously described. (See Figure 11). FIGURE 11 Further examination of the larynx, trachea and the oesophagus is performed with the endoscopic instruments. b. Eustachian Tube. (1) Equipment. Head mirror, aural speculum or electric otoscope, auscultation tube, Politzer bag, and Eustachian catheter. (2) Methods of examination. (a) Valsalva technique. A very necessary part of the examination is the determina- tion of the patency of the Eustachian tubes. This may be accomplished by the Val- salva technique, but should not be used when the examinee has an upper respiratory infection. The test consists of forcing air into the middle ear by a forcible expira- tory effort while the mouth and nose are closed. The examiner observes bulging of the drum, particularly the posterior superior quadrant, to make sure than inflation takes place. (b) Politzer technique. Inflation of the Eustachian tube may be performed by means of the Politzer bag, to which is attached a nose piece to fit the anterior nares. The aural auscultation tube is used to assure the examiner that inflation takes place. One end is inserted in the meatus of the ear under examination and the other end is in- serted in the meatus of the examiner’s ear. The nozzle of the Politzer bag is insert- ed into one nostril, while the opposite nostril is compressed by the operator’s hand. When the examinee swallows or says “K”, the bag is compressed, forcing air into the Eustachian tube and the inflation may be heard by the examiner through the aus- cultation tube. (c) Catheter technique. The use of the Eustachian catheter requires considerably more skill than the previous techniques. To those who are familiar with the technique this method will prove useful, but has resulted in little more than added trauma to the nasopharynx and can be a dangerous procedure in the hands of the inexperienced. c. The ear. (1) Equipment. Head mirror and lamp, ear specula; or, if available electric otoscope. (2) Methods of examination. (a) Objective examination. The external auditory canal is examined by the reflected light of the head mirror and a small coneshaped trumpet, the aural speculum. A small bit of paper or cardboard may be fashioned to the size and shape of a suitable speculum when necessary. Any light reflecting substance may substitute for a head mirror by attaching it to the forehead by tape or bandage. The electric otoscope may be used when available. Accumulated cerumen interfering with a complete view of the canal and tympanic membrane must be removed. This usually may be accomplish- ed by irrigation of the canal with a soap solution. Irrigation of the canal should not be attempted when there exists a perforation of the drum membrane, or history there- of. One should be cautious of using a solution too warm or too cold, either of which might result in unpleasant vestibular disturbances. A solution at body temperature is safe to apply. The nozzle of the syringe is gently inserted just beyond the external auditory meatus which is made receptive by pulling the auricle upward and backward. Holding the nozzle steadily against the postero-superior meatal wall which is formed by a triangle of soft tissue will serve as a fulcrum on which to firmly rest the instru- ment as well as direct the stream over and above the cerumen . The stream, after striking the drum membrane, is then deflected toward the meatus, carrying the ceru- men with it. Where the cerumen is firmly impacted and not removed readily by sim- ple irrigation the canal may be filled with a bland oil and stopped with a cotton plug. Several hours later, or on the following day, irrigation will usually remove the mater- ial. (Figure 12). (b) Subjective examination. Hearing will be tested by the whispered voice and by the audiometer when available. 1. Whispered voice test. Numerals such as 66, 18, 47 and 23 are whispered by the examiner at a distance of 20 feet, using only the air remaining in the lungs at the end of a normal expiration in order to give more uniform intensity. When done correctly as described, an accurate estimation of hearing may be made as the num- bers six and seven represent the high frequency range, while eight and nine repre- sent intermediate frequency and two and four represent the low frequency range. Other numerals and words with sibilants predominant should also be used, so that the examinee does not become familiar with the test numbers. If he misses any group of numbers or words, audiometric examination must be done. 2. Audiometer. The hearing by the audiometer should be done whenever practi- cable. The audiometer furnishes an accurate record of the hearing. Instructions for its use accompany the instrument. The audiometer is not unlike a radio in that among other accessories it has a power switch, a “station selector”,(or frequency selector) ranging in eight or more tones low frequency to high frequency, and a “volume controller intensity control) which is measured on the dial in decibels from 0 to 100. The head phone or ear piece is always connected with the receptor marked “Air Conduction’ . The examinee is then instructed to hold the ear piece firmly to the ear being examined, and to raise his index finger when he is aware of the tone or sound transmitted, and to lower his finger when he no longer hears the sound. The frequency 128 is then selected on the dial and the intensity increased until the sound is heard as indicated by the examinee. Intensity is then decreased until the sound is no longer heard. Again the intensity is increased until the exam- inee’s finger is raised and the reading of the intensity dial is recorded under 128 on the audiogram. This technique is repeated for each frequency on the audiometer up to and including the highest frequency. These are properly recorded on the gram. The performance is repeated for the opposite ear and recorded. A small E or L may be used to represent the right and left ear as designations on the audio- gram. When the audiogram is properly completed and the notations joined by lines, dotted for left and solid for right, a graph will be revealed which shows the hearing level for the various tones tested. Average hearing loss is determined by adding the decibel loss at 512, 1024, 2048, frequencies, dividing by 3 to establish the average decibel loss across that range. The result will be the practical hearing loss for the ear tested. The instrument gives accurate information of the hearing for eight or more tones and is of particular value in determining whether or not a man is enabled to hear radio or telegraph signals of a moderate intensity. It has been found that many ap- parently normal-hearing individuals are unable to hear certain tones, in many cases of the same pitch as the radio signals. The possible danger of missing radio or telegraph signals is a factor which must not be overlooked. In cases of defective hearing found on the whispered voice test or audiometer test, the low conversational voice test will also be given and recorded, d. The labyrinth. (1) The Romberg test is the easiest and simplest method for elicit- ing information concerning the function of the balance mechanism and should always be used in correlation with other findings. The individual stands before the examiner with both feet in contact and eyes closed. Any swaying or tendency to fall is noted. The head is turned to one side, then the other to determine if the position of the head changes the direction of falling. (2) Tests for labyrinthine function: (a) Barany chair. Head 30° forward so that tragus of the ear is on a horizontal plane with the external canthus of the eye. 1. Turn to right (10 times in 20 seconds). Nystagmus to left (10 to 34 seconds, average 26 seconds, is normal). Vertigo to left. P.P and falling to right. 2. Turn to left (10 times in 20 seconds). Nystagmus to right (normally, there should not be a variation of more than 5 se- conds between the two results). P.P and falling to left. 3. Relation of responses to labyrinth and direction of turn: Related to labyrinth stimu- lated after rotation Relation to direction of turn after rotation Nystagmus to same side Vertigo to same side P.P. and falling opposite Opposite Opposite Same FIGURE 12. TABLE XIV. - HEARING REQUIREMENTS, ARMY AIR FORCES (JANUARY 1, 1943) Type of Form Used Hearing Audiometer Examination Whisper Spoken Aviation cadet ap- plicant - aircrew 64 or 63 (and 22 if qualified) 20/20 on "64" 20/20 0*1 "63" Not required on "63". Maximum loss 20 decibels on "64". Aviation cadet ap- plicant - ground iuty 63 (and 21 or 22 if qualified) Not done 20/20 Not required Aviation cadet replacement center (classification aircrew) 64 (and 22 if qualified) 20/20 Not done Required if hear- ing below 20/20 Officer training in grade - air crew 64. 20/20 Not done Required if hear- ing below 20/20 Flying personnel (rated aircrew) 64 Not done 15/20 (Class 2) (Bombardier 20/20, Class 1) When practicable Rated Observer 64 Not done 8/20 (Class 3) Balloon Observer 15/20, Class 2) When practicable Non-rated Observer 64 Not done 8/20 (Class 3) When practicable Service pilot 64 Not done 15/20 (8/20 on recommendation of of CG, AAF) When practicable Glider pilot 64 Not done 15/20 (Class 2) When practicable Combat Crews (enlisted) 64 Not done 20/20 (Local C.O. can waive defects on train- ed or training personnel) When practicable TABLE XIV. - HEARING REQUIREMENTS, ARM! AIR FORCES (JANUARI 1, 1943) (CONT'D) Type of fixamination Form Used Hearing Audiometer Whisper Spoken Applicants for West Point 64 Not done 20/20 Not required Applicants for enlistment MR 1-9 General Service 22 8/15 bila- teral Not required Limited Service 22 5/15 bila- teral, 0/l5 in one, 15/ 15 in other 5/20 bl- lat. or 10/20 one ear, 0/20 in other Not required Candidates for commission in regular army 63 Not done 20/20 NNot required For commission in National Guard and for service with troops in organized Reserve 63 Not done 15/20 one ear, and 20/20 ir other NNot required Limited service officers 63 Not done 5/20 bilat. or i0/20 in one, 0/20 in other Not required Civilian flying instructors iors 64 Not done 15/20 (Class 2) When practicable NOTE* When hearing for whispered voice falls below 20/20, hearing for the spoken voice will be recorded and the audiometer test given when practicable. (b) Caloric test. L 1 cc of ice water placed in right ear canal, nystagmus to the left. (Average nor- mal onset is 30 seconds; average normal duration is 120 seconds). Vertigo to left. P.P. and falling to right. 2. 1 cc of ice water in left ear canal. Nystagmus to right (any significant variation between the two sides should be considered in the interpretation, and correlated with other pertinent information. Vertigo to the right. P.P. and falling to the left. Labyrinthine nystagmus is characteristically rhythmic, with a slow component and a quick component. 42. HEARING REQUIREMENTS. ALL CLASSES. See Table XIV. 43. HEARING TESTS, a. The following are tests lor the auditory function. For interpre- tation, See Table XV. (1) Whispered voice (2) Spoken voice (3) Audiometer (more than 20 decibels loss for 512, 1024, and 2048, is disqualifying for Class 1. For Class 2 and 3 no qualifying standards are set, but qualifications will be based on the results of low conversational voice test.) (4) Rinne' test, AC/BC or Air Conduction with 256 fork "Bone' Conduction (5) Weber - lateralization of sound with 128 fork at hair line of forehead (6) Schwabach - Comparing examiner’s bone conduction with examinee’s bone conduc- tion TABLE XV INTERPRETATION OF HEARING TESTS Test Normal Conduction Deafness Perception Deafness Mixed Deafness Wh. Voice (Stage Wh.) 20/20 Usually less than 20/20 Usually less than 20/20 Usually less than 20/20 Spoken 20/20 Usually less than 20/20 Usually less than 20/20 Usually less than 20/20 Rinne AC greater than BC BC greater than AC AC greater than BC, but diminished AC = BC Weber No latera- lization Lateralized to lesion Away from lesion Varies Schwabach BC same as exam- iner’s BC better than examiner’s BC poorer or same BC poorer or same Audiometer Normal Usually loss of low tones Usually loss of high tones May be general loss 44. TECHNIQUE FOR TAKING X-RAYS OF SINUSES AND MASTOIDS. a. X-ray of sinu- ses (see also TM 8-240). (1) Erect. Fluid level position, showing antra; chin in contact with plate; nose 1 inch away from plate; cone in contact with back of head and directed on a line running above the auricle through the orbit. Exposure, 6-7 seconds at 30 MA and 54 KV. (2) Prone. Chin position for antrum; 1 inch throat stick between teeth; cone in contact with vertex of skull, directed vertically half way between orbit and ear. Exposure, 5 seconds at 30 MA and 54 KV. (3) Prone. Forehead - nose position; slanting board for plate (23°); focus in front of ear; cone contact with head. Exposure, 5 seconds at 30 MA and 54 KV. (4) Lateral view. Side position; cone focused in front of ear at a distance of 28 inches. Exposure. 3/4 seconds at 30 MA and 54 KV. (5) Lateral view of neck. Shoulder against plate; tube 5 ft. distance. Exposure, 1/10 second at 100 MA and 75 KV. b. X-ray of mastoids. (1) Law position. Divide film, right and left on same film, fold ear forward; tip cone 20° toward feet and 10° toward face from behind; cover 1/3 ear lobe with cone in con- tact with temporal and parietal bone. Exposure, 2 seconds at 30 MA and 54 KV. (2) Occipital projection for petrous pyramids. Occiput on plate on slanting board, 23°; tip tube 15° toward feet; central ray through hair line. Exposure, 6 seconds at 30 MA and 54 KV. (3) Chin position for petrous pyramids. Chin on plate; cone tipped 20° toward feet and central ray directed from top of head through external auditory canal. Exposure, 6 seconds at 30 MA and 54 KV. (4) Petrous pyramid through the orbit. Patient on back; central ray through orbit; cone 1 inch from forehead. Exposure, 3 seconds at 30 MA and 54 KV. 45. REFERENCES. a. Texts. (1) Turner, A. L.: Nose, Throat, and Ear, Baltimore, William Wood and Company, 1936 (2) Gleason, E.B.:Nose, Throat, and Ear, Philadelphia and London, W. B. Saunders Company, 1929. (3) Ballenger, H.C.: Otology, Rhinology, Laryngology, Philadelphia, Lea & Febiger, 1940. (4) Ophthalmology and Otolaryngology, Military Surgical Manuals, Nat’l. Research Council, Philadelphia, W.B. Saunders and Company, 1942. (5) Morrison, W.W.: Diseases of the Nose, Throat, and Ear, Philadelphia and London, W. B. Saunders, 1940, b. Regulations. (1) AR 40-110 (December 3, 1942) (2) AR 40-105 (October 14, 1942) (3) AR 40-100 (November 16, 1942) (4) MR 1-9 (March 15, 1942) SECTION IV THE PSYCHOLOGICAL AND NEUROPSYCHIATRIC EXAMINATION Paragraphs General 46 Conduct of examination 47 Unfavorable findings 48 The adaptability rating for military aeronautics 49 References 50 46. GENERAL. The procedures and interpretations of a personality study are equally applicable in original examinations of applicants for flying training, in the examinations of those who come to the flight surgeon for guidance and advice, and in the examination of those who are referred as patients for neuropsychiatric study. Under actual combat con- ditions, and in the theatre of operations, there is reason to suppose that there will be many of the latter two groups, who are unable to make satisfactory adjustments to operational flying and combat. Many of these may not have had the benefit of a complete personality study by a trained examiner at the original examination, and many who have had such bene- fit may be unable to adapt themselves under such circumstances, in the presence of the cumulative effects of the ever-potent agents of fear and anxiety. It is particularly impor- tant that the flight surgeon should be able to make sound recommendations as to the dis- position of personnel so affected on the basis of information he can obtain through a psy- chological evaluation of the individual as a functioning unit. 47. CONDUCT OF EXAMINATION, a. Technique. The interview should be conducted in a quiet, friendly manner in surroundings of privacy and comfort. It is a formal examination informally conducted. The taking of notes, and other writing during the interview is to be discouraged. Abrupt, blunt questioning is uniformly unsuccessful, and questions must be carefully and intelligently worded. No question should be so framed that it will permit a “Yes” or “No” answer. The examiner is attempting to delve into the psychic constitution of the individual, and such an answer definitely blocks amf further approach. The examiner should always attempt to be “en rapport” with the examinee. If a clash of personalities is evident, or becomes apparent, as the examination progresses, it is ad- visable to terminate the interview, and if possible, have some other examiner continue the investigation. Each examiner must approach the personality study with a sympathetic un- derstanding, realizing that with a proper transference, the examinee may lay bare his soul. This is not a responsibility that may be approached lightly, and the medical officer should be definitely aware of the responsibility. During the course of the questioning it is expected that any unusual mental conflicts, morbid fears, phobias, etc., will be elicited. Information should be sought with a view of evaluating the family history, environment during the forma- tive years, intelligence, psychomotor activity and achievement, emotional content, somatic demands, particularly as to evidences of instability and control over these demands, and sociality. To satisfactorily elicit the information suggested above it is necessary for a chronolo- gical life history of the individual to be obtained. The method of doing this will vary some- what from examiner to examiner, but no aspect of the examinee’s life must be ignored, and no time left unaccounted for. During the questioning objective reactions as noted under paragraph c should be observed. b. Suggested inquiries. The list of questions presented here are intended only as a guide, with the thought that they may suggest the type of information to be sought for. Each ex- aminer will, because of his own background, have to develop his own technique. (1) What is your age? The ages of your brothers and sisters? (2) Where did you live as a child: farm, town, city? (3) What was your father’s occupation? (4) Have your parents always lived together? If not, why not? (5) Has there been or is there now any nervous breakdown in your family? (6) Has any member of your family ever been a resident of a mental hospital? (7) Has there been any suicide in your family? (8) Has any member of your family frequently used alcohol excessively? (9) What was the financial status of your home: poor, average, better than average? (10) How old were you when you finished high school? (11) What failures did you have in the grades or in high school? (12) How much college work have you accomplished? (13) What colleges have you attended? (14) What failures have you had in your college work? (15) As a student have you been on the whole: superior, better than average, average, below average? (16) What has been the goal of your education? (17) In what activities did you participate in high school and college aside from academic school work? (18) When did you stop going to school or college? (19) Why did you stop going to school? (20) Who financed your education? (21) What particular skills or ability do you have? (22) What jobs have you had and for how long? (23) How many years and months have you been unemployed since out of school? (24) What hobby do you have? (25) Does anyone have it in for you - a real enemy? (26) During the past five years how many fights have you had? (27) What major disciplinary actions have been taken against you, as expulsion from school, military discipline, civilian arrests? (28) How many auto accidents have you had? hi how many of these were you the driver? How often have you been arrested - for what reasons? (29) How do you get along with girls; enjoy their company, indifferent, avoid them? (30) How many romances have you had (steady girl for weeks or months)? (31) Have you ever been married? (32) What illnesses have you had that were so severe that you were out of your head, or delirious? (33) Did you ever stammer or stutter? Are you left handed? (34) Have you had any periods of unconsciousness due to accident, injury, or being knock- ed out? Duration of such periods? (35) Have there been any instances of fainting, giving age and circumstances? (36) Have there been any Instances of walking in your sleep? Give age and place. (37) Do you have headaches? Frequently, rarely, never? (38) Have you ever taken medicine to help you get to sleep? (39) Have you ever been wakened by frightening dreams? If so, when? (40) How old were you the last time you wet the bed (urinated) while asleep? (41) Have you ever had anjr fits or convulsions? (42) Do you get the “blues ’: frequently, seldom, never? (43) Of what things are you afraid? (44) How many cigarettes or pipefuls of tobacco do you smoke a day? (45) How much liquor do you use: frequently drunk, occasionally drunk, occasional social drink, occasional beer, none? (46) Is there any period of your life that is blank to you - of which you have no memory - for 15 minutes, half an hour, or longer? (47) Have you fad any previous military service? Army, Navy, Marines, ORC, ROTC, CMTC? (48) What ratings or advancements have you had? (49) How long have you been interested in flying? (50) Why have you wanted to do army flying? (51) How many minutes or hours have you spent flying (student or passenger) ? Soaring? Gliding? (52) Have you ever been sick or dizzy in the air? •(53) What is the attitude of your parents toward your flying; enthusiastic, content, op- posed? c. Objective reactions to be observed. The following reactions should be noted during the interview, and correlation attempted between their occurrence and precipitating sti- muli if possible: Facial expression, postures, attitudes, tenseness, motor movements - as gait, gestures, restlessness, fidgetiness, tears, blushing, mottling of extremities, sweating, tachycardia, increase In blood pressure, sighing, tremor, pupillary dilation, obvious embarrassment, lack of poise, ill at ease, speech defects, nail biting, tics, and mannerisms. 48. UNFAVORABLE FINDINGS IN THE PERSONALITY STUDY AND EVIDENCES OF INSTABILITY. a. History of multiple (2 or more) instances of mental disturbances in the family. b. IhteHigence is considered below the required standard because of: (1) Many failures in the grades and high school, requiring extra months or years to complete high school. (2) Inability to accomplish coHege work because of many academic failures. (3) Complete lack of accomplishment to date, and failure to take advantage of oppor- tunities (school and work). (4) Specific instances of applicant's benavior indicating questionable intelligence. Re- cord must be made of evidence demonstrating poor judgment, poor comprehension, poor memory, poor attention, poor learning, or other faulty intellectual operations. These must be so obvious that they outweigh any educational attainments. c. A history of stammering. d. A history of migraine or migraine type of headache. e. A history of psychogenic amnesia. f. A history of severe head injury with persistent symptoms - or prolonged unconscious ness. g. A history of epilepsy. h. A history of repeated fainting due to inadequate cause. (The only adequate cause being: (1) pain following a severe injury, (21 during convalescence from an acute illness, (3) moderate to severe loss of blood). _i. Persistent insomnia (anxiety). _j. Obsessions or phobias which motivate conduct. k. Instability manifest by combinations of following: (1) Convulsions in minor illness (2) Prolonged enuresis (3) Frequent headaches (4) Multiple histories of momentary unconsciousness in minor injuries (5) Pavor nocturnus (anxiety) (6) Mild insomnia (anxiety) (7) Nail Biting (8) Tics (9) Excessive tobacco (10) Repeated low Schneider indices (11) Tenseness l. Excessive alcohol. m. major psychosis. n. Any minor psychosis. o. Any consitutional psychopathic state. p. The following personality trends, if present to a considerable degree: Seclusive, over active, depressive, suspicious, egotistical, irritable, sexually abnormal, and criminalis- tic. 49. THE ADAPTABILITY RATING FOR MILITARY AERONAUTICS (ARMA). a. Rating. (1) Qualified. The majority of aviation cadet applicants will be found to be satisfactory psychologically for flying. (2) Disqualified. A psychological disqualification may be the only disqualification, but it is just as valid a reason for disqualifying as any physical defect. (a) A psychological disqualification should be well supported althougn the reasons need not appear on the “64” (suspected of being sexually abnormal, for instance). (b) In most instances psychological disqualifications will be supported by evidences of instability. (Repeated instances or combinations of items listed above.) b. Report of psychological examination. (1) Score. A theoretically perfect score is considered to be 200 points. Scores above 160 are qualifying, those below that figure disqualifying. While the assignment of nu- merical values to personality traits is somewhat impracticable the following numeri- cal values for certain conditions are suggested in order that there may be a uniform system of evaluation. The smallest figure represents the minimum amount to be sub- tracted from 200 if that particular condition exists, and the largest figure the maximum. It can be seen that in those instances in which an applicant has two conditions, the min- imum value for which is 20, he is automatically disqualified, as he cannot be assumed to be perfect in all other respects. Similarly, in those Instances in which the maximum value for a given condition is 40, that condition may be disqualifying in itself. The ex- aminer must exercise his judgment in assigning values to other conditions not specifi- cally mentioned, and which may influence qualification or disqualification. Evidence of marked vasomotor instability and other emotional phenomena, for example, will be given special unfavorable consideration particularly if occurring in conjunction with some other condition such as nail-biting, even though the latter is minimal in degree. Suggested numerical values to be deducted from total score: (10-20) Nervous and mental disease in family (each instance) (10-20) Alcoholism in family (each instance) (10-20) Criminality in family (each instance) ( 5-10) Insomnia in applicant (persistent) (20-40) Hay fever, asthma or other allergic phenomena (10-40) Enuresis (prolonged) (20-40) Sommambulism ( 5-40) Alcoholism (15-40) Fainting (inadquate) (12-40) Unconsciousness (duration and cause) ( 40) Fracture of skull or severe concussion ( 5-40) Phobias and obsessions (excessive fears) (10-20) Nail-biting (20-40) Amnesia (20-40) Fits, spasms and convulsions (10-40) Speech defects (corrected or uncorrected) (10-40) Chorea, poliomeyelitis, encephalitis, meningitis (10-40) Arrests Probably relatively few applicants will be disqualified who do not have some positive findings in the above list, although final decision may be influenced by other factors in each individual case. (2) Entry in pax. 36, WD, AGO Form No. 64. (a) State ‘ satisfactory” or “unsatisfactory”, (b) Record the ARMA score. (c) A low ARMA is sufficient reason for an unsatisfactory rating. Do not put unfavor- able remarks concerning applicant’s personality on the “64”. 50. REFERENCES. a. Manuals. (1) TM 8-230, Notes on Psychology in Aviation Medicine. (2) TM 8-325, Outline of Neuropsychiatry in Aviation Medicine. b. Regulations. (1) AR 40-110 (December 3, 1942). THE DENTAL EXAMINATION SECTION V Paragraphs Notations used 51 Dental classification 52 Standards 53 Dental identification record 54 References 55 51. NOTATIONS USED. a. In par. 11. WD, AGO Form 63, or par. 19(a), WD, AGO Form 64, Indicate by (x) missing teeth, (0) carious teeth (restorable), (/) carious teeth (not re- storable, caries involving pulp chamber or possibly only carious roots remaining). b. In par. 11, Form 63, or par. 19(b), Form 64, remarks including other defects: Enter here various conditions such as: gingivitis, pyorrhea alveolaris, Vincents Stomatitis, etc. This paragraph may be used to note any dental irregularities or peculiarities which may be valuable for such as ‘no symptoms”, and “tooth pulpless R 1, no sym- ptoms (or fistula if present)’ . A broad classification of malocclusion is valuable for record, such as neutrocclusion in which all incisor teeth, in some types, fail to occlude in any movement of the jaw; mesioccluslon in which the lower teeth are generally forward (anterior) of the upper (pro- gnathism); and distocclusion in which the lower teeth come to rest generally distal (pos- terior) of normal, causing the upper anterior teeth to appear protruded. If space is insufficient, paragraph 24, Form 63, or paragraph 37, Form 64, may be used for further remarks. In case of malocclusion, severe or marked, which is considered disqualifying, dental casts will be forwarded to Headquarters Army Air Forces with at least two penciled lines on each side drawn across opposing casts to denote rest occlusion. They should also be plainly marked with the individuals name and organization or address. In the absence of a dental officer the services of a civilian dentist may be secured to make these casts. No expense to the Government will be incurred in this connection. c. In par. 11, Form 63, or par. 19(c), Form 64, prosthetic appliances: Artificial appli- ances replacing missing teeth are charted as follows: Enter further remarks about prosthetic appliances in this paragraph, such as: Bdg. Fx, Rl, 2, 3, L, 1, 2, 3, defective. Bdg. Rm. R5, 6, 7, serviceable. Dtr. Pr. R 14, 15, L13, 15 unserviceable, crown R 4 etc. d. Explanation of abbreviations used on “63” and on “64”. _(1) Bdg. Rm. - bridge removable. This appliance is usually made of metal with porce- lain teeth, replacing one or two missing teeth. It can be removed by the wearer. It is held in place with clasps around neighboring natural teeth or abutments. The clasped teeth are included within the oval brackets. (2) Bdg. Fx. - bridge fixed. This appliance is fixed premanently to the natural abutment teeth and cannot be removed by the wearer. The abutment teeth are included within the oval brackets. {5JT)tr. Pr. - denture partial. This appliance is constructed of some plastic material, metal, and porcelain teeth. Masticating stress is borne mostly by the alveolar ridge. Clasps aid in stabilizing it and it is removable by the wearer. The clasped teeth are not included within the square brackets - see charted example above, e. In par. 11, Form 63, or par. 19(d), Form 64: Enter here classifications I, n, m, or IV", as described below in par. 36. 52. DENTAL CLASSIFICATION OF INDIVIDUALS. Class I Persons requiring immediate treatment of conditions such as: (a) traumatic injuries (b) acute infections (pulpitis, gingivitis, stomatitis, etc.) (c) conditions necessitating extractions (d) defects not listed above but of a nature requiring emergency- treatment (e) Insufficient teeth to masticate the Army ration. Class U Persons requiring early treatment (favorable cases for preventive dentistry, except persons in Class I) such as: (a) filling operations which do not involve pulp canals (b) replacement of defective fillings (except root canal fillings) (c) prophylactic treatment (d) correction of defects not listed above but of a nature favoring preventive procedures, including orthodontia Class HI Persons requiring extended treatment (constructive dentistry, except persons in Class I and Class n), such as: (a) treatment of chronic infections (b) filling operations involving pulp canals (c) replacement of defective root canal fillings (d) construction of crowns, bridges, and dentures (e) correction of defects not listed above but of a nature requiring extensive treatment Loss of one or two teeth does not necessarily warrant Classification III. Class IV Persons not requiring dental treatment. 53. STANDARDS. a. Requirements for commission (Section IX, AR 40-105). No applicant or candidate will be accepted unless he has a minimum of three serviceable natural masticating teeth above and three below opposing, and three serviceable natural incisors above and three below opposing. Therefore, the minimum requirement consists of a total of six masticating teeth and of six incisor teeth, all of which must be so opposed as to serve the purpose of incision and mastication. (1) Definitions: ‘‘Masticating Teeth” include bicuspids and molars, “incisor Teeth” include incisors and cuspids. A restorable carious tooth is considered a serviceable natural tooth. (2) Causes of rejection: (a) Loss of teeth in excess of those noted above. (b) Marked pyorrhea. (c) Gross prognathism or irregularity which interferes with serviceable occlusion, (3) Teeth replaced by bridge work which appears sound may be accepted in lieu of natural teeth if candidate otherwise meets the requirements. b. Requirements for Aviation Cadet training, officer candidate schools, enlistment, recruiting and induction under Selective Service (par. 15 b. Section m, WD Circular No. 86, March 24, 1942 and par. 20 f, AR 40-110, December 3, 1942). Applicants who meet the following minimum dental requirements and who are otherwise qualified will be eligible for commission for general military duty in all arms and services. (1) Individuals may be accepted who have a minimum of three serviceable natural masticating teeth above and three below, and three serviceable natural incisors above and three below, so opposed as to serve the purpose of mastication and in- cislon during the excursions of the mandible, even though they are not in actual contact when the mandible is at rest, in centric occlusion. (2) In lieu of the minimum number of serviceable natural teeth set forth above, the following will be acceptable for individuals who otherwise do not show evidence of phy- sical impairment either from loss of masticatory efficiency or from ill health incurred from the pathological processes which led to their loss of teeth: (a) In the upper jaw, a minimum of an edentulous ridge corrected or correctible by a full denture. (b) In the lower jaw a minimum of a sufficient number of natural lower teeth in pro- per position and condition to support a partial denture which can be removed and re- placed by the individual and which is retained by means of clasps with rests and or special precision attachments to abutment teeth wherein the stress of mastication is borne partially by the abutment teeth and partially by the soft tissues of the mouth. Interpretation of the above regarding the lower jaw is that candidates must have two natural teeth in the lower jaw, one on each side in such a position that they will serve as support for a partial denture. The teeth may be cuspids, bicuspids, or molar teeth but not incisors. (c) Malocclusion. When it is evident from the individuals general physical condition and his occupation in civil life that his malocclusion has not seriously interfered with the mastication of a normal diet, provided that in the excursions of the mandible or with the mandible at rest the teeth do not impinge upon opposing soft tissue and that the malocclusion has not resulted in secondary pathological changes. 54. DENTAL IDENTIFICATION RECORD. A complete Dental Identification Record for all flying personnel including air borne troops and officers in the military service will be made out by a dental officer on M.D. Form No. 79 (revised February 24, 1941). 55. REFERENCES. a. Regulations. (1) AR 40-110, (December 3, 1942). b. Letters. “(1) SGO Circular Letter No. 6, January 2, 1943, Subject: Dental Identification Record for All Flying Personnel. c. Circulars. (1) WD Circular No. 86, March 24, 1942. CHAPTER 4 PROBLEMS IN THE CARE OF THE FLYER SECTION I SICK CALL AND MEDICAL ATTENDANCE Paragraphs General 56 Flying Pay 57 56. GENERAL. Until the Flight Surgeon has established the confidence which must exist in any physician-patient relationship, it is difficult to make the flyer report to the hospi- tal for even moderately serious illnesses. By personal contact, comradeship, and partici- pation in all activities of the pilot, the Flight Surgeon can create an understanding of his good intentions in relation to health. It has been found that the best medical attendance can be given by the Flight Surgeon who diligently visits and associates with his pilots daily at their work. A short visit to each hangar or other gathering place in the morning, not to be construed as a formal inspection visit, with a discussion of common interests, will of- ten bring to light ailments which ordinarily would be neglected. Arrangements can then be made, if necessary, for further examination and possibly prevention of significant disease. 57. FLYING PAY. When a flying officer is incapacitated ior illness or injury other than that due to an airplane accident, he should be restroed to flying duty if possible within ninety days; otherwise, flying pay is lost for the entire period of illness (par. 2, 3, AR 35- 1480). If he has been incapacitated as a result of an airplane accident, the following ab- stract from the Comptroller General’s Decisions applies with respect to aviation pay (see Decisions of the Acting Comptroller General of the U.S., vol. 16, p. 134, July 1, 1936 to June 30, 1937): “The three months’ period, stipulated by Executive Order issued pursuant to law, during which flights are not required of an Army officer, incapacitated for flying duty by reason of an aviation acci- dent while making an authorized flight, to entitle him to additional pay for flying, commences with the first of the month following the accident where prior to the accident the officer had completed sufficient flights to qualify for additional pay for flying for the month in which he was injured. ‘Where the flights required by Executive Order are made at any time during the three successive calendar months next following the three months period during which no flights were required, ad- ditional pay for flying for the three months period is authorized.” FLYING FATIGUE SECTION n Paragraphs Definition 58 Symptoms and characteristics 59 Prevention 60 Treatment 61 Conclusions 62 References - - - - - 63 58. DEFINITION. “Flying fatigue” may be observed in normal or predisposed individuals as the result of strain from prolonged or hazardous flying. It is an acute illness having mental, emotional, and physical symptoms and is particularly found in members of com- bat crews engaged in combat missions. The term “flying fatigue” is not an adequate or exact one, in that fatigue itself is a subjective phenomenon, degrees of which are diffi- cult to measure. It is thought that fatigue consists of physical factors, resulting from the appearance of certain metabolites in the body, and of psychic or emotional factors. The latter are apparently the most distressing to the affected individual. “Aeroneurosis”, “aeroasthenia”, and “flying stress” are the chronic forms of flying fatigue. “Shell shock’ and the fatigues seen in Tank Crews and in Merchant Seamen are apparently the same es- sential illness occurring in different dangerous occupations. It is becoming generally re- cognized that most of the symptoms probably result from states of anxiety and that, rela- tively, flying fatigue is an anxiety neurosis just as are “shell shock” and the related anxiety states seen in civilian life. “Staleness” is an apt term that can be applied to the early manifestations of the condition. (SeeCh, 4, Section XI). 59. SYMPTOMS AND CHARACTERISTICS. a. The characteristics of flying fatigue are extremely variable, but in every case there is a sufficiency of symptoms and signs which are as likely to be spotted by a good squad- ron or flight commander as by the squadron medical officer. However, the early diagnosis of this condition is the medical officer’s responsibility for, if not diagnosed early, irre- parable harm may be done to the individual and he may be lost permanently to the Air For- ces, A good Flight Surgeon will so surely know his men that he will quickly discern the slightest variations in the personalities of his squadron. There should be close liaison between the Flight Surgeon and Squadron Commander so that deviations in flying skill of a particular individual will be part of the Flight Surgeon’s data in arriving at a diagnosis. Flying fatigue may show itself first in a reduction or change in flying ability. The various symptoms run the gamut from the mild so-called “fed-up’ state, or staleness, to complete mental and emotional break down. Irritability, insomnia, depression, nightmares, anor- exia, and loss of weight, are common signs. In fact, weight loss is one of the most signi- ficant changes which can be objectively measured. It usually occurs when flying fatigue is developing. All sorts of cardio-respiratory and gastro-intestinal symptoms, similar to those seen in neurotics in civilian practice, may be observed. Cold hands, cold feet, and tremors are common. Alcohol and tobacco may be used to excess. The pilot may be- come seclusive and develop a marked sense of guilt and shame. He loses his love for fly- ing and begins to find fault with his airplane. His flying skill deteriorates and his judg- ment is poor. His tolerance to anoxia may actually be lowered. b. As a general guide to the diagnosis, flying fatigue is especially likely to occur in cer- tain periods in the flying life of an individual. Roughly speaking, symptoms of fatigue may develop in the first 10-20 hours of operational flying. This is so because of the strange- ness and tensions of early combat work. During these hours the predisposed or emotion- ally unstable pilots become ill. But it is believed that anyone, even the most stable indi- vidual, when subjected to severe, prolonged, hazardous, combat work will develop the symptoms. In general, this is likely to occur after 100 hours for fighter*pilots and upwards from 120 to 150 hours for bomber pilots. It also may occur when the individual is physi- cally below par, when he has had little sleep, or when he is recuperating from physical Illness. c. There is no apparent yardstick by which the development of flying fatigue can be measured. The factors determining the cause are not simply long hours of duty, hurried meals, curtailed sleep, etc., although these do have a bearing. Of much importance is the mental tension on the ground between flights. For example, pursuit pilots when on the alert react with a feeling of excitement and tense anticipation to telephone calls which might be an order to take to the air. d. The bodily fatigue occurring with operational flying seems disproportional to the phy- sical effort involved. As a matter of fact, there is little physical effort involved in flying under ordinary circumstances. Pilots returning from an engagement often feel exhilara- ted but, nevertheless, “washed-out” and fatigued. Usually there are no symptoms of this nature after non-operational flights of similar duration. The average pilot is capable of from 100 to 130 hours of operational flying. After this he experiences increasing physical and mental tiredness or boredom during the day and unrefreshing sleep at night. When in this condition his reaction to tactical situations is neither as rapid nor as satisfactory as it should be. Some pilots clearly recognize the condition in themselves but hesitate to speak of it for fear of misinterpretations. With unrelieved fatigue various nervous sym- toms having an anxiety background appear. Pilots with a strong sense of duty usually will not report sick until they are definitely ill and for this reason it is sometimes difficult to detect early symptoms of fatigue. Loss of weight may be one of the earliest objective symptoms, but will usually develop subsequent to the earliest subjective manifestations. Frequent checking of weight has one advantage. It enables the Flight Surgeon to observe the pilot and to note changes in personality which might ordinarily pass unobserved. It is the earliest detection of flying fatigue that is important both from a preventive, as well as therapeutic, point of view. Once severe fatigue has set in the results of therapy are disappointing. Individuals thus affected must be hospitalized, and a large percentage of these never return to duty. 60. PREVENTION. a. Prophylaxis is the only successful therapy of flying fatigue. It is fundamentally and primarily an administrative responsibility, the measures of prevention governing such matters as discipline, leaves of absence and rest periods, recreation and diversion, suitable living quarters, comforts off and on duty. Unless these measures are properly controlled the only result will be an ever increasing number of cases of fatigue, many of which will be stressed to the danger point which may well render them unfit for further operational duties. b. It has been observed statistically in an active theater of operations in World War II that the incidence of flying fatigue is directly proportional to the “degree of hazard” and the “casualty rate” or “missing rate” of the air crews involved in operational duties. There was no correlation in this study between the incidence of flying fatigue and non-op- erational flying, nor was there any definite relationship to other factors such as cold, vibration, glare, etc. The degree of hazard, the casualty rate, and the “missing per sortie”rates were the important etiological factors related to the incidence of flying fatigue It would seem, statistically at least, that anxiety, fear of injury or death in combat, and the tension and danger of operational flying are the causes of most fatigue. Other factors such as cramped position in a gun turret, low temperatures, vibration of the plane, and glare do produce flying inefficiency, but apparently do not alone cause flying fatigue. c. The following suggestions are offered as a guide to Commanding Officers in offsett- ing and comba ing the devastating effects of flying fatigue within their organizations: (1) Use young individuals for combat missions insofar as possible. (2) Assign medical officers to squadrons who are familiar with the problems of flying, and who are good mixers and keen observers. The medical officer should enjoy the privilege of having the confidence of his squadron. No rule of thumb instructions can produce in him the qualities he should have. No one can detail the activities of a wise friend. (3) Evenly space the operational effort required of the individual, i.e., not four missions one week and one the next. Bomber - a minimum of 24 hours between missions. Fighter - on 8 hours alert, off 16 hours during which time he is subject to call. (4) limit the effort required of an individual except under very unusual cir- cumstances, The aim should be: Fighter - 90 - 110 hours operational flying or 6 wee*ks. Bomber - 120 - 130 hours operation, 20 missions or 3 months. Leave should then be given in manner to be discussed later, followed by a short per- iod of alternative employment before return to operational duty. The nature of the al- ternative employment should not be to give a ~udden rest such as might be produced by a long leave, but to provide flying duties which will carry no operational risk, and yet keep the individual fully occupied and prevent possible reaction after removal from op- erational strain, (5) Long leaves of absence should not be given - 7 days as a rule, and not over 14 under any circumstances. Leaves should be at regular intervals, and only exceptional circum- stances should be allowed to interfere. The following schedule is offered: 1/2 day every three or four days, 48 hours every two weeks. 7 days at end of limit of effort. More than 7 days’ leave at one time appears to encourage a disinclination to return to operational flying. (6) Upon completion of a mission, crews should be taken to a point 3 to 5 miles from the airdrome for sleep and rest. (7) The importance of tactfully organizing games at operational stations cannot be over- emphasized. (8) Mild degrees of anoxia increase fatigue. Strict oxygen discipline should be insisted upon. (9) It is important to realize that pilots fear weather conditions as much as enemy ac- tion, and in determining leave and rest periods due allowance for weather conditions must be made. (10) Pilots, where squadrons have suffered many casualties, should be given frequent rest periods, (11) New personnel joining operational units should be carefully watched during the first fifteen or twenty hours of operational flying. It is during this period that those persons who are unable to face the strain of operational flying reveal their inadequacy. 61. TREATMENT. a. The squadron medical officer is best equipped to treat mild cases of flying fatigue. His main function is diagnosis. He must follow hunches and if in doubt about the diagnosis it is recommended that the pilot in question be grounded for 2 to 3 days for further ob- servation. b. Psychotherapy consists in frank explanatory and advisory discussion with the pilot. Verbalization of complaints is probably of most value to the pilot. Adequate sleep with sedatives may be recommended for several days and a short leave period afterwards. If the case appears more serious it should be discussed with the Commanding Officer and a longer leave may be recommended. If the pilot has lost his courage and refuses to fly, it is best to talk this over with the Squadron Commander who may then reclassify the pilot, or, in some cases, the Fighter pilot may be transferred to Bomber work with good effect. c. The severe case is hospitalized. Psychotherapy is carried out as for the various neuroses encountered in civilian life. Pilots so afflicted should be removed at the ear- liest possible time from their squadrons, for they are detrimental to the morale of other personnel. 62. CONCLUSIONS. It is emphasized (1) that a proper selection of personnel for air crews is essential. (2) That the pilot may not be capable of under standing the nature or development of flying fatigue. (3) That it is the responsibility of the Flight Surgeon to detect the illness in its incip- iency. (4) That neurotic behavior, an ofttimes escape mechanism, is infectious or contagious to other members of the group and is detrimental to morale. (5) That the problem, etiologically, is essentially psychological; e.g., an anxiety type of reaction. (6) That the pilot should be able to anticipate his leave well in advance; that leaves should be regular and that they should be brief. 63. REFERENCES. a. Articles. (1) A Study of Some Factors in the Causation of Flying Stress. W.A.M. 153-6, F.P.R.C 450 (2) An Enquiry into Psychological Disorders in Flying Personnel. W.A.M. 153-2, F.P R.C. 412 (b). (3) A Series of Cases with Psychological Disorder Examined in Relation to the Proble of Selection of Flying Personnel. F.P.R.C. 412 (a). (4) Memorandum on the Use and Abuse of the Term “Flying Stress”. F.P.R.C. 412. b. Bulletins. (1) A.A.F. Bulletin No. 42-6, Washington, February 26, 1942. SECTION m AERO-OTITIS MEDIA Paragraphs Definition 64 Dynamics 65 Differential Diagnosis 66 Prophylaxis 67 Treatment 68 References 69 64. DEFINITION. Aero-otitis media is an acute or chronic traumatic inflammation of the middle ear, caused by a pressure difference between the air in the middle ear and that of the surrounding atmosphere. Literally the term is translated and transposed to read aero- middle ear inflammation. 65. DYNAMICS. Ventilation of the middle ear is dependent upon the normal function of the Eustachian tube. When obstruction exists between the middle ear and the nasopharynx at- mospheric pressure differentials are built up during flight which may be sufficient to cause pathologic changes in the mucosa of the middle ear. At 18,000 feet the atmospheric pressure is 380 mm of Hg. If the pilot is forced to dive to 5,000 feet, where the atmospheric pressure is about 632 mm. Hg., a difference of over 150 mm of Hg will exist between the middle ear and the external ear. This difference represents a column of mercury about 15 cm. high pressing against the drum. Fig. 13 illustrates diagramatically the factor of difference in atmospheric pressure on either side of the tympanic membrane involved in producing aero-otitis media. 66. DIFFERENTIAL DIAGNOSIS. The different traumatic inflammatory stages may easily be differentiated from the various stages of infectious otitis media. A history of flight usually simplifies the diagnostic problem. AERO-OTITIS MEDIA OTITIS MEDIA EXTERNAL OTITIS 1. Due to barometric pres- sure changes Inflammatory Inflammatory 2. Retraction of drum Bulging of drum View of drum may be obstructed 3. Drum land mark accen- tuated Drum landmark obliterated ““ 4. Rupture of vessels Diffuse Erythema -- 5. No thickening of drum Thickening of drum May be thickening of drum if visible 6. Usually no fever Fever usually present May be fever 7. White blood count normal White blood count elevated White blood count ele- vated 8. Sero sanguineus fluid in middle ear Serous or seropurulent fluid in middle ear No fluid in middle ear 9. Deafness profound Deafness profound Hearing normal if canal not obstructed 10. No pain on pressure over No pain or pressure Pain on pressure over tragus and movement of over tragus and move- tragus and movement of auricle ment of auricle auricle 11. No swelling of canal Slight if any swelling of canal Swelling of canal 67. PROPHYLAXIS. The Air Crew should be advised against flying during episodes of rhinitis or nasopharyngitis. Discriminate selection and subsequent education with em- phasis on the hazards of flying with rhinitis and nasopharyngitis will limit considerably the frequency of occurrence of aero-otitis media. Recurrences of the disease should suggest meticulous search for infections of the up- I. OIAGRAMATIC REPRESENTATION OF THE THICKNESS OF MIDDLE EAR MUSCOSA AT SEA LEVEL *. DIAGRAM Or THE THICKNESS OF MIDDLE EAR MUSCOSA DURING ASCENT TO 18,000 FT ARROWS REPRESENT FORCE OF RELATIVE POSITIVE PRESSURE WITHIN THE MIDDLE EAR IF THE MIDDLE EAR IS NOT VENTILATED 3. DIAGRAM SHOWING THE RESULT OF RELATIVE NEGATIVE PRESSURE WITHIN THE MIDDLE EAR CAVITY ON DESCENT FROM 'S.OOOFT WHEN THE MIDDLE CAR IS NOT VENTILATED 5ERO SANGUINOUS EXUDATE ACCUMULATES IN THE MIDDLE EAR FIGURE 13. per respiratory tract and for evidence of allergy. Allergy is far more frequent than one is likely to suspect. The presence of eosinophiles in die nasal secretions is practi- cally pathonomonic of nasal allergy. 68. TREATMENT. AERO-OTITIS MEDIA OTITIS MEDIA EXTERNAL OTITIS 1. Vaso constriction to Vaso constriction to — nasopharynx nasopharynx 2. External heat External head External heat 3. Analgesics Analgesics Analgesics 4. Gentle politzerization -- -- 5. Paracentesis Paracentesis contra- 6. Sulfonamides indicated Sulfonamides may be of 7. Hygroscopic medication value Mild antiseptics in in canal canal In aero-otitis media conservative measures in the form of rest, analgesics or hypnotics for control of severe pain, and vasoconstriction to the nasal passages, are indicated. External heat to the ear is the most effective pallative treatment. The vasoconstrictions may be applied by dropper, atomizer or inhalator. Applications of liquid detergents are more effective when administered in the head-low position. Relief from severe pain has been accomplished in some instances by the Proetz Dis- placement technique. Politzerization is effective for relief of pain and the concomitant deafness in mild cases of aero-otitis media. Catheterization of the Eustachian tube in experienced hands has not infrequently afforded relief of pain and alleviated the sensa- tion of fulness in the ears. If unskillfully used it may cause undesirable trauma. Recov- ery, in most cases, will take place without treatment of any kind. 69. REFERENCES. a. Armstrong, H. G.: Principles and Practice of Aviation Medicine, Baltimore, Williams and Wilkins Company, 1939. b. Armstrong, H.G. and Heim, J.W.; The Effect of Flight on the Middle Ear. J.A.M.A. 109:417, 1937. c. Kos, C.M.: Otolaryngological Problems in Aviation Medicine. Texas State Journal of Medicine, 38:281, 1942. SECTION IV AEROSHSTUSITIS Paragraphs Definition 70 Dynamics 71 Differential diagnosis 72 Prophylaxis 73 Treatment 74 References 75 70. DEFINITION. Aerosinusitis is a sudden or delayed traumatic inflammation of the para- nasal sinuses caused by a pressure difference between the air in the sinuses and that of the surrounding atmosphere. The sinuses most commonly involved are the frontal and max- illary. 71. DYNAMICS. Ventilation of the paranasal sinuses depends upon a normally functioning nasal passage, free from obstruction. Certain deviations of the septum, redundant or inflam ed tissues in and around the orifices or ostia of the sinuses may impinge on these openings in the manner of ball-valves and thus interfere with the exchange of air necessary to main- tain pressure equilibrium at various altitudes (Figures 14 and 15). When such an effect exists in flight the pressure differentials which result will produce pathologic changes in the mucosa of the sinuses. The process is very similar to that which takes place in aero-otitis media. 72. DIFFERENTIAL DIAGNOSIS. The different traumatic stages of aerosinusitis sympto- matically resemble the various stages of infectious sinusitis. History of flight will aid ma- terially in making the diagnosis, but will not obviate the possible existence of infection or allergy. INFECTIOUS SINUSITIS ALLERGIC OR VASO- MOTOR SINUSITIS AEROSINUSITIS HISTORY Acute U.R.I. Recurrent sensitivity Aerial flight SYSTEMIC REACT. Sepsis Toxicity None C.C. Headache with pain accentuated in the sinus Heavy headache Sneezing, “watery” discharge Severe, localiz- ed sinus pain TEMPERATURE Usually elevated Subnormal or normal Normal LOCAL FACIAL FINDINGS Tenderness, may have edema May have tenderness Usually have tenderness NASAL FINDINGS Inflammation, brawny edema Hypertrophy Pus Pale, boggy edema Alternating obstruction Serous or mucoid discharge Hyperplasia Polyps and polypoid degeneration Normal NASAL SMEAR Polymorphonuclear cells Causative organism Eosinophilia Normal nasal bacteria Normal nasal cells and bac- teria maxillary sinus in flight (ball valve action of redundant tissue) P. - POLYP MM- MUCOUS MEMBRANE C - SINUS CAVITY 4- POSITIVE PRESSURE — NEGATIVE PRESSURE -}- - EQUILIBRIUM FIGURE 14. 83 H.S-HIATUS SEMILUNARIS F. S-SINUS N.F.D.-NASAL DUCT + POSITIVE PRESSURE - NEGATIVE PRESSURE +- EQUILIBRIUM FRONTAL SINUS IN FLIGHT (ASPIRATION OF NASAL SECRETION ON DESCENT} FIGURE 15. 84 TRANS- Affected anterior sin- Clear Affected anterior ILLUMINATION uses dull or “black” sinuses dull X-RAY Opacity with increased Irregular mucosal thicken- Regular mucosal bone density ing (hyperplasia) thickening (ed- Regular mucosal thick- Bone density normal or ema) ening (hypertrophy) decreased Bone density normal 73. PROPHYLAXIS. The same precautionary measures referred to in the discussion of aero-otitis media apply to prevention of aerosinusitis. Recurrences of the disease should suggest the necessity of establishing adequate drain- age by removing obstruction in the nasal passages. The presence of polyps and edematous tissues in the nose are suggestive of allergy. 74. TREATMENT. INFECTIOUS SINUSITIS ALLERGIC OR VASO- MOTOR SINUSITIS AEROSINUSITIS TREATMENT Vaso-constrictor drugs Heat or cold Analgesics, rest, etc. Sulfonamides Nasal lavage and suc- tion Surgery, if inadequate drainage Vaso-constrictor drugs topically Sympathomimetic drugs systemically Tests to determine the causative antigens Specific desensitization or elimination of antigens Vaso - constr ict or drugs Analgesics Cold or heat SURGERY If no adequate response to medical treatment, as conservative as possible to obtain re- sults Contra-indicated, except for drainage of secon- dary infection Contra-indicated Treatment of aerosinusitis is directed primarily toward the relief of pain and rees- tablishment of paranasal sinus ventilation. Vaso constrictors applied to the nose in the head-low will be found to be most effective. It is perhaps safer to refrain from further topical treatment to avoid, in so far as possible, a super imposed infection. Recovery usually takes place without treatment and a temporary localized catarrhal sinusitis is the only unfavorable result. 75. REFERENCES. _a. Articles. (1) Behnke, A.R., and Willmon, T.L.: Physiological Effects of High Altitudes, U. S. Nav. M. Bull. 39:163, 1941. (2) Campbell, P.A.,: Aerosinusitis, Arch of Otolaryng. 35:107, 1942. CHANGES IN HEARING PRODUCED BY FLIGHT SECTION V Paragraphs Factors affecting auditory acuity 76 Effect of noise 77 Effect of changing barometric pressure 78 Effect of anoxia - - - 79 Effect of age 80 Summary 81 References 82 76. FACTORS AFFECTING AUDITORY ACUITY. Three of the unalterable characteristics of flight affect auditory acuity. In order of magnitude of effect, they are noise, change in barometric pressure, and anoxia. 77. EFFECT OF NOISE. Noise in aircraft may at times reach the rather extreme inten- sity of 115 decibels. The resultant loss of hearing produced by such noise follows the gen- eral pattern of fatigue, and is reversible following rest. Contrary to expectation, there is little relationship between the frequency of sounds producing the decrease in hearing thresh- hold, and the frequency area of the hearing affected. For the most part, the frequencies of the noises of highest intensity produced by aircraft lie below 1,000 double vibrations per second, whereas the hearing range which is affected usually extends between the 4,000 and 6,000 frequencies. As the area used in normal conversation represents frequencies oi from 300 to 3,000 double vibrations per second, speech intelligibility is not much affected However, if the insult is great enough, the area of loss may spread into this range. After many hours of exposure (300 to 12,000 hours), permanent notching of the curve of hearing may occur in some individuals. 78. EFFECT OF CHANGING BAROMETRIC PRESSURE. Barometric pressure alterations coincident with altitude change, may, if the eustachian tube is not ventilating the middle ear properly, also affect hearing. Any disruption in the equilibrium between the air pres- sure inside the middle ear and that of the outside atmosphere produces a form of conduc- tion deafness, which in turn may affect any or all of the frequencies used in conversation. Again it is the rule that these changes are reversible, and hearing returns to normal after equilibrium is established, providing- the changes produced by this condition (aero-otitis media) have subsided. 79. EFFECT OF ANOXIA. Little is known of the effect of anoxia upon the end organ of hearing. However, it is known that anoxia affects all nervous tissues, especially those of the higher functions. 80. EFFECT OF AGE. Age in itself produces a certain loss of high tones. This variation takes place decade by decade, and must be considered in the interpretation of the audiogram of any airman. 81. SUMMARY. The effect of all of these changes may be best demonstrated by a compo- site audiogram (Figure 16, Audiogram 4). 82. REFERENCES. a. Campbell, P.A., and Hargreaves, J.: Aviation Deafness - Acute and Chronic, Arch. Otolaryng., 32:417, 1940. b. Dickson, E.D.D., Fry, D.B., McGibbon, J.E.G., Winfield, R.H.: Discussion on the Ef- fects of Flying on the Nose and Ear, Proc. Roy. Soc. Med. 35:245, 1942. c. Montgomery, H.C.: Do Our Ears Grow Old? Bell. Lab. Rec., 10:311, 1932. d. Campbell, P.A.: The Effect of Flight Upon Hearing, J. Aviat. Med., March, 1942. e. Campbell, P.A.: Aviation Medicine with Reference to the Ear and Upper Respiratory Apparatus, Year Book of Eye-Ear-Nose-Throat, pp, 355-389, 1940. Audiogram 1 Effect of age upon hearing acuity Audiogram 2 Example of the effect of noise upon hearing acuity. Audiogram j} Example of the effect of barometric pressure change upon hearing acuity. Audiogram U Composite audiogram de- monstrating the effect of age, noise and barometric pressure change upon hearing acuity. FIGURE 16. Audiograms demonstrating changes which must be considered in the analysis of the hearing of an airman. SECTION VI NIGHT VISION Paragraphs Anatomical and physiological considerations 83 Summary of visual characteristics of rods and cones 84 Practical applications 85 Visibility of lights at night 86 References 87 83. ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. Night vision is quite differ- ent from day vision and the use made of the eyes at night must be quite different from the daytime use If anywhere near maximum efficiency is to be obtained. However, mere know- ledge of the principles Involved is not sufficient. Repeated practice in the use of the eyes at night is absolutely essential to efficient night vision. The proper use of the eyes at night is based upon the anatomical distribution of end or- gans in the retina. The macular area with its density of cones gives most acute vision by day (central vision). The cones are also the end organs which are responsible for the per- ception of color. So when colors can be distinguished as true colors, not merely as lighter or darker shades of grey, it is known that there is sufficient light present for the cones of the central visual area to function. i The cones have one very serious limitation, however. They are not capable of function- ing in light of less intensity than moonlight. When light becomes less Intense than moon- light, the individual has a central blind spot and cannot see things at which he is directing his gaze. The rods in the peripheral portion of the retina give only gross vision both day and night. Small objects are not picked up by peripheral vision. The rods cannot distinguish color, all colors being seen as varying shades of grey. They can, however, become sensitive, when dark adapted, to light which is roughly l/1000th as Intense as that to which the cones are sensitive. Thus peripheral vision is possible even where there is much too little light for central vision. The rods have one other characteristic which is extremely useful in the application of night vision; that is, the fact that the rods are entirely insensitive to red light of wavelengths longer than 600 millimicrons. A period of dark adaptation is necessary before individuals can see well at night. The cones became adapted in 8 minutes but it requires 30 minutes in the dark before the rods reach their maximum sensitivity. In order that proper dark adaptation can occur there must be an adequate amount of Vitamin “A” present in the system of the individual for the proper formation of Visual Violet and Visual Purple. To have adequate amounts of these substances in the eye requires adequate ingestion of Vitamin “A”. While deficiency in has been overrated, it can occur. The important fact to bear in mind is the fact that Vitamin “a” deficiency of only relatively short duration may cause a decrease in night vision. After this has oc- curred it takes a relatively long period (3 to 6 months) to return the condition to normal even with large doses of Vitamin “A”. Prevention is thus much more effective than cure. Vitamin “A” or its precursor Carotene is obtained in the diet by ingestion of vegetables or fruits contalnirg chlorophyll(those that are or have been green during growth, especially carrots and spinach), from butter, cheese, cream, eggs, liver, etc. If an adequate diet is ingested, added Vitamin “A" Is not effective In increasing night vision. Dark adaptation is an Individual process In each eye. Thus if one eye is closed it will become dark adapted even though the other eye is being exposed to bright light. At present no drug is known which will increase night vision. Efficient night vision is decree ad by age, significantly so over 35 years of age; by ano- xia, significantly so over 5,000 feet, and by anything which decreases general physical ef- ficiency such as fatigue, drinking or excessive smoking. 84. SUMMARY OF VISUAL CHARACTERISTICS OF RODS AND CONES. Cones Rods Visual Acuity Very acute for form Not acute for form but very sensitive to motion Color perception Colors recognized All colors seen as shades of gray Time required for Dark Adaptation About 8 minutes About 30 minutes Smallest amount of light to which sensitive when adapted. About l/1000th ft. candle About 1/1,000,000th ft. candle Sensitive enough to function in moonlight Yes Yes Sensitive enough to function in starlight No Yes 85. PRACTICAL APPLICATIONS. From a study of the above facts tne following practical applications should be pointed out to Air Forces personnel: a. The necessity for a diet adequate in Vitamin “a”. b. That if the night is bright enough to detect colors, the eyes can be used as they are used in daylight. c. That on dark nights it is necessary to look 10° - 15° above, below or to either side ofthe object to be seen. d. That repeated practice of the use of peripheral vision is necessary and that it will much improve vision. e. That prior to takeoff on any night mission the pilot must be dark adapted. He can be- come adapted by spending at least 30 minutes In the dark or by wearing light-tight red goggles of the proper color in a lighted room for at least 30 minutes. Wearing of the red goggles permits the use of central vision because the cones are sensitive to it but since the rods are insensitive to this color of light the eye becomes dark adapted. f. That once dark adaptation has been attained it can be preserved only by avoiding light. When light must be used it should be as dim as possible, used as briefly as possible and should be red light if that can be used. The pilot should be so familiar with his ship that all gauges that can be read by the sense of touch are not illuminated. g. That If exposure to light becomes unavoidable, dark adaptation can be preserved In one eye by closing it during exposure to light. This is especially useful if caught In a searchlight, if maps or instruments must be read, etc. h. That a slowly roving gaze should be used as the eye is more sensitive when used in this fashion. J.. That objects are seen at night only by contrast differences, being either lighter or darker than their backgrounds. These contrast differences will be reduced by light reflect' ed on the windshield or goggles, by fog, haze or scratched or dirty windshield or goggles. Goggles or windshields must be spotlessly clean for night operations. _j. That contrast differences should be used to aid in finding enemy planes and hiding their own ships. Thus in flying over dark areas such as land, fly below the enemy. Fly- ing above white clouds, desert, moonlit water or snow, they should fly above the enemy. k. That peripheral vision is very gross and large retinal images are required to see things at night. Therefore, enemy planes should be followed either above or below where they form large retinal images. When seen from directly behind they form such a small retinal image that they are apt to be lost. I. That oxygen should be used on night missions from the ground up to prevent poor night vision. m. That adequate rest and the best possible physical condition are required to have satisfactory vision. 86. VISIBILITY OF LIGHTS AT NIGHT. Light in the blue end of the spectrum is seen more easily by the rods than any other. If used just above minimum threshold, only the gross vision of the rods is available and it requires an adapting period of 30 minutes before it can be used. It can be seen by the enemy throughout his visual field so he can readily pick it up if it strikes any part of his peripheral retina. If the light is made bright enough to use central cone vision it is 1,000 times as intense as a minimal stimulus and can be seen at a great distance. Red light of over 600 millimicrons in wavelength however, is not seen by the rods at all. If just above threshold cone vision can be used and an adapting period of only 8 min- utes is required. In order to see it the enemy must be looking directly at it. By actual test red light of intensity just above the cone level can be seen only l/10th as far as blue light just above the cone intensity level. Red light is therefore preferable for illumination of objects subject to enemy observa- tion. White light is next best and blue light the poorest. 87. REFERENCES, a. Articles. (1) Navy Department, Bureau of Medicine and Surgery, The Use of the Eyes at Night, Navy Night Vision Report, April 15, 1942. (2) Macdonald, R., and Adler, F.H.: Effects of Anoxemia on Normal and Vitamin A Deficient Eyes, Arch, Opth. 22:980, 1939. (3) Mandelbaum, J.: Physiological and Clinical Considerations of Dark Adaptation, Arch, Opth, 24:203, 1941. SECTION VII DECOMPRESSION SICKNESS Paragraphs Definition 88 Synonyms 89 Dynamics 90 Symptoms 91 Factors concerned in production of symptoms 92 Diagnosis 93 Treatment 94 References 95 88. DEFINITION. The physiological effects on some individuals of reduced barometric pressure, independent of the effects of hypoxia or anoxia. 89. SYNONYMS. For the manifestations arising from the evolution of gases in the blood, body fluids and tissues the synonyms are aeroembolism, nitroembolism, aeroem- physema and aerial bends. 90. DYNAMICS. Reduced barometric pressure produces: a. Hypoxia and anoxia - decreased partial pressure of alveolar oxygen (See Ch. 5). b. Decompression sickness. The term is now used to include the manifestations aris- ing from: (1) Expansion of gases in closed cavities. (a) Ears and sinuses (See Ch. 4, Sections HI and IV). (b) Gastro-intestinal tract. - “Gas Pains”. (c) Teeth - especially in those with caries or large fillings. (2) Evolution of gases in blood and tissues. Bubbles, consisting chiefly of nitrogen but also of oxygen, carbon dioxide, other gases in the body, and water vapor are form ed in the blood and in the tissues. 91. SYMPTOMS. a. From trapped gases they are purely mechanical. Special symptoms arise from the expansion of gases in the nasal sinuses and in the ears (See Sections HI and IV). b. From the evolved gases (the so-called “nitrogen” bubbles) symptoms are dependent upon the size of the bubbles (increase in size by coalescence and by expansion as altitude is increased), their location (high nitrogen content in fat and nerve tissues) and the state of tissue in which they occur (activity leads to symptoms). (1) In inelastic structural tissues (bones, joints, tendons) pressure of the bubbles is greatest. The symptoms resulting are called “bends” and consists of severe pro- gressive pain in and around the joints, especially the larger ones. These are the most frequent severe symptoms. (2) In soft tissues (skin, subcitaneous fat, muscle) the effects are in either the vascu- lar or nervous elements. This produces paresthesias as “itch” or “creeps” and also various skin rashes. These are the most common symptoms but usually are not severe. (3) In the cerebro-spinal system (brain, spinal cord and peripheral nerves) the “bubbles” may produce “palsy”, “paralysis”, “fits”, “staggers”, “visual defects”, and collapse. These are infrequent but are the most serious symptoms. (4) In the chest the “chokes” occur and account for about 10% of the severe symptoms. They usually start as a burning sensation under the sternum, which becomes more severe in time, and is usually painful and is accompanied by a desire to cough and a sense of suffocation. In some cases the pain is absent. (5) The cardio-vascular system is rarely involved as such. Bubbles can form in blood vessels and be carried to any part of the body. (6) In the gastro-intestinal system the greatest difficulty arises from expanding trapped gases on ascent. Other phenomena are very infrequent. (7) The genito-urinary system is rarely involved. 92. FACTORS CONCERNED IN PRODUCTION OF SYMPTOMS. a. Individual susceptibility. In general symptoms are more common in older persons, and in obese persons, but there are many unknown factors in Individual susceptibility. b. Rate of ascent. The slower the ascent the better altitude is tolerated. c. Altitude attained. Symptoms seldom occur below 30,000 feet. d. Length of time at altitude. Appearance of symptoms is apt to be delayed. If none appear in 4 hours they are unlikely to occur, e. Temperature. Cold may aggravate all the symptoms. 93. DIAGNOSIS. History of exposure to reduced barometric pressure simplifies the diagnosis. For cases occuring during flight a conclusion must depend on self-diagnosis by members of the crew. Instruction of all personnel is therefore important. In a crash from a high altitude, this diagnosis must always be considered as a possible contributing cause. 94. TREATMENT. a. Active. Recompression to 25,000 feet relieves “bends”. In cases with “chokes” or cerebro-spinal symptoms a return to ground level should be accomplished as soon as possible. AH bubbles must be eliminated from the body and equilibrium again es- tablished between internal and external environment before again proceeding to altitudes above 30,000 feet. b. Prevention. (1) Selection. Attempts to detect susceptible individuals are made in the Altitude Training Program. Several flights are of more value than a single one in determin- ing individual susceptibility. (2) Prophylaxis. (a) Slow ascent or limited ceHlng may prevent symptoms of aeroembolism, but not always symptoms caused by trapped gases in body cavities. (b) Denitrogenatlon - Wash out dissolved nitrogen in the body by breathing addi- tional oxygen on the ground prior to ascent or during slow ascent below levels of about 20,000 feet. 100% oxygen is necessary only when rapid ascents are made. Exercise whHe breathing increased percentages of oxygen is of little value and may be dangerous if personnel is exposed to low temperatures. Exercise above 30,000 feet wHl produce “bends” around the joints used. (c) Use of pressure cabins or pressure suits. 95. REFERENCES. a. Texts. (1) Armstrong, H.G.: Principles and Practice of Aviation Medicine, Baltimore, Williams and Wilkins Company, 1939. (2) Physiology of Flight, The Aero Medical Research Laboratory, Experimental Engineering Section, Materiel Center, Wright Field, Dayton, Ohio, 1942. (3) Henderson, V.E.: Air Crew in Their Element, Toronto, University of Toronto Press, 1942. b. Memoranda. (1) AAF Memorandum 25-2, 1942, Effects of High Altitude on Flying Personnel. c. Manuals. (1) TM 1-705, Physiological Aspects of Flying. d. Letters. (1) WD, Hq, AAF, November 15, 1942, Subject: Altitude Training Program. SECTION vm AIRSICKNESS Paragraphs Definition 96 Etiology 97 Symptoms 98 Physiological mechanism 99 Incidence 100 Prevention and treatment 101 References 102 96. DEFINITION. Airsickness is a term now generally used to describe a symptom com- plex that results from alterations in the speed and direction of motion experienced in air- craft. It is a form of motion sickness and is analogous to seasickness, trainsickness, and carsickness. It should not be confused with other variations from normal, manifested at times byflyers, such as anoxia, decompression sickness, and aero-neurosis. 97. ETIOLOGY, a. The primary factor in the production of airsickness is the motion of the aircraft in flight. No precise analysis of the random motion of aircraft has been ac- complished to date. From subjective analysis, the types of random motion taking place during attempted straight and level flight may be classified as follows: (1) Lateral rotation - a deviation of the vertical axis of the aircraft through variable arcs at a right angle to the long axis. (2) Scendlng - vertical acceleration either up or down. (3) Pitching - a rapid change, tending to be irregular, of the long axis of the aircraft in which the nose and tail deviate vertically in opposite directions from a parallel to the line of progression. (4) Yawing - the tail of the aircraft swings in an arc from a relatively stable nose that remains on the axis of progression. (5) Any combination of the above motions. b. These motions of the aircraft in flight are for the most part due to: (1) Atmospheric conditions. (2) Design of the aircraft. (3) Load distribution. (4) Control efficiency of the pilot or automatic pilot. (5) Any combination of the above. c. In addition to the random motions described above which may occur in attempted straight and level flight the motion of the aircraft induced by standard flying maneuvers and, more important, the motion secondary to aerobatics and combat flying, contribute to the production of airsickness. d. The amplitude of motion to which any occupant of an aircraft is subjected is a function of his position relative to the center of rotation of that particular aircraft. 98. SYMPTOMS, a. A previously well individual becomes ill during flight. The usual order of occurrence of symptoms is as follows. An epigastric awareness gradually pro- gresses to nausea. Concurrently salivation is increased, pallor develops, sweating is noted, and the individual loses his general feeling of well being. Yawning may occur. If the stimulus continues the symptoms progress until the subject feels utterly wretched, volition disappears, any constructive task seems Impossible, nausea progresses and vomiting occurs. Seldom is headache and vertigo present. The act of vomiting may tem- porarily relieve the other symptoms and an approach to a feeling of well being may recur only to disappear in another cycle of symptoms. b. No consistently noteworthy changes in blood pressure, pulse rate, blood chemistry or respiration can be measured. Loss of gastric tone and peristalsis associated with pylor- ospasm is usually seen. All symptoms usually subside without sequelae soon after the stimulus is eliminated either by landing the aircraft or by encountering smooth flying conditions. 99. PHYSIOLOGICAL MECHANISM. Apparently every individual is susceptible to air- sickness when the motion of the aircraft is of sufficient degree or is prolonged. Individual susceptibility varies within wide limits. No adequate explanation for this individual varia- tion in susceptibility is available. It can be said that as groups the blind, the deaf, the tabetic, the insane, and infants are relatively immune. Experimentally, dogs that are blind' folded, subjected to labyrinthectomy or placed in plaster casts to restrict movements of their extremities are made less susceptible to induced motion sickness. These pathologic or experimentally induced states, as well as the immaturity of infancy, have in common the elimination or minimization of sensory stimuli reaching the brain stem, or the impair- ment or underdevelopment of the cerebral cortex. The sensory stimuli so attenuated are all related to the individuals mechanism for maintaining equilibrium in space. This equilibratory mechanism includes the vestibular apparatus, the ocular system, and mus- cle and joint sensations. Of these the vestibular apparatus is probably the most important. When the equilibratory mechanism is normal it functions well while the individual pur- sues his hereditary forms of locomotion. This same mechanism, however, when subjected to the unusual motion of aircraft transmits the sensations of a constantly changing position in space to the centers in the brain stem. In addition, these centers are bombarded by afferent stimuli from the viscera and from the vascular system. Apparently each individual has a level at which these multitudinous and unusual stimuli, when they are of sufficient intensity, will produce the symptom complex of airsickness. This level of susceptibility varies greatly. Roughly it is found to be high in stable indivi- duals and lower in the unstable races and types. In each individual this level of suscepti- bility can be lowered temporarily, and apparently at times permanently. Apprehension, anxiety, fear, fatigue and physiologic variations such as are produced by recent over-in dulgence in alcohol and dietary indiscretions may lower the level of susceptibility. 100. INCIDENCE, a. The incidence of airsickness among trainees for air crew varies. Between 10% and 15% of all trainees become airsick at least once during training but only about 5% are airsick more than once. The “washout” rate because of chronic air- sickness is between 0.5% and 1.5% for all members of the air crew but is highest in the pilot and navigator classifications. b. From 3% to 9% of 10,000 airborne infantrymen were found to be susceptible to air- sickness during flight in troop carrying aircraft. Airsickness is a relatively unimportant problem among pilots probably because the most susceptible are eliminated before they get their wings. Even in an experienced air crew, however, all members may become air- sick while the pilot remains immune. His relative immunity under these circumstances is attributed to his feel of the aircraft on the controls. He is thus able to anticipate part of the motion and makes bodily adjustments accordingly. 101. PREVENTION AND TREATMENT, a. Complete prevention of airsickness in military aircraft is impossible because the design of the aircraft and the weather in which it flies are determined by its mission. At times, however, the method of completing the mission might be modified so that smoother air levels could be flown and personnel, during a var- iable proportion of the flight,should be allowed to ride in parts of the plane where motion is at a minimum. Violent and unnecessary maneuvers might be avoided. Aircraft with relatively stable flying characteristics might be produced in greater numbers at the ex- pense of less stable aircraft. b. Selection of personnel offers the best method of preventing airsickness. Individuals with a history of other forms of motion sickness are known to be more susceptible to air- sickness than those who have never been seasick, trainsick, carsick, etc. A properly ad- ministered ARMA should eliminate the unstable types. Tests for motion sickness that correlate well with airsicknessshouldbe applied to all candidates for air crew training. Such tests are now being developed. c. Apparently 50% of those who experience airsickness become relatively immune after a time. This is probably due to the gradual decrease in apprehension associated with early flying, and a resultant rise in the threshold of tolerance to motion. d. No adequate studies have been made concerning the effects of diet on the prevention of airsickness. There seems to be great individual variation in the matter of a full or empty stomach and the ratio of fluid to solid food intake immediately before or during flight. Each individual seems to have his own favorite feeding schedule. e. Drug therapy aimed towards the prevention or amelioration of airsickness has been adopted directly from seasickness therapeutics. None of these drugs can be safely used by members of the air crew because of the disadvantages of their side effects. (See Ch. 4, Section X). _f. Airsickness is self limited. If it occurs it needs no treatment per se. 102. REFERENCES. a. McEachern, D.. Morton, G., and Lehman, P.: Seasickness and Other Forms of Mo- tion Sickness, War Medicine 2:410, 1942. b. Proceedings of the conference on Motion Sickness, National Research Council of Canada, Ottawa, Aug. 28, 1942. c. Van de Water, M. and Wendt, G.R., How to Prevent Airsickness, Information and Statistics Service, Civil Aeronautics Administration, Washington, 1942. d. Airsickness,Cause and Prevention, Randolph Field, School of Aviation Medicine, 1943. SECTION IX INSTRUMENT FLIGHT Paragraphs Definitions 103 Bodily equilibrium 104 Sensory illusions in flight 105 References 106 103. DEFINITIONS, a. Instrument flight is defined as the method by which flying is ac- complished when the pilot is unable to maintain direct or Indirect (celestial) visual re- ference to the earth. The actual conditions under which such flights are made were ori- ginally defined as blind flight but the term has gradually given way to “instrument flight ’, and the pilot with special training qualifying him to make such flights is said to hold an instrument rating. b. Aerial equilibration and aerial orientation have somewhat different meanings al- though'' they are frequently used syonomously. “Aerial equilibration” is defined as the awareness of the pilot of the attitude of his airplane with respect to the earth’s surface. “Aerial orientation” is the awareness of the pilot of the spatial relationship between his airplane and some fixed point on the earth’s surface. 104. BODILY EQUILIBRIUM, a. Maintenance of equilibrium of the human body depends upon sensory impressions arising from: (1) The eyes. (2) The vestibular apparatus. (3) The joints, muscles, tendons, viscera, and skin. b. For maintenance of balance, at least two of these three mechanisms must be func- tioning. c. As soon as an airplane leaves the ground the pilot loses the normal kinesthetic stimulus of direct or indirect contact with the earth’s surface. If, in addition, visual reference with the earth is lost the relatively crude kinesthetic mechanism may easily mislead the pilot. For example, pressure on the seat in a turn may be interpreted as climbing; a decrease in tills pressure as the turn is ended may be interpreted as falling. d. Further, in instrument flight the vestibular apparatus is unaided by visual sensa- tions, and perhaps hindered by kinesthetic stimuli erroneously interpreted by the cere- brum. The vestibular apparatus itself is notoriously untrustworthy in flight, for it is stimulated only when there is a certain minimum rate of change in turning movement (2° per second per second). Turning, if it is gradual or of constant rate, is not perceived presumably because under these circumstances the movement of the endolymph does not differ enough from the movement of the semicircular canals themselves to stimulate the sensory end organs in the ampullae. If, on the other hand, a turn which has gone on for some time suddenly ceases then the fluid continues to move in the direction of ori- ginal turn after movement of the canals has stopped. It mechanically stimulates the sensory receptors and gives a sensation of turning in the opposite direction. 105. SENSORY ILLUSIONS IN FLIGHT. The limitations of the equilibratory apparatus lead to dangerous sensory illusions in instrument flight which must be overcome by im- plicit faith in the instruments. These illusions arise both from deliberate and random movements of the aircraft, and play an important part in the development of airsickness during blind flight. Among these illusions may be listed the following: a. The feeling of ascent while turning. b. The feeling of descent on recovery from a turn. c. The feeling of tilt to the opposite side during a shallowly banked turn. d. A feeling of turning during a straight and level flight. e. A feeling of spinning in the opposite direction after cessation of a spin. f. A sensation that a wing continues low if it should dip abruptly but return slowly to its original position. 106. REFERENCES. a. Texts. (1) Ocker, W.C., and Crane, C.J.: Blind Flight in Theory and Practice, San Antonio, Naylor Printing Co., 1932. (2) Armstrong, H.: Principles and Practice of Aviation Medicine, Baltimore, Williams and Wilkins Co., 1939. SECTION X DRUGS IN RELATION TO FLYING Paragraphs Modifying factors 107 Sulfonamides 108 Carbon monoxide and other toxic fumes 109 Arsenicals - 110 Atabrine 111 Use of drugs in fatigue 112 Use of drugs in airsickness 113 References 114 107. MODIFYING FACTORS. Two of the most frequently encountered modifying factors of of drug action found in the flyer are: 'a. Anoxia, b. Fatigue. 108. SULFONAMIDES, Anoxia may appreciably modify the action of the sulfonamide drugs The toxic effects of particular interest at altitude are: a. Mental disturbances which may be accentuated by anoxia and are particularly dan- gerous because they come on suddenly. b. Nausea and vomiting. This may not be serious at ground level but may be dangerous at high altitudes when an oxygen mask is being worn. c. Loss of available hemoglobin. This may be due to a gradual production of a secon- dary anemia or the rapid production of a hemolytic anemia. It also may be the result of methemoglobin or sulfhemoglobin formation which occurs occasionally with all of the sul- fonamides but is much more apt to occur after the use of sulfanilamide. d. Frequently the application of large quantities of the sulfonamides, particularly sul- fanilamide, to a large wound or burned area results in the extraordinarily rapid absorp- tion of sufficient sulfonamide to produce a marked cyanosis. This is probably in large part due to methemoglobinemia, and may also be of importance in the high altitude trans- portation of patients because of reduction in available hemoglobin. e. Although in some ways the toxic reactions following sulfanilamide administration are more frequent than after any other sulfonamide, there may be some advantage in preferr- ing sulfanilamide for local use on large burned areas where there is already a potential source of renal damage, since the solubility of both sulfanilamide and the acetylated sul- fanilamide are much higher than of any other sulfonamide in common use. f. Flying personnel are not permitted to participate in aerial flights while receiving sulfonamide therapy or for six days after the last dose of the drug (See Ch. 10, Section V). 109. CARBON MONOXIDE AND OTHER TOXIC FUMES. While in the usual sense of the word these are not drugs, they are frequent causes of a low tolerance to anoxia and should be suspected when no other obvious cause is known. (See Par. 152). 110. ARSENICALS. a. There is evidence that the action of arsenic upon protoplasm is essentially an interference with the oxidation - reduction processes hi the cell. Theoreti- cally, therefore, arsenic may cause symptoms of tissue anoxia with degrees of anoxic anoxia which ordinarily give rise to no symptoms. Proof of this is lacking, however. b. On the basis of these considerations and on the basis of the slow excretion of arsen- icals (80% mapharsen excreted in one week), it is probably desirable for flying personnel to avoid high altitude missions during and immediately after receiving a course arsenicals, 111. ATABRINE. It has been suggested that atabrine may diminish tolerance to anoxia. While the evidence for this is not conclusive, there is a tendency to prefer quinine for the prophylaxis of malaria in flying personnel. 112. USE OF DRUGS IN FATIGUE. When inadequate rest has been obtained or when long, fatiguing aerial missions must be undertaken the use of caffeine or benzedrine may be indicated. Both drugs are useful in producing sleeplessness and diminishing the sensation of fatigue. a. Caffeine: This drug may be given in doses of 0.3 Gm. of pure alkaloid or 0.5 Gm. of caffeine sodium benzoate. b. Benzedrine sulfate: Used in doses of 5 to 20 mg. It is more powerful than caffeine The effects are appreciable about one hour after administration and continue for 8 to 12 hours. If excessive sleeplessness is produced this may usually be counteracted with a sufficient dose of ethyl alcohol as ordinary whisky, or other suitable beverage at the end of the mission. 113. USE OF DRUGS IN AIRSICKNESS. La general the drug therapy of airsickness is un- satisfactory (See Ch. 4, Section VIII). Atropine, 1.0 mg., or scopolamine (hyoscine), 0.5 mg., may be effective. Some of the shorter acting barbiturates may be effective but are undesirable in pilots for they may produce undue central nervous system depression. 114. REFERENCES. a. Goodman, L., and Gillman, A.: The Pharmacological Basis of Therapeutics. New York, The Macmillan Co., 1941. SECTION XI THE PSYCHONEUROSES AND PSYCHOTHERAPY Paragraphs General 115 Neurasthenia 116 Hysteria 117 Psychasthenia 118 Anxiety State 119 Traumatic Neurosis 120 Psychotherapy 121 References 122 115. GENERAL, a. The psychoneuroses constitute a group of reactions which are first in importance, from a psychiatric point of view, to the practitioner of military or aviation medicine. Approximately 80% of all psychiatric casualties in the armed forces fall in this group. In this connection it is well to bear in mind that many conditions diagnosed as medical, surgical, orthopedic, etc., might also well be classified here. Some observers have estimated that as high as 25% of the cases seen in the general wards of army hospi- tals should properly be diagnosed as psychoneurotic. b. The two important factors to be considered in the development of a psychoneurosis are the personality of the individual involved, and the environmental situation. The psy- choneurotic reaction represents an effort on the part of the individual to adapt the person- ality to the situation. A psychoneurosis may be thought of further as the existence of an emotion in an unusual degree or for an unusual period after the stimulus has occurred. The emotion with which we are concerned here is anxiety, an expression of the primary emotion of fear. The environmental situation in the Army is ideally suited to the produc- tion of this emotional reaction, and the environment of aviation is peculiarly suited for its production. Fear, or anxiety, is the natural result of the frustration resulting from conflict. This reaction may arise as readily from a threat to self-esteem as from a threat to self-preservation. Its end-results are the same in either case, and its effects are cumulative in nature. c. From the moment that a man leaves the ground he is subject to one of the most in- herent fears that man is subject to - the fear of falling. He may become conditioned to it, and he may learn to ignore it, but it is with him always, and is constantly being reawaken- ed by new or unusual situations. The conditions under which the operational pilot works are conducive to the development of a high degree of anxiety and apprehension, both on and off the ground. Here again, the individual may be able to partially suppress or re- press his fears, but the very fact that they exist, is productive of new conflicts, making him uncertain and doubtful of himself. d. The psychoneuroses are reactions which result from repeated conflicts with atten- dant anxiety, repression, and an increased dynamic drive which finds expression in phy- sical and mental symptoms. These symptoms represent the effort of the personality to adapt itself to the existing environment. The symptoms are as real, as disturbing, and as incapacitating as any symptoms resulting from organic pathology, and physiological changes may be produced through the agency of these emotional disturbances. 116. NEURASTHENIA. This is a form of psychoneurosis in which the patient attempts to transfer the anxiety and worry which arises from mental conflict, to anxiety and worry regarding physical symptoms. a. Symptoms. There are certain general symptoms of neurasthenia which are so fre- quent in occurrence that they cannot be over-emphasized. (1) Continuous fatigue, accompanied by a low ebb of interest. Characteristically, the patient complains of fatigue being worse in the morning, and improving in the even- ing. His “rest doesn’t do him any good”. (2) Loss of weight. This is due in part to dietary idiosyncrasies which these patients develop and also to the fact that they do rest poorly. Here again, the complaint is that “his food doesn’t do him any good”. (3) Headache. The headache complained of may be either occipital or frontal or both and the classic complaint is that of a feeling of a bandlike constriction around the head. (4) In addition to these more or less cardinal symptoms these patients complain of a host of other symptoms, with which every physician is familiar, referable to every system in the body. They include nausea, constipation, abdominal discomfort, palpi- tation of the heart, excessive perspiration, urinary frequency, nocturia, dysuria, dy- spnea and low back pain. The latter seems to be a particularly frequent complaint in pilots. (5) The nervous and mental symptoms are largely insomnia, inability to concentrate and mild depression of mood. b. Predisposition. Neurasthenia occurs in disappointed, discouraged people, who are doing a job they do not like. They fear rejection because of failure and they want to stop functioning. There are some goal-seeking aspects to the reaction in that the conditions wins pity and attention and brings an illusion of being wanted and looked after. It also justifies laziness, increased sleep, etc., to a certain extent. 117. HYSTERIA. As described here this sub-classification includes only the so-called conversion phenomena and in this reaction the mental conflict is converted into physical symptoms which serve to solve the conflict or to gratify a disguised wish. The type of personality developing hysteria is usually characterized by mental instability, abrupt emo- tional changes, exaggerated self-consciounesss and susceptibility to influence. a. Symptoms. The physical symptoms of this condition occur in both the motor and sensory fields. (1) The motor symptoms are largely concerned with paralyses and/or contractures. Usually only an extremity is involved, but hemiplegias do occur, (2) The sensory symptoms include anaesthesias and hyperesthesias which are often associated with the paralyses, amblyopia of varying degree, deafness and hyperacusis. (3) The nervous and mental symptoms include the hysterical fugue in which the indivi- dual engages in a series of complicated acts for which he has no memory afterward, and the dream state in which there is an apparent partial clouding of consciousness. The dream state often terminates in convulsions, which may also occur independently. Pseudo-faints are also common. Absent corneal and pharyngeal reflexes are frequent- ly seen. (4) The complaints of globus hystericus or a feeling of a “ball in the throat” and cla- vus or a feeling of sharp object being driven into the head are fairly common. b. Predisposition. Hysteria occurs in individuals who are outgoing and dependent and who need and seek attachment to others. In general, the intellectual level is usually re- latively low. The symptoms are reactions to stress, by which the patient seeks to avoid responsibility, but the symptoms may become habitual and persist after the stress has passed. The symptoms may be a defense reaction (blindness to avoid unpleasant sights, etc.) but in general they are expressions of helplessness and a bid for protection. c. Differential diagnosis. The chief condition giving difficulty from a differential stand- point in hysteria is malingering. The differentiation lies in the conscious element and is often difficult to establish. It must be remembered that a mixture may exist, and that what began unconsciously, may later be motivated consciously. 118. PSYCHASTHENIA. This is a reaction characterized by doubt and hesitation, and fixed, though recognized by the individual as irrational ideas, and actions resulting from these ideas. Both the ideas and the action are usually so bizarre as to materially inter- fere with the leading of a normal life and the forming of normal relationships. Such indi- viduals are vacillating, hesitant and uncertain of themselves, and are attempting to cope with their conflicts through increased repression. a. Symptoms. The symptoms of this reaction fall in the foHowing groups: (1) Obsessions and compulsions. (2) Impulsions. (3) Phobias. b. Predisposition. Psychasthenia occurs in individuals of an extremely orderly, idea- listic personality, who are conscientious and often stubborn. They feel a great need for security and safety and they fear their own decisions. They are trying to establish an environment in which decisions are not necessary, and in which nothing unexpected can happen. The obsessive ideas usually have to do with injury to self and the compulsive feelings therefore most often deal with violence or counter-attack. The impulsion is a reaction of hostility to a threatening environment, and the phobia usually is an expression of displacement of a fear from one situation to another. The psychasthenic Is usually of a relatively high Intellectual level, and has a realization that his ideas are absurd, yet he cannot avoid them. This reaction is of particular interest in aviation because fear of heights, compulsions to jump, etc., are common manifestations. 119. ANXIETY STATE. This is a reaction characterized by feelings of anxiety or appre- hension which may arise at first from a real cause and later become habitual. In the latter case the anxiety becomes “free-floating'1 and is not consistently referred or attach- ed to any specific stimulus. The individual developing the anxiety reaction admits his in- ability to cope with his conflict by any of the methods previously described. a. Physical symptoms. These symptoms are the physical accompaniments of fear and include dry mouth, rapid heart, excessive perspiration, nausea, vomiting, diarrhea, mus- cular tremor, etc. Loss of weight occurs early in the syndrome. b. Nervous and mental symptoms. The outstanding early symptom is increased irrita- bility which represents counter-attack, insomnia, often in the form of sudden awakening with a feeling of extreme apprehension after having gone to sleep, and frightening dreams. The last are usually concerned with the patient’s occupational pursuits and involve injury to him. Vertigo is a common complaint. The patient’s anxiety often takes the form of the fear of recurrence of some physical symptoms previously experienced. c. Predisposition. The individual developing the anxiety state is usually of a relatively high intellectual level. He has a self-evaluation of helplessness and expectation of injury either to his whole body or parts of it. The emotion of fear which he expresses and shows openly is an admission of his inability to solve his conflict, and is a dramatic appeal for help. The anxiety state is of particular interest in aviation, inasmuch as the majority of those conditions which are labelled “aeroneurosis”, “aero-asthenia”, etc., are manifestations of this reaction, for the most part. 120. TRAUMATIC NEUROSIS. Here are included a group of reactions which arise as a result of trauma. The trauma which occurs here is trauma to the personality, resulting in its disruption, and this is not the post traumatic personality change sometimes seen after actual organic damage to the brain. This group of reactions is sometimes referred to as the “war neuroses” and as “shell-shock” both of which are unfortunate terms. The reaction is not peculiar to war as it may arise in any situation which the individual inter- prets as constituting a sudden, serious threat to existence, and the lack of relationship between it and the concussive force of shells is now too well known to merit discussion. a. Symptoms The symptoms of this reaction fall largely in the same field as those discussed under hysteria and the anxiety states, but the following symptoms are most frequent: (1) Symptoms of shock, with typical manifestations of terror. (2) Comatose and stuporous conditions. (3) Maniacal reactions, excitements and fugues. (4) Delirious reactions. (5) Paralyses and sensory disturbances. (6) Epileptoid seizures. The individual who develops a traumatic neurosis suddenly perceives the world as a hostile, threatening place as the result of a threat to his life in the form of a severe trau- matic incident. Along with this altered conception of the environment comes a re-evalua- tion of himself and he begins to doubt his ability to deal with this threatening situation. Therefore, his symptoms largely take the form of psychological and physiological inhibi- tion which constitute a bid for increased protection and security. This altered conception of the world and of himself is capable of reversal during the first two weeks. After that the reaction becomes fixed and Ms highly resistant to therapy, resulting in the so-called “chronic war neuroses”. For this reason early treatment is imperative. The prognosis is best in those cases which are treated close to the scene of the precipitating incident. b. Treatment. In the treatment of the traumatic, neuroses the following principles should be observed: (1) Early treatment - as soon as the patient can be removed from the immediate stress. (2) Treatment of physical condition - rest, fluids, warmth, etc. (3) Psychotherapy - eliciting expression of underlying fears, making patient aware of break-down of fear-controlling mechanisms and the advantages he seeks to gain by being ill. (4) Recommend base hospital care only for the actual psychoses and traumatic neuroses which have been proven to be fixed, or resistant to treatment. (5) Avoid making organic diagnoses in functional cases. 121. PSYCHOTHERAPY, a. General. The type of psychotherapy which may be success- fully employed by the average flight surgeon .may be thought of as a superficial form of therapy and as such is applicable to the acute traumatic neuroses as described above, to early psychoneurotic reactions of aH types, and particularly to acute or early anxiety- states. The last often respond quite well under proper circumstances to rest, encourage- ment, and a chance to freely discuss their fears, and what they suppose is cowardice. The military environment is not the most suitable environment for successful psycho- therapy. In the first place, ideally, the merapist should be able to modify the environment as well as the patient s reaction to it. There is relatively little possibility of this in the military environment which is quite fixed and rigid. The time factor is also important as psychotherapy is often a long drawn out and tedious process. The exigencies cf the military situation are such that the necessary time is often not available. Further than this the military psychiatrist is in a rather anomalous position in his relation with the patient. The patient’s attitude toward the military physician is a mixture, as the latter represents at once a possibility of help, an avenue of escape, and the authority which keeps the patient in his undesirable situation. FinaHy, there are certain characteristics of personality required for successful adjustment in the military environment which no amount of psychotherapy can instill, and which must be thought of as inherent In the in- dividual. The individual must have a certain philosophy of life and a certain amount of stoicism. It is in those individuals already possessed of these innate qualities, and who have been overcome either by cumulative or sudden stress, that psychotherapy plays a successful role. In general, all psychotherapy can be divided into two types. These types are suggestion and analysis. The chief point of differentiation between these two types is the degree of insight developed by the patient. Suggestion aims at the removal of symptoms with the development of very little insight into their cause. Analysis aims at the removal of symp- toms with the development of a relatively complete insight. It is the first type of therapy with which we are concerned at present. b, Suggestion. In the final analysis suggestion implies the acceptance of some one else‘s opinion as being better than one’s own, and it Is therefore obvious that the evaluation of the second person is of utmost importance. If the therapist is able to establish the proper rapport with the patient, the latter can accept his suggestions. This is not a type of therapy which can be dispensed with the perfunctory attitude of most military sick calls. The statement is sometimes made that for psychotherapy to be successful it must deal with an inteHigent patient. Another requirement, that might be added, is that it be given by an intelligent therapist. The therapist must approach the patient with a kindly, sympathetic, understanding attitude, and he must make the patient feel that he (the therapist) is a strong, reliable individual who is interested in the patient’s problems and understands their existence. The therapist must neither minimize nor em- phasize the patient’s difficulties. To do the former, serves to convince the patient that ne is in worse danger than he suspected. To do the latter, tends to increase his symptoms and deprive him still more of any sense of responsibility in the matter. It should be the aim of the therapist to convince the patient that his problems are neither hopeless nor ignored, that they are recognized but can be helped, and that his present environment (hospital, etc.) is relatively safe. If this can be accomplished a long step has been taken toward providing the patient with hope, one of the necessary components of successful readjustment. Assuming that this relationship has been established between the therapist and patient the next step is the therapeutic interview which forms the primary basis of all psychother- apy. (1) Therapeutic interview. A therapeutic interview is any type of prolonged contact between the patient and the physician in which conversation plays a central role. This conversation centers around the patient’s difficulties and is chiefly carried on by the patient. Some patients will enter into such an arrangement readily, while others will need some guidance and encouragement. In no case should the patient be forced in this type of conversation, although sooner or later by appropriate questions, every significant aspect of his life can be touched upon. That being the case, this type of interview is diagnostic as well as therapeutic. The therapeutic value of such an apparently simple procedure as this lies in the fact that the patient is allowed and encouraged to verbalize his difficulties and aerate his conflicts to someone toward whom he feels as he does toward the thera- pist. This strong, reliable person (the therapist) listens to his innermost fears without condemning or punishing him. This is another long step towards reestab- lishment of his self-esteem, which is another necessary component of readjust- ment. This also makes him feel that he is facing himself and his problems, and is consequently more worthwhile. The emotional outbursts which often occur during this type of interview are also a desirable form of release of pent-up emotions. The situation which exists between the therapist and the patient is entirely similar to that which may exist between the patient and an older brother, between the patient and a trusted friend, or in some instances between the patient and the priest. It has the added advantage, however, that the physician is able to guide the patient’s conversation more intelligently to significant points of stress. The therpaist must never lose sight of the fact that all individuals solve their problems differently, and consequently he must not expect the patient to conform to any pre-conceived standards and he must not lecture or moralize with him. The duration of such an interview should be about an hour, and the frequency should be once or twice a week. In cases such as acute traumatic neurosis it may be advisable to have daily interviews. The total number required will vary with the individual case. (2) Reassurance. Into every relationship of this kind some element of reassurance, encouragement, etc. will enter. The very fact that the physician accepts the phy- sician-patient relationship in such a case is vastly reassuring to the patient. This provides him with the third of the necessary components for readjustment--secur- ity. This is accomplished due to the fact that he is accepted as worthy of help. He must also be reassured that his reactions are not unusual and are entirely normal, occurring in everyone. He must also be impressed with the fact that his symptoms and the things which he fears, are the result of a disturbance of the fear-controlling mechanism and are not evidence of cowardice as he supposes. This further in- creases his feeling of worthiness and enhances his belief that he may be helped and restored to usefulness with consequent increase in self-esteem. It also serves to divert his attention from his symptoms to their probable cause. (3) Advice. It is commonly thought that advice to the patient constitutes a promin- ent part of an interview such as this. This is not the case. The patient should sel- dom be given direct advice as to how to solve his problems. As the situation pro- gresses the majority of patients will begin to discover the answers for themselves, and will offer perfectly logical solutions for approval. In some cases in which this does not occur, after a reasonable time, the therapist may offer advice, but always with the qualification that that is the way he would handle a given situation. The patient must not be expected to solve his problems in the same way’, although an appropriate train of thought may be started. (4) Interpretation. Some element of interpretation enters into an interview of this kind by virtue of the fact that the therapist guides the conversation from one point to another. However, actual interpretation of the patient’s motives should not be attempted by any but well-trained therapists. Interpretation in the hands of others may well be incorrect and the appropriate time for it may not be recognized. There is good reason for the patient to be unconscious of his motives, and hasty or reckless destruction of his defenses may precipitate an emotional crisis. (5) Information, Information on various subjects may be of distinct value in such an interview. A simple explanation of the autonomic nervous system, its functions, and the results of disturbance of its functions may be quite beneficial. The explanation of other physiological phenomena, which seem quite common-place to the physician, may do much to convince the patient that his reactions are not abnormal. Various laboratory procedures, etc., may be employed to similar advantage. (6) Persuasion. Persuasion implies that the patient is able to logically reason that it is unnecessary for the symptoms to occur after their cause has been explained. The degree of success which will be attained here depends upon the amount of insight developed by the patient, and in general no great degree of success can be expected without resorting to analytic procedures. However, it is the aim of all therapy of this type to shift the patient’s attention from the symptoms to their cause, and to con- vince him that his illness is psychological rather than physiological. c. Hypno-analysis and narco-analysis. (1) General. In the more severe types of the traumatic neuroses, and in conversion phenomena and fugues the patient is usually not accessible to interview therapy. Most often he has a complete amnesia for the traumatic event and it is necessary that it be brought to consciousness for him in order that he may be benefited. Here, it is not the lifting of the amnesia which accomplishes the cure, for this is simply a de- fense reaction, but it is the ability of the patient to examine and reevaluate this un- conscious material after it has been brought to light, and consequently alter his con- ception of the dangerous world. (2) Hypno-analysis. This material may be brought to light through hypnosis and hy- pnosis may be employed in combination with partial analysis and suggestion. This in- volves forced recall of the traumatic incident and the patient may be given appropriate suggestions while still under the influence of hypnosis. He may also be forced to re- live the traumatic incident, many times if necessary, until he is able to evaluate it at its true worth. Many times it is found that the symptoms the patient shows are repeti- tions of his behavior at the time of the traumatic incident. (3) Narco-analysis, A similar result to that achieved by hypnosis may often be obtain- ed by inducing a partial narcosis through the administration of small amounts of the barbiturates intravenously. Sodium amytal (0.5 Gm.) or pentothal sodium (10 cc. of a 2-1/295 solution) may be employed in this connection. It must be remembered that the majority of these patients are extremely tolerant of the barbiturates, and a dosage producing sleep in a normal individual ordinarily serves only to make them more accessible. Oftentimes, in acute reactions, a single treatment of this type may suffice. Those cases which are resistant to all these forms of therapy, will probably require extensive, and intensive, therapy of various types. The point of cardinal importance is to reverse the patient’s reevaluation of himself and his environment, before it is firmly fixed or established. 122. REFERENCES. _a. Texts. — (1) Maslow, A.H., and Mittelmann, B.: Principles of Abnormal Psychology, New York, Harper and Bros., 1941. (2) Menninger, K.A.: The Human Mind, New York, Alfred A, Knopf, 1937. (3) Miller, E.: The Neuroses in War, New York, The Macmillan Company, 1940. (4) Kardiner, A.: The Traumatic Neuroses of War, Washington D.C., National Re- search Council, 1941. (5) Sadler, W.S., Theory and Practice of Psychiatry, St. Louis, C.V-. Mosby Co., 1936. (6) Armstrong, H.G.: Principles and Practice of Aviation Medicine, Baltimore, Williams & Wilkins Co., 1939. b. Bulletins. ~ (1) Knight, R.P.: The Successful Treatment of a Case of Chronic War Neurosis, Topeka, Kansas, Bulletin of Menninger Clinic, September, 1942. c. Manuals. (1) TM 8-325 Outline of Neuropsychiatry in Aviation Medicine, 1940. SECTION XII ANOXIA Paragraphs Definition 123 Classification of anoxia , 124 Signs and symptoms of anoxia of high altitude 125 Therapy 126 References 127 123. DEFINITION. The term anoxia, literally meaning “without oxygen” is used physiolo- gically to mean a deficiency rather than lack of oxygen in the tissues, A more correct term is “hypoxia”, for the tissues at altitude are probably never entirely without oxygen. Both terms are to be differentiated from “anoxemia” and “hypoxemia” which mean, liter- ally and respectively, absence of oxygen from and decrease of oxygen in the blood. The reason for the differentiation of the latter terms from the former is that oxygen want may exist in the tissues when the blood has a normal oxygen content. (See Par, 124). For convenience sake, the dividing line between anoxia and hypoxia is sometimes arbi- trarily taken as 15,000 feet altitude roughly corresponding to an atmosphere containing 12% oxygen or an oxygen tension of 90 mm Hg. 124. CLASSIFICATION OF ANOXIA. a. Anoxic anoxia. The type of anoxia pertinent to aviation resulting from a deficiency of oxygen in the respired air. b. Anemic anoxia, A cellular anoxia due to a deficiency in the transport of oxygen to the tissues. Carbon monoxide poisoning is primarily of this type of anoxia. c. Stagnant anoxia. A type of oxygen deficiency due to local or general circulatory dis- turbances with stagnation of blood in the capillaries. d. Histotoxic anoxia. A type of intracellular oxygenation defect attributable to a poison- ing of the oxidative enzymes. The usual example is cyanide poisoning. 125. SIGNS AND SYMPTOMS OF ANOXIA OF HIGH ALTITUDE. a. The chief factors that influence tolerance to anoxia are: (1) Absolute altitude. (2) Rate of ascent. (3) Duration at altitude. (4) Ambient temperature. (5) Physical activity. (6) Individual factors as inherent tolerance, physical fitness, and emotionality. b. Too much emphasis cannot be placed on the fact that intellectual impairment may occur so early that the individual may never show a definite protective reaction. It is the lack of comprehension of his general impairment that makes the individual, not indoctrin- ated in high altitude work, so dangerous to himself and to others. c. Subjective symptoms that can occur at high altitude (above 12,000 feet) may be divi- ded into three principal groups; (1) Fatigue, lassitude, headache, and somnolence. (2) Euphoria. (3) Absence of symptoms right up to the time of unconsciousness. d. Objective symptoms that may be observed: — (1) Cyanosis. (2) Impaired muscular coordination. (3) Poor judgment. (4) Release of basic personality traits. With euphoria there may be hilariousness, pugnaciousness, and overconfidence such as is often seen with acute alcoholism. (5) Hyperventilation. (6) Tetanic manifestations. (7) Syncope. (8) Unconsciousness with vascular collapse. e. After effects. Anoxia of even minor degree for moderate intervals is sometimes followed by headache or fatigue of variable duration 126. THERAPY, a. Objects. (1) To prevent death from anoxia either directly from lack of oxygen or indirectly from loss of ability to function with normal astuteness. (2) To augment fulfillment of military missions through the maintenance of a high level of personnel performance. (3) To prevent post-flight fatigue and help in the prevention of flying stress or gen- eral fatigue. (4) To maintain rapid dark adaptation on night missions. b. Methods. The proper use of oxygen equipment (See Chapter 5). c. Directions: Technical Order No. 03-50-1 states that oxygen should always be used at altitudes above 15,000 feet, and at altitudes of 10,000 to 12,000 feet if the flight at this height is of more than 1 hours duration. This will vary somewhat depending on the mission and the type of aircraft. For combat work where a considerable amount of phy- sical exertion is usually involved, oxygen should always be used above 10,000 feet. Under certain circumstances the pursuit pilot should use oxygen from the ground up, for his ascent may be rapid to high altitude, and his oxygen mask is not easily put in place dur- ing flight. On high altitude night missions all personnel should use oxygen from the ground up. On long bombardment missions at extreme altitudes (above 25,000 feet) the use of oxygen immediately on entering the plane will aid in denitrogenation and reduce the in- cidence of bends. 127. REFERENCES. a. Texts. (1) Armstrong, H.C.: Principles and Practice of Aviation Medicine, Blatimore, The Williams and Wilkins Co., 1939. b. Technical Orders. (1) No. 03.50-1, Use of Oxygen - Oxygen Equipment, June 15, 1942. CHAPTER 5 PHYSICAL FACTORS OF PHYSIOLOGICAL IMPORTANCE IN FLYING SECTION I PHYSICAL CHARACTERISTICS OF THE ATMOSPHERE Paragraphs Composition of the atmosphere 128 Altitude-pressure data 129 Temperature conversion table 130 References 131 128. COMPOSITION OF THE ATMOSPHERE. Gas Volume Partial Pressure mm Eg. Oxygen 20.93 159.07 Carbon dioxide 0.03 0.23 Nitrogen and 79.03 600.40 rare gases Water Vapor 1.00 (aver) 7.60 (aver) The measurements given for oxygen, nitrogen, and carbon dioxide are for dry air. Wet measurements are somewhat lower, and vary depending upon the amount of water vapor present. The rarer gases are physiologically inert and include helium, argon, neon, xenon, krypton, and others. Together they constitute approximately 1% of the atmosphere. 129. ALTITUDE-PRESSURE DATA (with equivalent percentages and partial pressures of oxygen), Table XVI and Figure 1Y (modified from TM 1-705). 130. TEMPERATURE CONVERSION TABLE (Centigrade to Fahrenheit), Table XVH. 131. REFERENCES. a. Texts. (1) Hodgman, C.D., and Holmes, H.N.: Handbook of Chemistry and Physics, 24 Ed., Cleveland, Chemical Rubber Publishing Co., 1940. (2) The National Geographic Society - U.S. Army Air Corps Stratosphere Flight of 1935 in the Balloon “Explorer n”, Stratosphere Series No. 2, Washington, National Geographic Press, 1936. (3) Physiology of Flight, Wright Field, Aero Medical Research Laboratory, 1942. b. Manuals. (1) TM 1-705, Physiological Aspects of Flying. (2) Brombacher W.G.: Altitude-Pressure Tables Based on the U.S. Standard Atmos- phere, N.A.C.A. Report No. 538, Washington, U.S. Government Printing Office, 1942. SECTION H EXTERNAL AND INTERNAL RESPIRATION Paragraphs Mechanical factors in respiratory gas exchange 132 Gas laws 133 Composition of pulmonary alveolar air 134 Formulae for partial pressure of alveolar oxygen 135 Prediction equations for alveolar oxygen tension 136 Carriage of oxygen and carbon dioxide in the body 137 Oxygen dissociation curve 138 References 139 132. MECHANICAL FACTORS IN RESPIRATORY GAS EXCHANGE. Figure 18 (in this figure the values for nitrogen include the rarer gases and the values for aH gases are on a dry basis.) TABLE XVI - Altitude Pressure Table to Which is Added the Equivalent Oxygen Percent and Partial Pressure (Based on the United States Standard Atmosphere (1935)) Altitude (feet) Pressure Temperature Equiva- lent oxygen percent Partial Pressure Oxygen Inches of mercury Millimeters of mercury UC. Decrease °C. 0 29.921 760.0 15 0 20.93 159.0 1,000 28.86 732.9 13 -2 20.18 153.3 2,000 — 27.82 706.6 11 -4 19.46 147.8 3,000 26.81 681.1 9 -6 18.76 142.5 4,000 25.84 656.3 7 -8 18.07 137.3 5,000 24.89 632.3 5 -10 17.41 132.3 6,000 23.98 609.0 3 -12 16.77 127.4 ■ 7,000 23.09 586.4 1 -14 16.15 122.2 8,000 22.22 564.4 -1 -16 15.54 118.1 9,000 21.38 543.2 -3 -18 14.96 113.6 10,000 20.58 522.6 -5 -20 14.39 109.3 11,000 19.79 502.6 -7 -22 13.84 105.1 12,000 19.03 483.3 -9 -24 13.31 101.1 13,000 18.29 464.5 -11 -26 12.79 97.2 14,000 17.57 446.4 -13 -28 12.29 93.4 15,000 16.88 428.8 -15 -30 11.81 89.7 16,000 16.21 411.8 -17 -32 11.34 86.1 17,000 15.56 395.3 -19 -34 10.89 82.7 18,000 14.94 379.4 -21 -36 10.45 79.4 19,000 14.33 364.0 -23 -38 10.02 76.1 20,000 13.75 349.1 -25 -40 9.61 73.0 21,000— - 13.18 334.7 -27 -42 9.22 70.0 22,000 12.63 320.8 -29 -44 8.83 67.1 23,000 12.10 307.4 -31 -46 8.47 64.3 24,000 11.59 294.4 -33 -48 8.11 61,6 25,000 11.10 281.9 -35 -50 7.76 59.0 26,000 10.62 269,8 -37 -52 7.43 56.4 27,000 10,16 258.1 -39 -54 7.11 54.0 28,000 9.72 246.9 -41 -56 6.80 51.6 29,000 9.29 236.0 -43 -58 6.50 49.3 30,000 - 8.88 225.6 -44 -59 6.21 47.2 31,000 - 8.48 215.5 -46 -61 5.93 45.1 32,000 — 8.10 205.8 -48 -63 5.67 43.0 33,000 7.73 196.4 -50 -65 5.41 41.1 34,000 7.38 187.4 -52 -67 5.16 39.2 35,000 7.04 178.7 -54 -69 4.92 37.4 36,000 6.71 170.4 -55 -70 4.69 35.6 37,000 6.39 162.4 -55 -70 4.47 33.9 38,000 6.10 154.9 -55 -70 4.27 32.4 39,000 — 5.81 147.6 -55 -70 4.06 30.8 40,000 5.54 140.7 -55 -70 3.87 29.4 41,000 5.18 134.2 -55 -70 3.70 28.0 42,000— 5.04 127.9 -55 -70 3.52 26.7 43,000 4.80 122.0 -55 -70 3.36 25.5 44,000 4.58 116.3 -55 -70 3.20 24.3 45,000 4.36 110.8 -55 -70 3.05 23.1 PHYSICAL CHARACTERISTICS OF THE ATMOSPHERE FIGURE 17. Temp. °C. 0 1 2 3 4 5 6 8 9 0 +32.0 30.2 28.4 26.6 24.8 23.0 21.2 19.4 17.6 15.8 -10 +14.0 12.2 10.4 8.6 6.8 5.0 3.2 +1.4 -0.4 -2.2 -20 -4.0 5.8 7.6 9.4 11.2 13.0 14.8 16.6 18.4 20.2 -30 -22.0 23.8 25.6 27.4 29.2 31.0 32.8 34.6 36.4 38.2 -40 -40.0 41.8 43.6 45.4 47.2 49.0 50.8 52.6 54.4 56.2 -50 -58.0 59.8 61.6 63.4 65.2 67.0 68.8 70.6 72.4 74.2 -60 -76.0 77.8 79.6 81.4 83.2 85.0 86.8 88.6 90.4 92.2 -70 -94.0 95.8 97.6 99.4 101.2 103.0 104.8 106.6 108.4 110.2 -80 -112.0 113.8 115.6 117.4 119.2 121.0 122.8 124.6 126.4 128.2 -90 -130.0 131.8 133.6 135.4 137.2 139.0 140.8 142.6 144.4 146.2 -100 -148.0 149.8 151.6 153.4 155.2 157.0 158.8 160.6 162.4 164.2 For temperatures above 0° C. 0 32.0 33.8 35.6 37.4 39.2 41.0 42.8 44.6 46.4 48.2 10 50.0 51.8 53.6 55.4 57.2 59.0 60.8 62.6 64.4 66.2 20 68.0 69.8 71.6 73.4 75.2 77.0 78.8 80.6 82.4 84.2 30 86.0 87.8 89.6 91.4 93.2 95.0 96.8 98.6 100.4 102.2 40 104.0 105.8 107.6 109.4 111.2 113.0 114.8 116.6 118.4 120.2 50 122.0 123.8 125.6 127.4 129.2 131.0 132.8 134,6 136.4 138.2 60 140.0 141.8 143.6 145.4 147.2 149.0 150,8 152.6 154.4 156.2 70 158.0 159.8 161.6 163.4 165.2 167.0 168.8 170.6 172.4 174.2 / 80 176.0 177.8 179.6 181.4 183.2 185.0 186.8 188.6 190.4 192.2 90 194.0 195.8 197.6 199.4 201.2 203.0 204.8 206.6 208.4 210.2 100 212.0 213.8 215.6 217.4 219.2 221.0 222.8 224.6 226.4 228.2 TABLE XVII. TEMPERATURE CONVERSION TABLE Centigrade to Fahrenheit For temperatures below 0° C. DEFINITIONS'- - TIDAL AIR-AIR WHICH ENTERS AND LEAVES BODY WITH EACH NORMAL RESPIRATION. SUPPLEMENTAL AIR- AIR WHICH CAN BE FORCIBLY EXPIRED AFTER A NORMAL TIDAL EXPIRATION. COM P'.EMENTAL AIR-AIR WHICH CAN BE FORCIBLY INSPIRED AFTER A NORMAL TIDAL INSPIRATION RESIDUAL AIR-AIR WHICH CANNOT BE VOLUNTARILY EXPELLED FROM LUNGS. CC- CUBIC CENTIMETERS. CO£ - CARBON DIOXIDE 02~0XYGEN N2— NITROGEN MECHANICS OF RESPIRATION large TIDAL AIR 350 cc 500cc 650cc SUPPLEMENTAL AIR ISOOcc I700cc I900cc jCOMPLEMENTARY AIR ISOOcc i70Qcc 2000cc I VITAL CAPACITY 3350cc 3900cc 4550cc (DEAD SPACE IQOcc l50cc 200cc FIGURE 18. 112 133. THE GAS LAWS. a. Boyle’s Law. With a constant temperature the volume of a mass of gas varies inversely as the pressure, or the product of the pressure times the volume is a constant v = JL p’v’=p”v”j PV=C P When using Boyle’s law for calculating the expansion of gases in body cavities on as- cent, allowance must be made for 47 mm. of Hg. pressure exerted by the water vapor found in these trapped body gases at 37°C. The effect of the water vapor pressure is relatively greater at altitude, and indicates that the expansion of a gas kept fully saturated with water exceeds the rate at which a dry gas expands with decreasing pressure. Comparison of the change in volume of a wet gas and a dry gas at sea level and at 40,000 feet (141 mm. of Hg.) demonstrates this. Saturated P1 ~ 47 = 760 - 47 =7.6 P2 - 47 l4r-"47 Dry PI = 760 =54 P2 141 b. Charles’ Law (Gay-Lussac). The volume of a gas at constant pressure is propor- tional to its absolute temperature (-273°C), or VI = T1 V2 T2 where VI and V2 are volumes of the same mass of gas at absolute temperatures, T1 and T2. c. Henry’s Law (solubility of gases). With a constant temperature the weight of a slightly soluble gas which goes into solution in a given liquid is proportional to the partial pressure of the gas. c. Dalton’s Law (law of partial pressures). The pressure exerted by each component in a gaseous mixture is independent of other gases in the mixture, and the total pressure of the mixture of gases is equal to the sum of the partial pressures (pp) of the separate components. pp = Barometric Pressure x volume percent Total Pressure = ppl + pp2 + pp3 etc, e. Standard conditions for gases. For comparative purposes any measured volume of gas is usually recalculated to the arbitrarily chosen standard conditions of 0 degrees C., complete dryness, and 760 mm Hg pressure. For some standards, such as the U. S. standard atmosphere at sea level, a temperature of 15°C is used in the definition. f. Water vapor tension. The force of molecules of water vapor in saturated air is known as the vapor tension and is expressed in mm Hg, This force is affected by temper- ature only, not by the barometric pressure. The tension of water vapor in saturated al- veolar air at body temperature (98.6°F or 37°C) is 47 mm Hg, This value does not vary with altitude. 134. COMPOSITION OF ALVEOLAR AIR. Gas Volume Percent Partial Pressure mm Hg Oxygen 13.6 103 Carbon dioxide 5.3 40 Water vapor’ 6.0 47 Nitrogen & others 75.1 570 The values given are for alveolar air saturated with water vapor at sea level and with a respiratory quotient of 0.83. The volume percentages of the dry gas are nitrogen 79.9; Oxygen 14.5; carbon dioxide 5.6. These are the values usually quoted, but vary somewhat depending upon the source consulted. At sea level the partial pressure of alveolar oxygen is approximately 35% less than the partial pressure of atmospheric oxygen. This is due to the constant presence in the lungs of water vapor at a tension of 47 mm Hg (6.0 volumes percent), and carbon dioxide at a tension of 40 mm Hg (5.6 volumes percent). With .-increasing altitude the tension of water vapor does not change although the volume percentage increases. This results in a rela- tively greater reduction in the partial pressure of oxygen in the lungs as compared to that in the atmosphere. 135. FORMULAE FOR PARTIAL PRESSURE OF ALVEOLAR OXYGEN. a. p02 = B - pCOg - pHgO - pN. Where pOg, pCOg, pHgO, and pN = partial pressure of oxygen, carbon dioxide, water vapor and nitrogen respectively. b. p02 = (B - 47) 02- Pc°2 RQ where B = barometric pressure 47 = partial pressure of water vapor in lungs in mm Hg at 37°C. 02 = volumetric fraction of oxygen in Inspired air. RQ= respiration quotient. pC02 = partial pressure of carbon dioxide in lungs in mm Hg c. p02 = (B - 47 - pC02) 02 - N2JF.Pg.92 RQ where B = barometric pressure pC02 = partial pressure of alveolar C02 O2 and N2 = volumetric fraction of oxygen and nitrogen respectively in inspired air RQ = respiration quotient d. Formula a. is a restatement of Dalton's law. Formula b. (Boothby), though arbi- trarily derived, is convenient to use, and reveals that the partial pressure of alveolar oxygen under any given conditions will be maximal when the respiratory quotient is one. Formula c. (Gray) is similar to b. but was derived mathematically, and more accurately represents the facts. 136. PREDICTION EQUATIONS FOR ALVEOLAR OXYGEN TENSION. From the equation 135 c. various prediction formulae have been derived (Gray). a. Prediction of average alveolar 02 tension at various altitudes while breathing air (RQ assumed to be 0.83). p02 = 0.176B - 30.8 where p©2 is partial pressure of alveolar oxygen, and B is barometric pressure. b. Prediction of average alveolar oxygen tension at high altitudes (above 33,000 feet) while breathing 100% 02. p02 = 0.851B - 58.7 c. Prediction of percentage of oxygen needed in the inspired air at any altitude to pro- vide a normal sea level value for alveolar oxygen tension. 0 ...161.2. ... z B-38.8 where O2 Is the volumetric fraction of oxygen required (see Table XIX). 137. CARRIAGE OF OXYGEN AND CARBON DIOXIDE IN THE BODY. Figure 19. 138. OXYGEN DISSOCIATION CURVE. Figure 20. This figure is based upon pH of 7,4, a partial pressure of CO2 of 40 mm Hg, and a body temperature of 37°C. 139. REFERENCES. a. Texts. (1) Haldane, J.S., and Priestley, J.B.: Respiration, 2nd Ed., New Haven, Yale Univer- sity Press, 1935. (2) Henderson, L.J.: Blood; A Study in General Physiology, New Haven, Yale Univer- sity Press, 1938. (3) Best, C.H., and Taylor, N.B.: The Physiological Basis of Medical Practice, 2nd Ed., Baltimore, William Wood and Co., 1939. (4) Dill, D.B.: Life, Heat, and Altitude, Cambridge, Harvard University Press, 1938. (5) Armstrong, H.G.: Principles and Practice of Aviation Medicine, Baltimore, William and Wilkins Co., 1939. (6) Physiology of Flight, Wright Field, Aero Medical Research Laboratory, 1942. b. Articles. (1) Gray, J.J.: Unpublished data. (2) Boothby, W.M., Lovelace, W.R., and Benson, O.O.: High Altitude and its Effect on the Human Body, I. J. Aeronaut. Sc. 7:461, 1940. (3) Lutz, B.R., and Schneider, E.C.: Alveolar Air and Respiratory Volume at Low Oxygen Tensions., Am. J. Physiol. 50:280, 1919, f 02 CONTENT-19 VOL. Jo TENSION - 85-100 MM HG PHYSICAL SOL. 0.24cc.VOL.% C02 CONTE NT - 45 “50 VOL.% TENSION -40 M M. HG PHYSICAL SOL. 2.5cc.V0L,% H EMOGLOBI N CONTENT- 15 CMS % OXY. HGB. - 96 % UHGB. 4 % FIGURE 19. .0^5 « J 2 - 0 5° 5 k0 °2° rQ O —| n (O J *7 in O O - o g O ± - i"- rO ! ! (0. | | OQ I ' HZ< hZJ 3 tod I 2 z >-• CD ™ O wiU OUJx u 0X0 Oloi-clO oi— a. x oox 116 OXYGEN DISSOCIATION CURVE OF ARTERIAL BLOOD (40 MM COg PRESSURE) FIGURE 20. SECTION m ANOXIA Paragraphs Equivalent altitudes breathing air and breathing 100% oxygen 140 Arterial oxygen saturation and degree of physiological handicap 141 Oxygen requirements at altitude 142 References 143 140. EQUIVALENT ALTITUDES BREATHING AIR AND BREATHING OXYGEN. (Table XVHI). 141. ARTERIAL OXYGEN SATURATION AT VARIOUS ALTITUDES WHILE BREATHING AIR AND WHILE BREATHING PURE OXYGEN IN RELATION TO THE DEGREE OF PHY- SIOLOGICAL HANDICAP . Figure 21. (From “Physiology of Flight”, Aero Medical Re- search Laboratory, 1942.) 142. OXYGEN REQUIREMENTS AT ALTITUDE. The values given in Table XIX are aver age requirements and will vary for different individuals depending upon many variables. 143. REFERENCES. (Same as for Section H). Alveolar Air Breathing Air Breathing 100% 02 02 * Tension mm. Hg. co2 * Tension mm. Hg. H2O vapor Tension mm. Hg. Barometric Pressure mm. Hg. Altitude Feet Barometric Pressure mm. Hg. Altitude Feet 103 40.0- 47 760 0 190 33,700 81 37.5 47 632 5,000 166 36,000 61 35.5 47 523 10,000 144 39,500 45 32.5 47 429 15,000 125 42,500 38 31.0 47 380 18,000 116 44,000 35 30,0 47 349 20,000 112 44,800 9 (* Means of measurements made by Lutz and Schneider, and by Boothby, Lovelace, and Benson.) TABLE XVIII. EQUIVALENT ALTITUDES BREATHING AIR AND BREATHING 100% OXYGEN. 119 FIGURE 21. Oxygen saturation (percent of capacity) of arterial blood and range of performance at various altitudes in subjects breathing air and in subjects breathing oxygen (from “Physiology of Flight”, Aero Medical Laboratory). J3 % LOWEST NORMAL 907. UNDETECTABLE ANOXI* 84% APPRECIABLE HANDICAP 77% CONSOERABLE HANDICAP | 71% SERIOUS HANDICAP ’ 66% IMMINENT COLLAPSE Altitude in Feet Barometric Pressure mm Hg. % Oxygen Required “ideal” (Sea level equivalent) “Safe” (10,000 feet equivalent) “Dangerous” (20,000 feet equivalent) 0 760 21 -- — 5,000 632 25- -- -- 10,000 523 31 21 — 15,000 429 39 26 -- 20,000 349 49 33 21 25,000 282 62 42 27. 30,000 226 81 55 36 33,700 190 100 -- 35,000 179 74 49 39,000 144 100 — 40,000 141 69 44,000 112 100 TABLE XIX. - OXYGEN REQUIREMENTS AT ALTITUDE , To maintain alveolar oxygen tension at sea level equivalent, 10,000 feet equivalent, and 20,000 feet equivalent (After Gray). 121 SECTION IV USE OF SUPPLEMENTARY OXYGEN Paragraphs Oxygen equipment 144 Oxygen duration data 145 References 146 144. OXYGEN EQUIPMENT. a. Continuous flow system, type A-8-B mask and A-9-A regulator. Figure 22. b. Demand system. Type A-9 mask and A-12 regulator. Figure 23. c. Portable (walk-around) cylinder. Figure 24. 145. OXYGEN DURATION CHART. For A-8 series masks and A-8-A and A-9-A regu- lators, (approximately the same for A-9 and A-10 masks and A-12 regulator), Figure 25. For data in connection with other types of regulators see Technical Orders. 146. REFERENCES. a. Technical Orders. (1) No. 03-50-1, Use of Oxygen - Oxygen Equipment, June 15, 1942. (2) No. 03-50-1A, Supplement on Demand Oxygen Equipment, November 9, 1942. (3) No. 03-50-6, Oxygen Masks, types A-7 and A-8, May 19, 1942. (4) No. 03-50-9, Oxygen Equipment Safety Precuations for Combat, December 31, 1941. (5) No. 03-50-15, Modification of Oxygen Masks - type A-8-B, June 26, 1942. (6) No. 03-50A-1, Oxygen Regulators: A-6, A-8, A-8-A, A-9, and A-9-A. (7) No. 03-50A-3, Oxygen Regulators, Reworking of types A-6 and A-8, May 20, 1940. (8) No. 03-50A-5, Preliminary Operation and Service Instruction, type A-12, May 5, 1942. b. Texts. (1) Physiology of Flight, Wright Field, Aero Medical Research Laboratory, 1942. OPERATING DIAGRAM 0FA-8-B OXYGEN MASK AND A-9-A CONTINUOUS FLOW REGULATOR Dark green arrows indi- of The re-breather bag or economizer stores incoming ox- ygen during exhal- ation and reduces waste of oxygen EXHALE Light green arrows in- with fresh incoming oxygen. j Additional Sponge Disc Exhalation Valves are furnished for replacing those which may become damaged or This regulator furnishes a con- tinuous flow of oxygen while in use. Therefore it should be set to correspond in altitude to the altimeter, thus assuring the proper supply. INHALE indicate £TtW from regulator to mask. 1^ Mm. n tmM •«~k FIGURE 22. I Attach fastener of strap to fitting on right side leak. To check this, place palms of hands over The operation cycle of oxygen masks A-8 and A-8-A are identical with A-B-B To insure a proper supply of oxygen at any altitude, make sure the indicator hand ia set at the some altitude as side of helmet, ready for quick attachment on face When not in use leave mask attached to left side of helmet. To get oxygen . . . attach coupling on end of hose to the regulator and open the manually operated valve until indicator hand points to altitude at which airplane is flying. If valve vibrates off yetting, tighten gland 123 OPERATING DIAGRAM OF A - 9 OXYGEN MASK AND A-12 OXYGEN DEMAND REGULATOR FOR USE IN CASE Of EMERGENCY dirsct from ths supply lins. Flow from ths supply lins at a higher rats. Watch your prsssur. gauge. Valve is openld the dioats ths iZ>w oI Prior to flight collar II mm»' OPERATION e! Ike AUTOMATIC AIK-MI2 At 30.000 fsst and above ths Auto-Mix sylphon be- Rsgulator. Grssn arrows indicats ths movsmsnt of oxygen from ths supply lins to the mask D.AORAM OP OXYOiH M'XTURI AT 10,000 PUT At intermediate altitudes ths Auto-Mix sylphon con- trols a variable mixture of oxygen and air. Ths percentage of oxygen de- pending on ths altitude. AH of this is automatically controlled by the action of sylphon. The higher the altitude the greater is the percentage of oxygen flow. The black arrows indicate incoming air and the green arrows indicate the in- coming oxygen. DIAGRAM OP OXYDIN MIXTURI AT SIA ICVIl At sea level the Auto-Mix sylphon is completely de- pressed because of the barometric pressure; thus stopping moat of the oxygen flow through the Regulator. Black arrows in lllustration show ths incoming air as it flows through the Auto-Mix into the Regulator and to the mask. Small green arrows indicate trickle of oxygen flow Into mixing chamber. FIGURE 23. i X H A L E ARROWS SHOW ROW OT EXHALO MEATH FROM THE KASK Diagram show* co- ordinated action *4 I oxygon flow auiicai- i or with diaphragm j being ueod. INHALE ARROWS SHOW OXYGEN FLOW FRO* REGULATOR TO MASK WHEN INHALING Diagram ohowc co- ordinated action of oxygon flow indicator with diaphragm of Regulator whon oxy- gon is boing ucod 124 BREATHE NORMALLY AT ALL TIMES PORTABLE | WALK-AROUND) CYLINDER (This assembly is earned in Air Corps stock as No. 41G2437' The portable unit consists of a small cylin- der which contains 6 to 12 minutes supply of oxygen, per charging. It is fitted with a demand regulator to which is attached a suspension clamp, recharging valve, a pressure gauge, and a mask hose coupling. DONT DELAY \ WHEN POINTER ON PRESSURE GAUGE REACHED RED AREA REFILL CYLINDER To recharge this cylinder, it is necessary only to connect the recharging nipple to the filler valve on a supply hose found in the airplane. To use portable unit 1st; Check pressure gauge of portable unit; 2nd; Inhale deeply, then discon- nect mask from regular hose and .. . . . quickly open spring cover of regulator connec- tion and snap in male fitting on end of mask hose. Clamp portable unit to clothing. CHECK MASK FOR LEAKS EVERT FIVE MINUTES BY SQUEEZING CORRUGATED TUBE AND INHALING 'FIGURE 24. HOURS SUPPLY PER MAN - USING A-8A 4 A-9A REGULATOR WITH MASK. (APPROX. THE SAME FOR A-12 REGULATOR.) RATES OF FLOW A-8A 4 A-9A REGULATOR its A-8A REGULATOR USE A-9A REGULATOR APPROX. THE SAME FOR A-12 REG. ED WITH HIGH PRESSURE D WITH LOW PRESSURE FLOW AT ALTITUDE CORRECTED TO ALT. (FEET) SEA LEVEL. \ MIN. / CYLINDER. 1800 if/SO. IN. CYLINDER. 900 #/SO. IN. WORKING '•RESSURE. WORKING PRESSURE. H.P. CYLINDER INTERNAL VOLUME (CU.IN.) FREE GAS CAPACITY 1800-200 H/SO. IN. (CU. FT.) L. P. CYLINDER INTERNAL FREE GAS CAPACITY VOLUME 900-50 #/SO. IN. (CU. IN.) 1 (CU. FT.) 10,000 1.6 APPROX, A-2 96 6.9 0-2 | 500 6.9 20,000 2.2 APPROX. B-l 295 19.6 F-l 4 F-2 I 1000 13.8 30.000 3.2 APPROX. C-l 4 AN-C-51 386 25.6 6-1 1 2100 29.0 0-1 BIN 39.2 E-l 696 92.9 FIGURE 25. Figure 25. OXYGEN DURATION 126 SECTION V ACCELERATION IN AIRCRAFT Paragraphs Definitions 147 Linear acceleration 148 Angular acceleration 149 Radial acceleration 150 References 151 147. DEFINITIONS, a. Linear velocity is the distance in a straight line traversed per unit of time v= X where v is velocity, s distance, and t time. Linear velocity has no physiological effect on the body if there is adequate protection from wind. b. Acceleration. Motion is said to be accelerated when the distance covered per unit of time is always greater than that covered during the preceding interval of time. The opposite of acceleration is deceleration, a term which means that the velocity of the mov- ing body is decreasing for each unit of time. Motion is also said to be accelerated if its direction is changed (radial acceleration), or if both its rate and direction are changed (angular acceleration). For uniform acceleration a = IX2_z_Yl)_ t where is the initial velocity, V£ the final velocity, and t the time. c. Linear acceleration is the rate of change of velocity without a change in direction. This may be expressed symbolically in terms of the acceleration of gravity (g units): la = (v2)2 - (vi)2 2s x g where la is linear acceleration, V2 is the final velocity, the initial velocity, s the dis- tance through which the change in velocity occurs, and g the acceleration of gravity (32 feet or 10 meters per sec. per sec.). d. Radial acceleration. The moving body undergoes a change of direction but no change in rate. An example of radial acceleration is an aircraft moving in a circle at constant velocity. This velocity can be measured in terms of the angle at the center of the circle which it traverses per unit of time. This angular velocity, measured in radians (57.296°), is constant. Radial acceleration results in the development of centrifugal and centripetal forces which are equal and opposed. The acceleration may be calculated in g units from the formula: ra = rxg where ra is radial acceleration, v velocity, r radius of curvature, and g the acceleration of gravity (32 ft. per sec.2). The formula shows that the acceleration involved will be greater when the velocity of a turning aircraft is rapid, and when the radius of the turn is small as in a tight spiral or sharp banking turn. (Figure 26). THE RELATION BETWEEN VELOCITY, RADIUS OF CURVATURE AND FORCE OF RADIAL ACCELERATION IN G UNITS. FIGURE 26. e. Angular acceleration. If in addition to changing its direction a moving body also changes velocity it is said to display angular acceleration. In this type of acceleration the angular velocity is changing. 148. LINEAR ACCELERATION. Linear acceleration and deceleration occur in the cata- pult take-off, carrier deck landings, crash landings, and parachute jumps. The distance factor, s, given in the denominator of the equation in par. 147 c., emphasizes the impor- tance of the distance through which a change in velocity occurs. Even when this distance is small the total force involved is greatly reduced compared to what it would be if this distance were zero. It probably explains the relatively minor injuries sometimes encoun- tered in crash landings and in falls from great heights into snow banks or soft earth. The other variable involved is the area of the body over which such forces act. When this is large the human body apparently can withstand instantaneously as much as 200 g. 149. ANGULAR ACCELERATION. This occurs in an aircraft when it is changing both its velocity and direction of motion. It is encountered in some maneuvers especially the spin. 150. RADIAL ACCELERATION, a. The centrifugal force involved in radial acceleration (Figure 27) may cause marked physiological effects because of the inertia and the mobil- ity particularly of the fluid contents of the pilot’s body. These effects depend upon (1) Direction of the force, (a) Positive acceleration. The applied (centripetal) force is perpendicular to the line of flight and is directed toward the under surface of the airfoil. The reaction (centrifugal force) is in the opposite direction, and with respect to seated occupants acts from head to seat. (Figure 27). Positive acceleration is encountered in the in- side loop, a sharp banking turn, the inside spin, the barrel roll, and in a pull out after a dive. Subjectively, radial acceleration of +2 to +3g will cause a sensation of being compressed in the seat (“concertina action”), and heaviness of the hands. For most individuals +4g acting for seconds will cause graying of vision, +5g will cause blackout (“amaurosis fugax ’) for the same Interval, and +6g will cause loss of consciousness. Thresholds, in terms of g’s and time, may be de- termined for these three manifestations in different individuals. Objectively, the pulse and respiratory rate increase early, and the blood pressure in the carotid arteries falls. The soft tissues of the face are pulled downward from the facial bones causing a drawn, haggard appearance. Manifestations cease as soon as the force stops acting except that if unconscious- ness has occurred confusion may persist for 5 to 10 seconds. (b) Negative acceleration. The applied (centripetal) force is perpendicular to the line of flight, and is directed toward the upper surface of the airfoil (Figure 27). The opposing centrifugal force acts from the seat to the head of the seated occupants of the aircraft. Negative acceleration is encountered in outside loops, oustide spins, and push downs. Subjectively, it is accompanied by a feeling of congestion of the head and face, throbbing pain in the head, and above -4.5 g by redout. Objectively, there may be facial and conjunctival congestion, increased pulse and respiratory rates, increased intracarotid perssure, and mental confusion. For several hours after the force ceases to act headache may persist. (2) Duration of force. To cause physiological effect the forces involved in radial ac- celeration must act over a certain minimum period. For centrifugal forces this min- imum is probably about 1 second, (3) Condition of flying personnel. The individual tolerance to negative acceleration probably does not vary. On the other hand tolerance to positive acceleration varies greatly. It may be reduced by such factors as inadequate sleep, fatigue, anoxia, alcohol and tobacco to excess, and illness. (4) Velocity of the aircraft and radius of turn (see par. 147 d. and Figure 26), b. Pathological physiology. Physiological effects of radial acceleration are explained largely on the basis of simple hydrostatics. During positive acceleration, circulation to the head is impaired for two reasons. First, the hydrostatic effect of positive acceleration on the intracarotid blood opposes the pumping action of the heart. Second, the hydrostatic FIGURE 27. Acceleration in aircraft. In positive acceleration the applied force (Cp, centripetal) is to the under surface of the airfoil, and the inertia of the pilot’s body is in the opposite direction (Cf, centrifugal), acting from his head to his seat. A reversal of these forces occurs in negative acceleration. Transverse acceleration occurs when velocity is increased or decreased in level flight. In an arrested landing the applied force (A, solid arrow) is from front to back, with the force of inertia (I, dashed arrow), acting from back to front. A reversal of these forces occur in the catapult takeoff. It is to be noted that when an aircraft changes its direction the forces Cp and Cf do not replace lift and gravity but occur in addition to them. effect on venous blood below the level of the heart impairs return flow to this organ with consequent reduction in cardiac output. Visual disturbances, namely, the “grayout” and “blackout”, are ascribed to the normal intraocular pressure of 20 mm Hg. Any reduction of blood pressure in the vessels of the head will therefore find the central artery of the retina already at a disadvantage of approximately 20 mm Hg. With negative acceleration, blood is driven to and retained in the upper part of the body, raising the intracarotid and intracranial pressures. c. Prophylaxis. (1) Positive acceleration. (a) Personnel - crouching position, grunting or yelling, eating before flying, physi- cal and various types of anti-blackout suits and devices increase tolerance to g. (b) Materiel - high rudder bars, limited elevators, diving flaps, horizontal seats (pilot prone), and automatic tilting seats have value. (2) Negative acceleration - none. Avoidance is the only preventive. 151. REFERENCES. a. Reports. (1) Bulletin of the Subcommittee on Acceleration, O.S.R.D., C.A.M., N.R.C., Septem- 1942. (2) Rose, B., and Martin, W.R.: The Determination of the Blackout Threshold in Aircrew Trainees, and Factors Concerned in its Variations, No. 2, Initial Training Center, RCAF, 1942. b. Articles. (1) De Haven, H.: Mechanical Analysis of Falls from Heights of Fifty to One Hundred and Fifty Feet, War Medicine 2:586, 1942. (2) Ham, G.C.: Effects of Centrifugal Acceleration on Living Organisms, War Medi- cine, 3:30, 1943. SECTION VI NOXIOUS GASES IN AIRCRAFT Paragraphs Carbon monoxide 152 Gasoline fumes 153 Hot oil fumes 154 References 155 152. CARBON MONOXIDE; a. Sources of carbon monoxide in the cockpit. (1) Exhaust fumes of aircraft engines (concentration 1% to 7%, average 2.8%). (2) Leaky cockpit or cabin heaters which utilize exhaust gases for heating. (3) In some single-engine airplanes it may be impossible to eliminate carbon mono- xide entirely from the cockpit. The maximum concentration safely permissible has been established as 0.005%. b. Toxicology. The affinity of hemoglobin for carbon monoxide is 250 times as great as its affinity for oxygen. The union is a strong one so that oxygen cannot combine with hemoglobin and anemic anoxia results. In addition the dissociation curve of whatever oxy hemoglobin is present is shifted to the left making it difficult to supply the oxygen that is present in the blood to the tissues (Figures 28 and 29). Dangerous concentrations of car- bon monoxide are as follows: Concentration, percent Effect 0.01, or 1 part in 10,000 No symptoms for 2 hours 0.04, or 4 parts in 10,000 No symptoms for 1 hour 0,06 to 0.07, or 6 to 7 Headache and unpleasant parts in 10,000 symptoms in 1 hour 0.10 to 0.12, or 10 to 12 parts in 10,000 Dangerous for 1 hour 0.35 or 35 parts in 10,000 Fatal in less than 1 hour c. Symptoms. (Figure 30). (1) Depend upon (a) Concentration of carbon monoxide in the inspired air. (b) Duration of exposure. (c) Altitude at which exposure occurs. (2) Symptoms which develop at various concentrations of carbon monoxide in the blood are as follows: Carbon monoxide, percent in blood Symptoms 0-10 None 10-20 Tightness across forehead, possibly slight he'adache, dilatation of cut- aneous blood vessels. 20-30 Headache, throbbing in temples. 30-40 Severe headache, weakness, dizzi- ness, dimness of vision, nausea and vomiting, and collapse. 40-50 Same as previous, with increased pulse rate and respiration and collapse, or unconsciousness. 50-60 Unconsciousness, increased respir- ation and pulse, intermittent con- vulsions, Cheyne-Stokes’ type of respiration. EFFECT OF CARBON MONOXIDE ON ARTERIAL HB SATURATION AT VARIOUS ALTITUDES FIGURE 28. (AFTER HEIM). EFFECT OF CO ON THE SHAPE OF THE OXYGEN DISSOCIATION CURVE FIGURE 29. (AFTER HEIM). BLOOD SATURATION AND RESULTING SYMPTOMS PRODUCED BY VARIOUS CONCENTRATIONS OF CARBON MONOXIDE IN THE INSPIRED AIR. FIGURE 30. 60-70 Coma with intermittent convulsions, depressed heart action - possibly death. 70-80 Weak pulse and slowed respiration, respiratory failure and death. d. Treatment. (1) Secure maximum ventilation by opening cockpit canopy or cabin windows. (2) Turn off any exhaust type heaters in use. (3) Use supplementary oxygen. (4) Descend to low altitude or return to ground. 153- GASOLINE FUMES. Aviation gasoline contains ethyl fluid. This is a volatile liquid containing about 60% by weight of tetraethyl lead, a volatile organic lead compound. Ethyl fluid is mixed with aviation gasoline in a concentration of about 0.2%. During some maneuvers in airplanes, particularly some aerobatics, a strong odor of gasoline may be present in the cockpit. Breathing the vapor of aviation gasoline should be avoided as the lead content of ethyl fluid is volatile and the fumes are toxic. If gaso- line fumes are noted, maximum ventilation should be secured by opening the canopy or cabin windows. 154. HOT OIL FUMES. Breakdown products of lubrication oil, particularly the aldehyde acrolein, are toxic. Symptoms are similar to those of carbon monoxide posioning. Differ ential diagnosis is based on the finding of hot oil fumes in the cockpit in the absence of carbon monoxide in the blood of the individuals affected. If hot oil iumes are preceived adequate ventilation should be obtained. 155. REFERENCES. a. Articles. (1) Heim, J.: The Toxicity of Carbon Monoxide at High Altitudes, J. Aviation Med. 10:211, 1939, b. Texts. (1) Drinker, C.K.; Carbon Monoxide Asphyxia, New York, Oxford University Press, 1938. c. Manuals. (1) Industrial Hygiene Manual, Patterson Field, Air Service Command, 1942. CHAPTER 6 MEDICAL TRAINING SECTION I MEDICAL DEPARTMENT ENLISTED MEN Paragraphs General 156 References . — 157 156. GENERAL. The Flight Surgeon will usually have one or more Flight Surgeon’s assistants who have been trained at the School of Aviation Medicine. However, he may be required to give medical training to enlisted men, recently acquired by the Army, who have had no specialized instruction. To accomplish this the Flight Surgeon may obtain guidance from the following references: 157. REFERENCES. a. Manuals. (1) MTP 8-1, Medical Department Mobilization Training Program for Medical Depart- ment Units at Unit Training Centers. (2) MTP 8-5, Medical Department Mobilization Training Program, (3) TM 8-220, Medical Department Soldier’s Handbook. b. Letters. (1) WD, AGO, April 17, 1940, Subject: War Department Training Directive, 1940-1941 (Medical Department Training). (2) Instructor’s Guide for Medical Department Mobilization Training Program 8-1, Carlisle Barracks, Medical Field Service School, 1942. c. Texts. (1) Military Medical Manual, 4th Ed., Harrisburg,The Military Service Publishing Co., 1940. d. Regulations. (1) MR 3-1, Organization and Training. e. Schedules. (1) Program of Instruction, Flight Surgeon’s Assistants, The School of Aviation Medicine, Randolph Field, texas. SECTION n AIR CREWS AND COMBAT CREWS Paragraphs Objective 158 Scope 159 Duration of instruction 160 Method of instruction 161 Program 162 158. OBJECTIVE (Modified from AAF Memo No. 25-1, WD Hq. AAF May 21, 1942). To provide air crews, combat crews, and air crew replacements with sufficient knowledge of first aid, sanitation, and preventive medicine to protect themselves and those under their command from various diseases and dangers in the Theatre of Operations. To ren- der proper and efficient first aid to themselves and to the members of their command when medical personnel are not available. 159. SCOPE. The program of instruction will include the general subjects of first aid and sanitation, as well as the application of hygiene and preventive medicine to the parti- cular problems to be met by the Unit in its proposed Theatre of Operations. Instructions will consist of film strips, lectures and demonstrations by the Unit Surgeons, and the actual application of first aid to simulated war time injuries by each crew member. 160. DURATION OF INSTRUCTION. The length of the course will be regulated to conform with the time available and the objective to be attained. 161. METHOD OF INSTRUCTION. Lectures and demonstrations must be carefully pre- pared and rehearsed in advance In order to provide a maximum of instruction in the mini- mum amount of time. Sanitary appliances will be prepared and demonstrated. Dramati- zation of simulated injuries will be utilized to the fullest extent. Attendance will be re- quired of all members of the Unit. Upon the completion of the course, each Unit Surgeon will forward a report direct to the Office of the Air Surgeon outlining the course, accom- panied by a certificate that all members of his organization have received this instruction, 162. PROGRAM OF INSTRUCTION. The emphasis of all training must be placed on prac- tical measures which can be accomplished by non-medical personnel to relieve suffering and to save lives of members of the crew who are wounded in the air or who are injured on the ground in places which professional medical personnel cannot reach in a relatively short period of time. Simple details of the following must be covered: a. First aid treatment of gunshot, shell, and bomb wounds. In the control of hemorrhage too much confusing detail on “pressure points” should be omitted, and more detail given on the use of large, sterile, compress type of bandages over wounds caused by explosives. When the lower part of the face has been shot away, it is imperative to keep the tongue, or what remains of it, out of the pharynx. b. First aid treatment of burns. c. The first aid kit aeronautic including the use of sulfanilamide powder in fresh open wounds, and the use of “Syrettes” of morphine. d. Preventive aspects of disease especially of malaria (mosquito bar, mosquito head net, mosquito boots, long trousers and shirt sleeves, mosquito control), of venereal diseases, and of gastrointestinal diseases (sterilization of water, thorough cooking of foods, fly control). e. The following is a guide for the medical officer in giving this medical instruction to flying personnel (approximately 20 hours). Throughout the personal, individual aspects of each subject must be emphasized. It is more important, for example, to tell the combat crew how to sterilize a canteen full of water, should they be forced down, than to give them details of a complicated purification plant that will be used only by an Engineering Unit attached to a relatively large task force. In addition, if the Flight Surgeon has an inkling of where the Unit is going, he may emphasize, with the unit Intelligence Officer’s permiss- ion, the problems most likely to confront the group or squadron. Subject Reference (1) Field Sanitation and Personal Hygiene. (a) Essential steps in transmission of diseases. (b) Water purification. (c) Mosquito and fly control. (d) Field sanitary appliances. (e) Individual delousing methods. (f) Care and prevention of trichophytosis. (g) Prophylaxis of venereal diseases. FS 8-3; FS 8-5; Military Medical Manual; Field Sanitation (FM 8-40); Dun- ham’s Military Preventive Medicine” (Army Medical Bulletin No. 23); Desert Operations (FM 31-25). (2) First aid. (a) Use of first aid kit, aeronautic. (b) “Shock”, prevention,, treatment. (c) Hemorrhage, methods of control. (d) Wounds; Dressings; Topical use of sulfanila- mide powder. (e) Burns. (f) Fractures. (g) Heat exhaustion and heat stroke. FS 8-33; Guides to Therapy for Medical Officers (TM 8- 210); Military Sanitation and FirstAid (AM 21-10); Military Medical Manual; Medical De- partment Soldier’s Handbook (TM 8-220); Desert Operations (FM 31-25). (3) Tropical Medicine. (a) Mosquito-borne diseases. The discussions of these should be brief with greatest em- phasis on the habits and control of mosquitos Jungle Warfare (FM 31-20); Stitt’s “Diagnosis, Prevention, and Treatment of Tropical Di- and the prevention of mosquito bite. seases,>; Dunham’s “Mili- 1. Malaria. tary Preventive Medicine”. 2. Dengue. S. Yellow fever. (b) Louse-borne diseases. Control of body infestation is again the most important aspect. 1. Typhus. (c) Miscellaneous. 1. Trypanosomiasis, S. Tropical sore. 3. Filariasis. 4. Schistosomiasis. 5. Snake Bite. S. Poisonous shrubs. 7. Poisonous insects. $. Poisonous and dangerous acquatlc animals e.g. barracuda, morays, sting rays, scorpions. (4) Arctic Medicine. (a) Frostbite. The Arctic Manual (TM 1-240); (b) Arctic clothing; principles of heat regulation Operations in Snow and Extrem of body. Cold (FM 31-35) (c) Arctic rescue unit. (d) Snow blindness. (5) Desert Medicine. (a) Heat exhaustion, heat stroke, and heat cramps. Desert Operations (FM 31-25) Relation of Intake of salt, water, and vitamins. (b) Protection of eyes from glare and sand. (c) Sanitation in the desert. (d) Sandfly fever. (6) Aviation Medicine. (a) Anoxia. Use of supplementary oxygen; demon- High Altitude Physiology, stration of oxygen equipment. Wright Field, Aero Medical (b) Decompression sickness including aero-em- Research Laboratory, 1941. bolism, aero-otitis media, aerosinusitls, and Air Crew in their Element the effect of altitude on the gastrointestinal (Maj, Y.E. Henderson), U. of tract. Toronto Press, 1942) (c) Airsickness, causes and prevention. Physiological Aspects of Flying (d) Acceleration in aircraft; physiological effects; and Maintenance of Physical Anti-blackout equipment and methods. Fitness (TM 1-705) (e) Eyes: Solar retinitis; Prevention of foreign Airsickness, Causes and Pre- bodies (from propeller blast while taxiing); vention, S.A.M., 1943 Flight Surgeon’s Handbook, burns of eye in combat; night vision; effect of foci of Infection, anoxia, and fatigue on 2nd Ed., S.A.M., 1943. vision. (f) Ear, Nose, Mouth and Throat: Dangers of flying with an upper respiratory infection or tonsillitis; aviation deafness and prevention; methods of equalizing pressures in middle ear and throat on ascent and descent; dental hygiene. (f) Flying Fatigue: causes, prevention; importance of recreation, hobbies, adequate diet, rest, tobacco and alcohol, adequate protection from cold, comfortable position in aircraft, physical fitness. (f) Flying Clothing SECTION m MEDICAL OFFICERS ON DUTY WITH A.A.F. Paragraphs Outline of basic training 163 Didactic program for rating as aviation medical examiner 164 References 165 163. OUTLINE OF BASIC TRAINING, a. Military Training. (1) Military Courtesies and Customs of the Service. (2) Military Training Methods. (3) Shelter Tent Pitching and Display of Equipment (4) Heavy Tent Pitching (5) Litter Drill and Ambulance Loading (6) Interior Guard Duty and Drill, Close Order (7) Soldiers Medical Field Equipment (8) Physical Training b. Military Art. (1) Organization of Army (2) Organization of Air Forces (3) Organization of Medical Department (4) Organization of Medical Service of AAF (5) Evacuation (a) Rail (E) Motor (Mobile & Stabilized. Situations) 0 Air Evacuation 1. by Light Plane Ambulance 13. by Transport Ambulance 5. by Liaison Plane 3. by Transport Plane E. the Air Ambulance Squadron E. the Air Ambulance Section (6) Medical Service with AAF in Zone of Interior (7) Medical Service AAF Units when operating with Ground units in Theater of Operation (8) Medical Service with AAF units when operating alone in the Theater of Operation (9) Medical Plan in Ground-air Defense of an Airdrome (10) Medical Plan for Defense and Against Treatment of Chemical Casualties and Chemicals (11) Map Reading (12) Aeronautical Charts (13) Avlgation (14) Theory of Flight (15) Meteorology (16) Jungle Warfare (17) Operations in Snow and Ice (18) Desert Operations (19) Landing Operations (20) Identification of Aircraft (21) SOP for Medical units AAF (22) Camouflage (23) Staff Procedure (24) Defense against Chemicals (General) (25) Identification Foreign Vehicles c. Military Sanitation (1) Housing of Troops (2) The Medical Inspector (3) Food Inspection (4) Mess Sanitation (5) Field Disposal of Human Wastes (6) Field Disposal of Kitchen and Animal Wastes (7) Field Water Supply (8) Disinfestation in the Field (9) Control of Respiratory Disease (10) Control of Intestinal Diseases (11) Malarial Control (12) Control of Chiggers, Sand Flies, Ticks, Ants, Bed Bugs, Cockroaches, and Lice (13) Rodents - Rodent Fleas and Rodent and Flea Borne Diseases (14) Control of Venereal Diseases (15) Sanitary Problems in Tropical Countries (16) Sanitary Problems in Desert Operations (17) Sanitary Problems in Arctic Operations (18) Sanitary Orders d. Military Administration (1) Military Law (2) Manual of Courts Martial (3) Service Records (4) Morning Reports and Rosters (5) Pay Vouchers - Pay Rolls- Allotments (6) Daily Sick Report and Sick Call (7) Property: Accountability and Responsibility (8) Clothing and Equipment (9) Rations and Mess Management (10) Sick and Wounded Register (11) EM Tag and Field Medical Record (12) Report of Sick and Wounded (13) Statistical Reports (14) Hospital Administration (15) Military correspondence (16) Board of Officers (17) Efficiency Report (18) Operation of the Dispensary (19) Deserters and Reports of Desertion (20) Death Reports (21) Squadron Surgeon Administration (22) Group Surgeon Administration (23) Safeguarding Military Information (24) The General Hospital (25) The Station Hospital (26) The Evacuation Hospital (27) The Field Hospital (28) The Surgical Hospital (29) The Convalescent Hospital (30) The Medical Supply Depot (31) The Medical Laboratory (32) The Auxiliary Surgical Group (33) The Hospital Train (34) The Hospital Center (35) The Medical Regiment (36) The Medical Battalion (37) The Ambulance Battalion e. Logistics (1) Motor Maintenance and Care (2) Selection of Motor Vehicle Drivers (3) Training of Motor Vehicle Drivers (4) Motor Movements (5) Shuttle Movements (6) Medical Supply (7) Air Depot Group - Function of (8) Service Group - Function of L Field Medicine and Surgery (1) Operation of Aid Station (2) Treatment of Shock and Burns (3) Treatment of Chest and Abdominal Wounds (4) Treatment of Fracture and Crushing Injuries (5) Emergency of Plastic Repair (6) Treatment of Chemical Casualties (7) Dental Field Service (8) Veterinary Field Service (9) Tropical Field Medicine (10) First Aid in Flight (11) Removal of Injured from Plane 164. DIDACTIC PROGRAM FOR RATING AS AN AVIATION MEDICAL EXAMINER. The didactic program at the School of Aviation Medicine consists of lectures, demonstrations, and appllcatory exercises in opthalmology, otorhinolaryngology, neuropsychiatry, psy- chology, and Aviation Medicine. The latter includes a consideration of the Army Regula- tions pertaining to the physical examination for flying, physical diagnosis, cardiology, and the physiological aspects of flying. During the war emergency courses are included to cover tropical medicine, field medicine and sanitation , and military surgery. 165. REFERENCES. a. Schedules. (1) Program of Instruction, The Six Weeks Course, School of Aviation Medicine, Randolph Field, Texas. (2) Program of Instruction (Medicine), Officer Training School, AAFTTC, Miami Beach, Florida, September 30, 1942. b. Manuals. (1) FM 21-5, Military Training. (2) FM 21-6, List of Publications for Training and Training Films. c. Films. (1) TF 7-295, Military Training. d. Texts. (1) Military Medical Manual, 4th Ed., Harrisburg, The Military Service Publishing Co., 1940. CHAPTER 7. SANITATION SECTION I Paragraphs Model of sanitary report 163 SANITARY REPORT 166'. MODEL OF SANITARY REPORT. The following is a model of a monthly sanitary report rendered by a station hospital (see AR 40- 275); STATION HOSPITAL Office of the Surgeon Randolph Field, Texas March 10. 1942. SUBJECT: Sanitary Report for February, 1942. TO; The Commanding Officer, Randolph Field, Texan. 1. The following report of sanitary conditions at this station for the month of Febru- ary, 1942, is submitted in accordance with paragraph 1, c, AR 40-275, dated November 15, 1932, Section Ht, WD Circular No. 114, dated Tune 13, 1941, and letter, Surg, 721.5- (General), Headquarters Eignth Corps Area, Fort Sam Houston, Texas, dated Decem- ber 19, 1941: a. Environmental Sanitation: (1) General environmental sanitation is satisfactory. (2) Water supply: (a) Adequate supply at ail times during the month of February, 1942. (b) Maximum daily usage in gallons 1,060,000 Average daily usage in gallons 840,000 Average daily usage per capita in gallons 82 Maximum daily available gallons 2,280,000 (c) Number of samples from post water supply examination for bacteria during the month - (No analysis of water made). Number of specimens from post water supply reported as unsatisfactory - None . Copies of reports on examination of water inclosed. (d) No improvement in effectiveness of chlorination system over last month. (3) Sewage Disposal; (a) Average daily flow in gallons 564,527 MsTamum daily flow in gallons 615,273 Number of times plant “by-passed” during month - None. (b) Suspended solids (monthly average) Raw Sewage PPM - 6,000 Suspended solids (monthly average) Final Effluent PPM - 1,000 Suspended solids (monthly average) % removal - 76% BOD (not obtained) Relative stability (monthly average) on Raw Sewage (Methylene Blue Test) - 27% Relative stability (monthly average) on Final Effluent (Methylene Blue Test) - 83% Chlorine Residual (monthly average) in Final Effluent PPM - 0.4 (c) The receiving stream is intermittent in its flow above entrance of the sewage effluent, dry above plant. b. Personal Hygiene: Monthly physical inspection of the command was held Febru- ary 19, 20, 1942, with approximately 100% attendance. No “New" cases of venereal diseases were detected at this inspection. Personal hygiene is satisfactory Venereal rate for the command for the month of February, 1942, 30.3. c. Undue Prevalence of Acute Communicable Diseases; One case of Typhus Fever occurred in the command during the month of February, 1942. d. New or Improved Administrative Measures and Sanitary Appliances: None. e. Subjects Not Covered Under Other Headings: (1) The menus of all organizations are checked frequently by the Medical Inspector and from time to time by the Post Surgeon. They are well balanced as to protein carbohydrate, and fat contents. The feeding of butter, milk, fresh fruit, and vege- tables dally assures an adequate supply of vitamins. (2) As a result of one case of Typhus Fever developing on this post and a report of nine cases in the City of San Antonio, Texas, a rat extermination campaign was car ried out at this station on February 26 to 28, 1942. f_. Recommendations: (Signed) Lieut. Col., Medical Corps, SURGEON, 6 Incls. - MD Form 95 SECTION n SANITARY ORDER Paragraphs Problem 167 Solution -168 167. PROBLEM. You are the Squadron Surgeon of the 361st Pursuit Squadron located at Base, California. Your squadron is ordered to patrol duty along the Mexican border with establishment of a camp 7 miles north of Brownsville, Texas. Water can be supplied from a nearby rancher's windmill and well. Other supplies must be obtained by truck transportation from railhead at Brownsville, Texas, or by local purchase. Prepare a sanitary order for this situation as of date of arrival at camp site. 168. SOLUTION. Headquarters, 361st Pursuit Squadron, Brownsville, Texas, February 20, 1942, GENERAL ORDER NO. 1 1. The following provisions for the sanitation of this command are published for the information and guidance of all concerned; a. The unit commanders are responsible for the carrying out of the provisions of this order in the units and the areas occupied by them, b. The squadron surgeon is responsible for the inspection, reporting on and the making of recommendations on all matters which affect the sanitation and the general health of this command. c. Police officer will be responsible for the sanitation of those areas not occupied by individual units and will cooperate with the squadron surgeon and unit commanders in the maintenance of correct sanitary conditions within the camp area. d. Water Supply Water for all purposes will be obtained from tank at Ranch X by water cart transportation. Water for cooking and drinking will be sterilized by clori- nation in water carts as directed in memorandum attached hereto (or par. 20, Field Manual 21-10). Due precaution will be taken to prevent contamination of water after sterilization. Common drinking cups will not be used. Water for bathing and laundry will be drawn each morning from water cart at bathing area. e. Food and Messes; Squadron mess officer will be permitted to purchase such arti- cles of food as may be offered by local markets and which conform with the provisions of this paragraph. Only meat and dairy products will be used which have received the approval of the medical Inspector at either time of purchase or time of delivery. These purchases will be made only at places approved by the medical inspector. Food delivered from town or railhead will be accurately protected In transit. Only bottled and canned milk will be used. Bottled milk will be pasturized, and obtained only from markets approved by the medical inspector. All leafy vegetables will be thoroughly washed prior to use. The squadron mess officer will be held responsible for the pro- tection and storage of all food used. Preservation of food will be accomplished as described in attached memorandum (or par. 39, Field Manual 21-10). Mess kits will be washed in two cans of hot, soapy water and one of hot, clear water. i_. (1) Waste Disposal: Kitchen waste will be separated in edible, non-edible gar- bage, rubbish, and tin cans. Edible garbage will be called for daily by a designated civilian (Mr. X) at 9:00 A. M. and 6:00 P. M. each day. Non-edible garbage and rub- bish will be disposed of by incineration as described in attached memorandum. Tin cans and containers will be flattened, burned, and buried. Liquid waste will be disposed of in soakage pits and grease traps and cared for as described in attached memorandum. (2) Human Waste: Deep pit latrines will be dug as described in attached memoran- dum. Latrine boxes, screens, and other equipment necessary for care of latrines will be obtained from squadron supply officer. Crude oil will be sprayed daily in the latrines. Seat boxes will be scrubbed dally with soap and water and two times a week with a two per cent creosol solution. A urine trough will be built as in attached memorandum and run into soakage pit. A latrine orderly will be held responsible for proper policing of latrines and surrounding area. Night urinal cans will be placed in squadron street at taps and will contain two inches of two per cent creosol solution. These will be re- moved and emptied in soakage pits at reveille, scrubbed with soap and water and air dried. g. Quarters: Shelter tents and wall tents will be left open during the day when the wea- ther is favorable. All tents will be struck once a week to provide proper airing of site. Bedding will be aired twice a week. Head to foot sleeping arrangements will prevail. h. Insect Control: Fly traps will be obtained by units from squadron supply officer and placed about kitchens, garbage racks, and latrines. These will be properly baited, in- spected, and cleaned daily. Mosquito nets will be used on each bunk. These will be inspected and all holes repaired. A spray gun will be available in each tent. Mosquito bars will be neatly rolled during the day. Guards will be furnished with a repellant and head nets, supplied by squadron supply officer. (Breeding areas of mosquitos will be destroyed as described in attached memorandum). Scorpions: Because of prevalence of scorpions, all men are cautioned to shake out gloves, shoes, socks, and other articles of clothing before putting them on in the morn- ing and to shake out bedding at night. i_. Personal Hygiene; Shower baths will be made available daily at 4:00 P. M. Buck- ets of water and basins will be provided at ablution areas at other times. Clothes vTU be washed at times indicated by squadron commander. Hair will be cut to one inch length. j_. Dispensaries; Squadron dispensaries will be located at end of camp street at en- trance to camp, south of squadron headquarters. Red cross flag indicates location in day time. Due to blackout conditions, no light will be used at night. Sick call will be at 7:00 A. M. daily. Emergency cases or individuals who become sick at any other time, will report to the dispensary immediately. k. Venereal Prophylaxis; Will be available at squadron dispensary at all times and at prophylactic station maintained in the central court house, Brownsville, Texas, at times to be indicated by squadron commander. 1_. Physical Inspection: All men who did not complete typhoid or tetanus series of immunizations will report to squadron dispensary at sick call. Physical inspection of squadron will be held at a time designated by the squadron commander. m. Special Measures for Control of Communicable Diseases; Any personnel with evi- dence of acute illness or infection will be sent immediately to the dispensary. This entails cooperation of all officers and men. (If the body louse were to become a pro- blem, description of methods of control would be included here). 2. All civilians attached to this command will comply with this order insofar as it applies to them. (Signed) Commanding (Note: The commanding officer signs this, not the surgeon). OFFICIAL: (Signed) Adjutant Distribution; General A memorandum describing many of the sanitary devices could be attached to this or- der, or the details desired could be incorporated directly in the order. SECTION m SANITARY DEVICES Paragraphs References for 169 169. REFERENCES FOR. Descriptions of sanitary devices may be obtained in FM 8-40, FM 21-10, Dunham’s Military Preventive Medicine (Army Medical Bulletin No. 23), and AR 40-205 to 40-245, 40-270, 40-275, 40-2010, 40-2080, and 40-2150. The following lists the references principally In FM 8-40: a. Water. Water sterilizing bag, ref. par. 45 and 46, FM 8-40 Water sterilizing unit, ref. p. 336, Dunham’s Military Preventive Medi- cine, 1938 b. Waste. (1) Human: Straddle trench, ref. par. 59, FM 8-40 Pit latrine, ref. par. 60, FM 8-40 Bored hole latrine, ref. par. 65, FM 8-40 Urinal, ref. par. 62, FM 8-40 Urine soakage pit, ref. par. 66, FM 8-40 Pail latrine, ref. par. 69, FM 8-40 (2) Kitchen Semi-closed incinerator, par. 71 FM 8-40 Open incinerator, ref. par. 71 g, FM 8-40 Garbage stands, ref. par. 73, FM 8-40 Grease traps, ref. par. 79,-FM 8-40 Kitchen soakage pit, ref. par. 78, FM 8-40 Kitchen soakage trenches, ref. par. 80, FM 8-40 c. Storage of food: ref. par. 99, FM 8-40 d. Mess kit washing and dish washing: ref. par. 100, FM 8-40 e. Fly traps: ref. par. 131, FM 8-40 Fly baits: ref. par. 134, FM 8-40 i. Mosquito control: ref. Chapter 8, FM 8-40 g. Disinfestors: ref. par. 169 - 178, FM 8-40 SECTION IV ABSTRACTS FROM INTERNATIONAL SANITARY CONVENTION FOR AERIAL NAVIGATION (THE HAGUE: APRIL 12, 1933) Paragraphs General reference, sanitary regulations on the care of certain diseases 170 Measures applicable in the case of Plague, Cholera, Typhus, and Smallpox 171 Measures applicable in the case of Yellow Fever 172 General provisions — 173 170. GENERAL REFERENCE, SANITARY REGULATIONS ON THE CARE OF CERTAIN DISEASES (PART m, SANITARY CODE). Article 18 The diseases which are subject to the special measures prescribed by this Part of the Convention are plague, cholera, yellow fever, typhus, and smallpox. Article ig For the purpose of the present Convention the period of incubation is reckoned as 6 days in the case of plague, 5 days in the case of cholera, 6 days in the case of yellow fever, 12 days, in the case of typhus, and days in the case of smallpox. The chief health authorities shall transmit to the sanitary and authorized aerodromes of their re- spective countries all information contained in the epidemiological notifications and communications received from the Office International d'Hygiene pubhque (and the Regional Bureaux with which it has made agreements for this purpose) in execution of the provisions of the International Sanitary Convention of the 21st June, i926,* which may affect exercise of sanitary control in those aerodromes. Article 20 The measures prescribed in this Part of the Convention shall be regarded as constituting a maximum within the Limits of which High Contracting Parties may regulate the procedure which may be applied to airc raft. It is for each High Contracting Party to determine whether measures should be applied, unthin the Limits of the present Convention, to arrivals from a foreign local area or aerodrome. In this respect information received and measures already applied shall, in accordance with Article 54 of the present Convention, be taken into the fullest possible account. Article 21 Article 22 For the purpose of Part III of the present Convention a local area is considered to be infected when the conditions specified in the International Sanitary Convention of the 21st June, 1926, are applicable to it.** * Cmd. 320J ** According to the terms of the International Sanitary Convention of the 21st June, 1926, Article 10, and the first paragraph of Article II, a local area is considered "infected" by one of the diseases in question in the following circumstances: For plague and yellow fever when the first case recognized as non-imported is reported; for cholera when forming a foyer - that is, when the occurrence of new cases outside the imiediate surroundings of the first cases proves that the spread of the disease has not been confined to the place where it began; for typhus and smallpox when they appear in epidemic form. 171. MEASURES APPLICABLE IN THE CASE OF PLAGUE, CHOLERA, TYPHUS, AND SMALLPOX (CHAPTER I, PART IH, SANITARY CODE). Measures on Departure Article 23 The measures to be applied on the departure of aircraft from a local area infected by one of the diseases mentioned in this Chapter are the following: (1) Thorough cleansing of the aircraft, especially the parts Liable to be contaminated. (2) Medical inspection of passengers and crew. (3) Exclusion of any person showing symptoms of one of the diseases in question; as well as of per- sons in such close relation with the sick as to render them liable to transmit the infection of these diseases. (4) Inspection of personal effects, which shall only be accepted if in a reasonable state of clean- liness. (5) In the case of plague, deratization if there is any reason to suspect the presence of rats on board. (6) In the case of typhus, disinsectization, limited to persons who, after medical inspection, are considered as likely to convey infection, and to their effects. The aircraft's papers shall be annotated in accordance with the requirements of Article 9. Measures on Arrival Article 24 Aircraft, even when coming from a. Local area infected by one of the diseases to which this Chapter applies, may Land at any authorized aerodrome. Nevertheless, each High Contracting Party, if epidemi- ological conditions demand such action, has the right to require aircraft coming from particular Local areas to Land at prescribed sanitary or authorized aerodromes, account being taken of the geographical position of those aerodromes and of the routes followed by the aircraft, in such a manner as not to hamper aerial navigation. The only measures which, if necessary, may be taken at authorized aerodromes which are not also sani- tary aerodromes, are the medical inspection of crew and passengers and the Landing and isolation of the sick. Passengers and crew nay not move beyond the limits prescribed by the aerodrome authority except with permission of the visiting medical officer. This restriction may continue to be imposed on the aircraft at each Landing place until it arrives at a sanitary aerodrome, where it will be subject to the measures laid down in this Chapter, Article 25 The commander of the aircraft is required, on Landing, to place himself at the disposal of the sani- tary authority, to answer all requests for information affecting public health which art made to him by the competent service, and to produce the aircraft's papers for examination. Should an aircraft, on entering a territory, land elsewhere than on a sanitary or authorized aero- drome, the eomsander of the aircraft shall, if the aircraft cooes from an infected local area or is itself infected, notify the nearest local authority to this effect, and the latter shall take such measures as are appropriate to the circumstances, being guided by the general principles on which the present Convention is based, and shall, if possible, direct the aircraft to a sanitary aerodrome. Mo cargo shall be unloaded and no passenger or member of the crew shall leave the vicinity of the aircraft without the permission of the competent sanitary authority. Article 26 In the application of the present Convention, surveillance may not be replaced by observation except - (a) in circumstances in which it would not be practicable to carry out surveillance with sufficient thoroughness; or (b) if the risk of the introduction of infection into the country is considered to be exceptionally serious; or (c) if the person who would be subject to surveillance cannot furnish adequate sanitary guarantees. Persons under observation or surveillance shall submit themselves to any examination which the com- petent sanitary authority may consider necessary. (A) - PLAGUE Article 27 If there has not been a case of plague on board, the only measures which may be prescribed are - (1) Medical inspection of passengers and crew; (2) Deratization and disinsectization, if in exceptional cases these operations are considered neces- sary, and if they have not been carried out at the aerodrome of departure; (3) The crew and passengers may be subjected to surveillance for a period not exceeding six days from the date on which the aircraft left the infected local area. Article 28 If there is on board a recognized or suspected case of plague, the following measures are applicable: (1) Medical inspection; (2) The sick shall be nmediately disembarked and isolated; (3) All persons who have been in contact with the sick, and those whom the sanitary authority has reason to consider suspect, shall be subject to surveillance for a period not exceeding six days from the date of arrival of the aircraft; (4) Personal effects, linen and any other articles which in the opinion of the sanitary authority are infected, shall be disinsectized and, if necessary, disinfected; (5) Any parts of the aircraft which are suspected of being infected shall be disinsectized; (6) The sanitary authority nay carry out deratization in exceptional cases, if there is any reason to suspect the presence of rats on board and if the operation was not carried out on departure. Article 29 If the sanitary authority considers that merchandise coming from an area infected with plague may harbour rats or fleas, such merchandise shall not be discharged except with the necessary precautions. (B) - CHOLERA If there has been a case of cholera on board, the only measures which may be prescribed are - (1) Medical inspection of passengers and crew; (2) Surveillance of passengers and crew for a period not exceeding five days from the date on which the aircraft left the infected local area. Article 30 Article 31 If a case of disease presenting clinical signs of cholera appears on board during the voyage, the aircraft shall be subject, at places of call or on arrival, to the following procedure: (1) Medical inspection; (2) The sick shall be immediately disembarked and isolated; (3) The crew and passengers shall be kept under surveillance for a period not exceeding five days from the date of arrival of the aircraft; (4) Personal effects, linen and all other articles which in the opinion of the sanitary authority are infected, shall be disinfected; (5) The parts of the aircraft which have been occupied by the sick or which are regarded as liable to have been infected shall be disinfected; (6) When the drinking water on board is considered suspect, it shall be disinfected, and if practic- able emptied out and replaced, after the disinfection of the container, by wholesome water. In countries in which investigation for the detection of carriers of the cholera vibrio is prescribed for the inhabitants, persons arriving by aircraft who wish to remain in the country shall submit to the obligations imposed on the inhabitants. Article 32 Persons produc.ng proof that they have been vaccinated against cholera within less than six months and more than six days may be subjected to surveillance only. Proof shall consist of a written certificate signed by a doctor whose signature shall be officially authenticated; failing such authentication, the certificate shall be countersigned by either (a) the medical officer attached to a sanitary aerodrome or lb) a person, other than the person performing the vaccination, who is authorized to witness an application for a passport under the regulations of the country. The unloading from aircraft of the following fresh foods may be-prohibited: Fish, shellfish, fruit and vegetables, coming from a Local area infected with cholera. Article 33 (C) - TYPHUS (a) If there has not been a case of typhus on board, no sanitary measure may be carried out save those prescribed in Article 52 of the present Convention for persons who have within 12 days left a local area where typhus is epidemic. (b) The following measures are applicable if there is a case of typhus on board: (1) Medical inspection. (2) The sick shall be immediate ly disembarked, isolated and deloused. (3) Any person suspected of harbouring lice or of having been exposed to infection shall also be deloused, and may be subjected to surveillance for a period not exceeding 12 days, reckoned from the date of delousing. (4) Linen, personal effects, and other articles which the sanitary authority considers to be in- fected shall be disinsectized. (5) The parts of the aircraft which have been occupied by persons suffering from typhus and which the sanitary authority considers to be infected shall be disinsectized. Article 34 (D) - SMALLPOX (a) If there has not been a case of smallpox on board, no sanitary measure may be carried out save in the case of persons who have within 14 days left a local area where smallpox is epidemic and who, in the opinion of the sanitary authority, are not sufficiently immunized. Such persons may be subjected, without prejudice to the terms of Article 52, to vaccination, or to surveillance, or to vaccination fol- lowed by surveillance, the period of which shall not exceed 14 days from the date of arrival of the air- craft. (b) The following measures are applicable if there is a case of smallpox on board: (1) Medical inspection. (2) The sick shall be immediately disembarked and isolated. Article 35 (j) Other persons who there is reason to believe have been exposed to infection and who, in the opinion of the sanitary authority, aPe not sufficiently immunized may be subjected to the measures pre- scribed in paragraph (a) of this Article. (4) Linen, personal effects, and other articles which the sanitary authority considers to have been recently infected, shall be disinfected. (5) The parts of the aircraft which have been occupied by persons suffering from smallpox and which the sanitary authority considers to be infected shall be disinfected. For the purpose of this Article persons shall be considered immune (a) if they can produce proof of a previous attack of smallpox, or if they have been vaccinated within less than three years and more than 12 days, or (b) if they show local signs of early reaction attesting an adequate immunity. Apart from cases where these signs are present, proof shall be afforded by a written certificate of a doctor, authenticated in the manner prescribed in the second paragraph of Article 32. 172. MEASURES APPLICABLE IN THE CASE OF YELLOW FEVER (CHAPTER H, PART HI, SANITARY CODE). General Provisions In territories where endemicity of yellow fever is suspected, the High Contracting Parties shall take the necessary steps to ascertain whether yelloui fever exists in their territory m a form which, though not clinically recognizable, might be revealed by biological examination. Article 37 Independently of the notification of cases of and circumstances relating to recognized cases of yellow fever as laid down in Articles 1, 2, 3, 4, 5, and 8 of the International Sanitary Convention of the 21st June, 1926, each High Contracting Party undertakes to notify immediate ly to the other High Contracting Parties and at the same time to the Office International d'Hygiene publtque (either directly or indi- rectly through the Regional Bureaux with which it has made agreements for this purpose) the discovery in his territory of the actual existence of yellow fever in the above mentioned form. Article 36 Section II - Provisions concerning regions in which Yellow Fever has occurred or exists in an endemic form Article 58 Notwithstanding Article 4 of the present Convention, and subject to the terms of Article 46 here- after, every aerodrome which receives aircraft to which Article 1, I, second paragraph, applies, and which is situated in a region, that is to say, a part of a territory, in which yellow fever exists in a form clinically or biologically recognizable, shall become a sanitary aerodrome as defined in the present Convent ion, and in addition shall be - (1) Situated at an adequate distance from the nearest inhabited centre. (2) Provided with arrangements for a water supply completely protected against mosquitoes and kept as free as possible from mosquitoes by systematic measures for the suppression of breeding places and the destruction of the insects in all stages of development. (3) Provided with mosquito-proof dwellings for the crews of aircraft and for the staff of the aerodrome. (4) Provided with a mosquito-proof dwelling in which passengers can be accommodated or hospital- ized when it is necessary to apply the measures specified in Articles 42 and 44 below. Article 39 If, in the region where yellow fever has occurred or exists in an endemic form, there is not already an aerodrome fulfilling the conditions specified in the preceding Article, all aerial navigation from this region to any other territory shall be suspended until such an aerodrome shall have been established. Article 40 Every aerodrome estab lished and equipped in accordance with the provisions of Article gg above shall be called an anti-amaryl aerodrome, and shall be deemed to be a separate local area. The creation of such an aerodrome shall be notified by the High Contracting Party in whose territory it is situated to the other High Contracting forties, and either to the Office International d'Hygien* publique or to the International Commission for Aerial Navigation, under the conditions. laid down in Article 7. Consequent on this notification, the declaration of the presence of yellow fever in an adjacent town or village, or in another local area, shall not apply to the aerodrome, and the aerodrome shall not be declared infected unless yellow fever occurs among the persons residing therein. If an anti-amaryl aerodrome becomes an infected local area, aerial navigation from that aerodrome to any other territory shall be discontinued until all measures have been taken to free it from infection, and all risk of the spread of yellow fever has ceased. Artie le 41 Artie le 42 Where the anti-amaryl aerodrome is not infected, but yellow fever exists in the region, the following measures shall be taken on the departure, or in any event os late as possible before the departure, of an aircraft: (1) Inspection of the aircraft and cargo to ensure that they do not contain mosquitoes, and. if necessary disinsectization. A record of this inspection and any action taken shall be entered in the journey log-book. (2) Medical inspection of passengers and crew; those who are suspected of suffering from yellow fever, or in whose case it has been duly established that they have been exposed to the infection of yellow fever, shall be required to remin under observation either within the precincts of the aerodrome or eIsewhere, under condit ions approved by the sanitary authority, until s ix days have elapsed since the last day on which they were exposed to infection (3) The names of the passengers and crew shall be entered in the journey log-book, together with the revelant information with regard to their exposures to infection, and the period and conditions of the observation which they have undergone prior to departure. Aircraft in transit, not coming from a region in which yellow fever exists, and landing for the purpose of taking in supplies in an anti-amaryl aerodrome, shall be exempt from the prescribed sanitary measures on leaving that aerodrome. In the further course of the voyage they shall not be subject to the pro- visions of this Chapter provided that the fact that they have called at an anti-amaryl aerodrome for the sole purpose of taking in supplies is entered in the journey log-book. Article 42 Aircraft to which Article i, I, second paragraph, of the present Convention applies, flying between two regions where yellow fever exists must depart from and land at an anti-amaryl aerodrome in these regions. Bissengers, crew and cargo shall not be disembarked or embarked except at an anti-amaryl aero- drome . During the voyage between these aerodromes aircraft my land for the purpose of taking in supplies in any aerodrome not situated within a region where yellow fever exists. The measures to be taken on arrival at the anti-amryl aerodrome are the following: (1) Inspect ion- of the aircraft and cargo to ensure that they do not contain mosquitoes, and, if necessary, disinsectization. (2) Medical examination of passengers and crew to ascertain that they are free from symptoms of yellow fever. If a person is suspected to be suffering from yellow fever, or if it has not been estab lished to the satisfaction of the sanitary authority of the aerodrome of arrival that a person has completed a period of six days since possible exposures to infection, he my be subjected to observation either within the precincts of the aerodrome or elsewhere under c and it ions approved by the sanitary authority, for a period not exceeding six days reckoned from the last day on which that person could have been infected. Article 44 Aircraft having departed from an anti-amaryl aerodrome in a region where yellow fever exists and arriving at a region where yellow fever does not exist, shall be subject to the provisions of Sections III and IV below. Article 45 Article 46 For the purposes of local aerial navigation, nothing in this section shall be deemed to prevent the Governments of neighboring territories in which yellow fever is found or exists endemically from establishing or employing, by mutual agreement, aerodromes which are' not anti-amaryl aerodromes, for the needs of aerial navigation exclusively between these territories. Section III - Provisions in respect of Territories or Regions in which Yellow Fever does not exist, but in which there nay be conditions which permit of its deve lopment Article 47 In territories or regions where yellow fever does not exist, but where there my be conditions which permit of its development, the measures which may be taken on the arrival of an aircraft at a Sanitary aerodrome are the folLowing: 11) Inspection of aircraft and cargo to ensure that they do net contain mosquitoes, and, if necessary, disinsectization. (2) Medical examnat ion of passengers and crew to ascertain that they are free from symptoms of ye I low fever. If a person is suspected to be suffering from yellow fever, or if it has not been established to the satisfaction of the sanitary authority of the aerodrome that a person has completed a period of si* days since possible exposure to infection, he may be subjected to observation either within the precincts of the aerodrome or elsewhere, under conditions approved by the sanitary authority, for a period not exceeding six days reckoned from the last day on which that person could have been infected. Article 48 The High Contract ing Parties undertake, save in exceptional circumstances which will require to be justified, not to invoke sanitary reasons for prohibiting the landing in the territories referred to in Article 47 of aircraft coming from regions where yellow fever exists, provided that the provisions of Section II of this Chapter, part icularly those concerning the measures to be taken bn departure, are observed there. Article 4Q nevertheless, the High Contracting Parties may designate particular sanitary aerodromes as those at which aircraft from territories where yellow fever exists shall land for the purpose of disembarking passengers, crew or cargo. Section TV - Provisions in respect of Territories or Regions where the conditions do not permit of the development of Yellow Fever Article iso In territories or regions where the conditions do not permit of the development of yellow fever, air- craft coming from regions where yellow fever exists may Land on any sanitary or authorized aerodrome. The measures to be taken on arrival are the following: (i) Inspect ton of the aircraft and cargo to ensure that they do not contain mosquitoes, and, if necessary, disinsectization. (a) Medical inspection of passengers and crew. 173. GENERAL PROVISIONS (CHAPTER HI, PART m, SANITARY CODE), Article ki Article 52 Persons who arrive in aircraft in the territory of any High Contract ing Party and who have been ex- posed to risk of infection by one of the diseases referred to in Article 16 of the present Conventie:., and who are within the period of incubat ton, may, subject to the provisions of Chapter jj of this Art, be subjected to surveillance until the termination of that period. In the case of cholera and smallpox. the provisions of Articles go et seq. and relating to immunised persons apply equally to action under this Article. Persons who, on arrival at an aerodrome, are considered under the terms of this Pirp liable to s*tr- veillance up to the expiration of the period of incubation of the disease, may nevertheless continue Article 53 the voyage on condition that the fact is notified to the authorities of subsequent landing places and of the place of arrival, either by means of an entry in the journey log-book as prescribed in Article 9 of the present Convention, or by some other method sufficient to secure that they can be subjected to medical inspection in any subsequent aerodrome on the route. Persons who are liable to observation under the terns of Articles 26, 44 (fourth paragraph) and 47 (second paragraph) of this Convention shall not be authorised until the expiration of the period of in- cubation to continue their voyage, except - in case of diseases other than yellow fever - with the approval of the sanitary authorities of• the places of their destination. Article 54 In applying sanitary measures to an aircraft coming from an infected local area, the sanitary authority of every aerodrome shall, to the greatest possible extent, take into account all measures which have already been applied to the aircraft in another sanitary aerodrome abroad or in the same country, and which are duly noted in the journey log-book referred to in Article 9 of the present Convention. Aircraft coming frm an infected local area which have already been subjected to satisfactory sanitary measures shall not be subjected to these measures a second time on arrival at another aerodrome, whether the latter belongs, to the same country or not, provided no subsequent incident has occurred which calls for the application of the sanitary measures in question, and that the aircraft have not called at an infected aerodrome except to take in fuel. The aerodrome authority applying sanitary measures shall, whenever requested, furnish free of charge to the commander of the aircraft, or any other interested person, a certificate specifying the nature of the measures, the methods employed, the parts of the aircraft treated, and the reason why the measures have been applied. The authority shall also issue, on demand and without charge, to passengers arriving by an aircraft in which a case of one of the infectious diseases referred to in Article 18 has occurred, a certificate shaving the date of their arrival and the measures to which they and their Luggage have been subjected. Article 55 Article 56 Save as expressly provided in the present Convention, aircraft shall not be detained for sanitary reasons. If an aircraft has been occupied by a person suffering from plague, cholera, yellow fever, typhus or smallpox, its detention shall be limited to the period strictly necessary for it to undergo the pro- phylactic measures applicable to the aircraft in the case of each disease referred to in the present Convention. Article 57 Subject to the provisions of Chapter II of the present Convention, and particularly those of Article 47• any aircraft which does not wish to submit to the measures prescribed by the aerodrome authority in virtue of the provisions of the present Convention, is at liberty to continue its voyage. It may not, however, land in another aerodrome, of the same country except for the purpose of taking in supplies. An aircraft shall he permitted to land goods on condition that it is isolated and that the goods are subjected, if necessary, to the measures laid down in Article 10 of the present Convention. Aircraft shall also be permitted to disembark passengers at their request, on condition that such passengers submit to the measures prescribed by the sanitary authority. Aircraft may also take in fuel, replacements, food and water while remaining in isolation. SECTION V QUARANTINE, INSPECTION AND TREATMENT OF AIRCRAFT Paragraphs General 174 Nonstop flights without quarantine restrictions 175 Flights with quarantine restrictions 176 Use of insecticide— 177 Dosage for eliminating infectious mosquitoes from various types of military aircraft 178 Directions for aerosol method of disinsectization 179 Alternate method of disinsectization (Pyrethrum method) 180 Form to be completed after disinsectization of aircraft 181 References 182 174. GENERAL. In order to prevent the transportation of Aedes aegyptl (vector of yellow fever), Anopheles gamblae (vector of malignant malaria), and Glossina palpalis (vector of African sleeping sickness), or other harmful insects, from foreign areas to the United States, or from one foreign area to another, it is necessary to disinsecticize Army air- craft operating in areas where these insects are found. 175. NONSTOP FLIGHTS WITHOUT QUARANTINE RESTRICTIONS. Flights of Army air- craft may be made nonstop within the following areas without quarantine restrictions, pro- vided there are no quarantinable diseases or epidemic conditions at any port of departure or call: United States Virgin Islands Puerto Rico Cuba and Bahama Islands Canal Zone (All other islands of the Alaska Carribbean area where U.S. Canada air bases may be establish - British Isles ed are included) 176. FLIGHTS WITH QUARANTINE RESTRICTIONS, a. All flights of Army aircraft, ex- cept those on strictly confidential missions, having contact with any areas not listed in paragraph 175 above wiH be reported to the quarantine officer, U.S. Public Health Service, at the first point of landing in United States territory. The station of destination is charge with notifying the quarantine officer of such arrivals (except confidential missions) imme- diately upon receipt of flight plan, and in sufficient time to permit him to be on the field when the aircraft arrives. b. In the instance of aircraft going from one foreign area to another, notice shall be given well in advance of arrival to the national health authority at the place where the air- craft propose to land. Local requirements of such countries for the dlsinsecticizing of air craft will be complied with by all concerned. 177. USE OF INSECTICIDE, a. All Army planes flying nonstop (with the exception of thos« listed in par. 175) to the United States from any point on the earth’s surface (including Africa, Asia, South America, Australia, Europe, Oceania, and North America) south of 54 degrees north latitude and north of 45 degrees south latitude will be disinsecticized im- mediately before departure and one-half hour before arrival at their destination. All passengers, cargo equipment, and baggage must be aboard when disinsectization takes place. Flights of Army aircraft from one foreign country to another within these infested areas will likewise be disinfected before departure and before arrival. b. All flights departing from areas defined in par. 177 a. will be reported to the senior medical officer in sufficient time for him to supervise spray of the interior of the aircraft before take-off. The operations' officer of the station of departure is charged with notify- ing the senior medical officer immediately on receipt of flight plans. A record will be ke; of all treatments at the station where disinsectization is performed by the responsible medical officer. (See par. 181). c. Provisions for the disinsectization of Army aircraft will be provided at Morrison Field, Florida, Trinidad, Belem, Natal, Monrovia, Accra, Khartoum, Karachi, and such other locations as may be designated by responsible authority. No planes will be per- mitted to leave these fields for travel to another country until approval of the responsible senior medical officer is obtained. It will not be necessary to spray planes leaving Flori- da bases until they arrive at their first port of call. d. Planes will be dislnsectized as outlined in Table XX. All doors, windows, and all other openings will be closed during the spraying and the aircraft will remain closed for 5 minutes after treatment. e. The specifications for insecticidal material set forth in Par. 180 may be used as an alternate method for dislnsecticizing aircraft. i. The above quarantine measures shall be applied to Army aircraft coming 'from any area which may be designated by the Air Surgeon as dangerous on account of the presence of insect vectors of disease. 178. DOSAGE FOR ELIMINATING INFECTIOUS MOSQUITOES FROM VARIOUS TYPES OF MILITARY AIRCRAFT (see Table XX). 179. DIRECTIONS FOR AEROSOL METHOD OF DISINSECTIZATION, a. To operate dis- penser bend capillary tube backwards and forwards until it breaks off at the base. b. The aerosol is then automatically discharged. c. Walk from the rear of the ship to the pilots’ compartment spraying the aerosol into the air. Open all compartments and spray into them. d. Do not hold closer than one foot to any stainable articles. e. The number of seconds to spray are: B-17 series - 30 seconds; C-54 series - 90 seconds; B-25 series - 15-27 seconds; and Pr40 series - 3-4 seconds. f. Then invert dispenser, nozzle down, so that only gas is sprayed and screw on tem- porary cap. g. For further use remove temporary cap and proceed as above. (NOTE: About 10 seconds spraying in a pyramidal tent and 3 seconds in a shelter tent will kill flies and mosquitoes.) 180. ALTERNATE METHOD OF DISINSECTIZATION (PYRETHRUM METHOD). The standardized Pyrethrum extract variously designated as pyrethruxn concentrate, 20 to 1 strength, pyrethrum extract standardized, pyrethrum extract No, 20, pyrethrum concen- trate No. 20, and No. 20 extract standardized, contains 2 grams of pyrethrins per 100 cubic centimeters of deobase or other approved vehicle. The insecticide has a very low flash point, is non-staining and non-corrosive and, except for being mildly irritating to the skin on direct application, is harmless to humans in the concentration used. As the efficacy of the Insecticide depends largely on the degree of vaporization secured in spray ing, the vaporizer or hand spray producing the smallest droplets (densest cloud of mist) is the most satisfactory. Approved insecticide and hand sprayers may be obtained from the local Quartermaster. Form DISINSECTIZATION OF AIRCRAFT A.A.F. Field From Date_ 1. Type of Plane : Number 2. Volume : cu. ft. 3. Was plane completely closed: : The dosage for eliminating infectious mosquitoes from various types of military aircraft - Aerosol method. Ground treatment - planes should be kept closed for five" minutes after application. Basic dosage - 10 grams solution per 1000 cu; ft. * Plane Type B-17 (Flying Fortress) Volume cu. ft, 1738 Planes of the same series and of about the same size C 39, C 42, C 46, C 53 B 24, B 33. B 34 » Variance of Volume within series cu. ft. All of about the. same size. Dosage Spray Time** seconds 30 B-29 (Boeing) 5000 B 32, C 54, C 55 All of about the same size 90 B-25 (North Am- erican light bomber) 1490 B 26, B 23, B 18, A 20 C 67, A 26, A 28, A 24 A 29, C 40. Considerable. From 850 for A 20 and C 40 to 1490 for B 25 15-27 P-40 (Fighter) 175 P 39, P 38, P 43, P 51, P 66. 175 - 225. 3-4 Note: Wing size of these planes: Fighters — 150 - 500 cu. ft. Bombers & Commercial —. 700 - 4-000 cu. ft. * pie insecticidal solution to contain 1% pyrethrins, 2% sesame oil, 4% inert ingredients, and 93% Freon (dichlorodlfluoromethane). ** Spray time figures using the one pound bomb type” container that delivers approximately 1 lb. of Insecti- cidal solution in 13-14 minutes. TABLE XX 157 4. Dosdge* : seconds c.c. 5. Type of Treatment : 6. Insects noted : 7. Remarks : ♦Plane closed for 5 minutes after spraying Treated by: and not reopened before leaving. Rank:__ 182. REFERENCES. a. Memoranda. (1) Memorandum Report No. Exp. M-54-653-115, July 6, 1942, Aero Medical Research Laboratory, Materiel Division, Wright Field, Method of Killing Mos- quitoes in Aircraft". b. Regulations (1) AAF Regulation No. 61-3, “Flying, Outside the United States”, November 30, 1942. CHAPTER 8 ADMINISTRATION SECTION I REPORTS Paragraphs Rendered by station hospitals or dispensaries 183 Rendered by a tactical unit 184 Report of sick and wounded 185 Check system for forwarding of reports 186 List of forms commonly used, by number- 187 183. RENDERED BY STATION HOSPITALS OR DISPENSARIES. The following reports may vary as to kind, number, and distribution, depending on local conditions, however, the list will serve as a general guide. NAME OF REPORT DISTRIBUTION REFERENCE DAILY Morning Report (WD, AGO 1) Morning Report (WD, AGO 2) Sick Report (WD, AGO 5) Sick Report (WD, AGO 5) Report of Change (WD, AGO 303) Post Hq. though Personnel Sec. Post Hq. through Personnel Sec. Sick Call Officer Detachment Unit Personnel Headquarters AR 345-400 AR 345-400 AR 345-415 AR 345-415 AR 345-800 AR 345-900 WEEKLY Care of Flier (AC 203) Statistical (86 ab MD) Changes in Civ. Emp. Per. (Ltr. form) Progress Report, Civ.Ser. (Form 496) Report of Avn. Cadets Exam. (Ltr. Form) 1 copy to TCS 1 copy to Air Surgeon, OCGAAF, Sat. a.m., 1 copy filed Orig. Copy to SCS Dupl. to SGO and TCS ea. Sat. a.m., copy filed Form 4 a to Dist. Manager, U.S.Civ.Ser.Dlst. (direct), 5 copies made Dist. Manager, U.S. Civ.Ser. (direct) Monday, Make 4 copies 2 to G.G., S.C., 1 Air Surgeon, OCGAAF, 1 filed Instr . on form AR 40-1080 See Civ.Per. Regulations, SGO See Civ.Ser. Cir. Ltr. No. 584 Local regula- tions MONTHLY Commissary Credit, NCO (Ltr. form) Dental Ser. Report (MD 57) Expend, of Dental Materials (MD, AGO 18b) Hosp. Fund Statement (MD 49) 4 to Post Hq., 22nd Mo., copy filed Orig. and dupl. to SCS, 3rd of Mo., copy filed Orig. and dupl. to SCS, 3rd of Mo., copy filed Orig. to SCS, 10th Mo., copy filed AR 30-2290 AR 40-1010 AR 40-1010 AR 210-50 NAME OF REPORT DISTRIBUTION REFERENCE MONTHLY (Cont'd) Hosp. Laundry List and Voucher Orlg. to SCS., 10th of Mo., (MD 21) copy filed AR 40-590 Payroll of Detachment, by Per. Sec., Orig. and dupl. to Fin. Off., (WD, AGO 366 and 366a) 20th of Mo., copy filed AR 345-155 Ration Return of Det. (QMC 460) Orig. and 1 to Post Hq., 1st of Mo., copy filed Mess AR 30-2210 Patient Ration Voucher Orig. and 3 to Post Hq., 3rd Separate voucher for ea. component. of Mo., copy filed AR 40-590 also for civ. emp., cadets, CCC, etc. (WD 351) Sick and Wounded (MD 51 and 52) Orig, 51 with orig. cards to SGO, dupl. to SCS AR 40-1025 Statistical Report, with roster of Orig. to SCS, 1st, of Mo., officers attached, including dupl. SGO, tripl. to TCS duties (MD 86c) Quad, to Air Surgeon, OCGAAF, copy filed AR 40-1080 Medical and Hospital Care in Army Sextupl. to the Surg. Gen., be- Cir. ltr. SGO Hospitals of WPA and USEC, fore 1st of ea. mo., copy No. 93, 1941 (Ltr. form) filed Venereal Report (Mimeo. form) Orig. and 3 to Post Hq. last Sat, of Mo., copy filed AR 40-235 Mosquito Control Report (Ltr. form) 3 copies to SGO (through mil. channels) 1st of ea. Mo. Ltr. SGO, 3-28-41 Reports of number of allocated beds 2 to SCS, copy filed Ltr. SGO, occupied in General Hospital 11-12-41 (Ltr. form) Meat and Dairy Insp., Veterinary 2 to Post Hq. AR 40-2260 Vet. Statistical Report (MD 86c) 1 SCS, 1 SGO, 1 filed AR 40-2245 Vet. Sick and Wounded Report 1 SCS, 1 SGO, 1 filed AR 40-2245 Monthly-Ship. Ticket (Exp. Med. 1 to Post Hq., approved AR 40-1705 Supplies) vouch, to Stock Record Report on Bact. Exam, of Water 2 to SCS, 1 filed AR 40-310 Report on Tetanus React (720.3) 2 to OCGAAF, 2 SCS, 1 filed Cir. Ltr., SGO AR 40-1025 Report of patients in hospital over 2 SCS, 1 filed 60 days; give dlag., prog., and pro- bable length of stay in hospital QUARTERLY Progress of inventory (Ltr. Form) Orig. and 1 to Post Hq. end of ea. quarter. Copy filed AR 35-6520 Reqn., foj Med, Sup, Deteriorating Orig. and 2 to SCS, end of ea. AR 40-1705 quarter. Copy filed Med. Sup. Cat., 1941 Reqn. for Authorized Allow, of Orig. and dupl. to Post Hq. for WD Cir. Stationery and Cleaning Material approval, copy filed 58/192 Hospital Fund audit Inspector, Hq. AR 210-50 Request for funds for proc. of Civ. 3 copies to SCS., 15th of Mo., Civ. Ser. Ser. Emp. before next quarter Regulations and inst. from SGO NAME OF REPORT DISTRIBUTION REFERENCE SEMI-ANNUAL Semi-Ann.Reqn. for Med. Supplies Orlg. and 2 copies to Depot of Issue. March 31 and Sept. 30, copy filed Med. Sup. Cat., AR 40. 1705 Semi-Ann. Phys. Exam. AC Officers WD, AGO Form 64 or Certi- ficate AR 40-110 ANNUAL Officers’ Statement of Preference TO SGO, Oct. 1 AR 605-120 Report of Non-Standard Items used Ltr. to SGO in dupl., 1 filed SGO Clr. Ltr. No. 1, c.s. Annual Phys. Exam. AC Officers, Form 64 or 63 as required, in (AR 40-100 other officers, warrant officers and trip., 2 copies to Air Surgeon (AR 40-105 nurses OCGAAF, 1 copy to Sta. Commander (AR 40-110 Efficiency Report, Officers (WD, AGO 67) Orig. only to Post Hq. June 30 ea. yr., and on transfer of either reporting officer or officer reported on AR 600-185 Efficiency Report, NCO’s, (MD 90) 1st 3 grades) 1 copy to SGO, June 30 ea. yr., and upon transfer AR 600-185 Statement of Cost of Med. Service Lt. to Surg. Gen. through SCS July 30 AR 40-1705 Annual Inspect, of Records of Flying personnel April 1st to Air Surgeon, OCG AAF, through CO AR 40-110 OCCASIONAL Reqn. for Biologicals Ltr. to AMC direct in dupl., copy filed AR 40-1705 Flight Surg. Report of Aircraft 1 copy, Air Surgeon through See Inst, on Accidents (Form AC 205) TCS to accompany “Care of Flier’s Report” if from lo- cal st.; 2 to home station F/S if personnel is from different station. (These are not sent immediately but with Form 205) 1 file in each instance (See inst. on form) form Immunization Record as required. (Typhoid, smallpox, tetanus, yel- In Dupl., one to Orgn. CO., 1 files AR 40-215 low fever, etc.) Abbreviations; TCS - Training Center Surgeon SCS - Service Command Surgeon OCGAAF - Office of Commanding General, Army Air Forces AGO - Adjutant General’S' Office SGO - Surgeon General’s Office 184. RENDERED BY A TACTICAL UNIT. The following directive Indicates the reports rendered by a representative tactical unit. There will be variations in each unit usually dictated by the tactical situation. HEADQUARTERS Nth AIR FORCE OFFICE OF THE COMMANDING GENERAL Tampa, Florida Date MEDICAL DEPARTMENT Medical Reports MEMORANDUM) NUMBER ) (Memoranda 25-3, this headquarters, August 7, 1941, 25-3A, this headquarters, September 6, 1941, and 25-3B, this headquarters, November 22, 1941, are rescinded) The following will govern as a guide in the preparation and distribution of Medical Reports by all medical Installations and detachments of the Nth Air Force. 1. Station and Air Force tactical unit Surgeons are directly responsible for the preparation and prompt submission of medical reports in the Nth Air Force. a. Surgeons of tactical units that are assigned to the Interceptor, Bomber or Air Support Commands will prepare such extra copies of reports listed herein as may be requested by the Surgeon of the concerned Interceptor, Bomber, or Air Support Command. When an Air Force tactical unit is attached to another armed force as a supporting element medical reports will be submitted as directed by the Surgeon of the unit to which the Air Force unit has been attached. Extra copies of such reports will be submitted to the Surgeon of the appropriate command (Interceptor, Bomber, Air Support or Air Base Command) for information purposes. Interceptor, Bomber, and Air Support Surgeons will forward reports received frmo such attached units to the Surgeon, Nth Air Force Base Command, within 24 hours of receipt of these information copies. 2. Air Base Surgeons will submit separate reports for all tactical units which do not have a Surgeon assigned and for the Station Complement (when a tactical unit is so reported it will not be included in the Station Complement report). Tactical units with assigned Surgeons will not be included in the Air Base Surgeon’s reports. 3. Tactical Unit Surgeons will submit reports for the unit to which they are as- signed. The Senior Medical Officers assigned to a Group or Squadron will render reports for their respective units. The next ranking Medical Officer or Dental officer (if no Medical Officers are present) becomes Acting Group Surgeon in the absence of the Group Surgeon and will submit the necessary reports. Group Sur- geons will consolidate reports by their respective Squadron Surgeons when at the same location. Independent squadrons will submit reports in a similar manner as Group Surgeons (e.g, when a Squadron leaves the parent group and is acting as a separate squadron, the Surgeon of the Squadron will submit an initial report, mark- ed “INITIAL REPORT’'. When the squadron rejoins the group the squadron surgeon will submit a final report, marked, “FINAL REPORT”.). Where several squadrons are located at a station other than an Air Base, the reports designated for tactical units will be submitted as follows: If one of the squadrons does not have a Surgeon assigned, the reports of that squadron will be the responsibility of the Senior Air Corps Tactical Unit Surgeon of the Nth Air Force at that station. 4. Reports by Air Base Surgeons rendered for the Station Complement and the Air Base Hospital: a. Weekly Statistical Report: Form 86 ab - 4 copies; Mailed each Saturday (See AR 40-1080, FM 8-45). Original to Service Command Surgeon; carbon copy to SGO; carbon copy to Surgeon, Nth Air Force Base Command, Tampa Florida; and carbon copy to file. b. Monthly Report of Medical Department Personnel and Equipment: Form MD 85" c - 4 copies; prepared as of last day of each month and mailed within 3 days (AR 40-1080, Circular Letter No. 55, SGO, June 13, 1931, and Circular Letter No. 84, SGO, August 19, 1941). Original to Service Command Surgeon; carbon copy to SGO; carbon copy to Sur- geon, Nth Air Force Base Command, Tampa, Florida; and carbon copy to file. c. Care of Flier Report: Form AC 203 - 3 copies; mailed each Saturday, sub- mitted by the Senior Flight Surgeon at each Air Base for the Air Base and Tactical Units to which no Surgeon is assigned. Original to Air Surgeon, OCGAAF ; carbon copy to Surgeon, Nth Air Force Base Command, Tampa, Florida? carbon copy to file. d. Report of Aircraft Accident: Form AC 205 - 3 copies; mailed, when indicated, with Care of Flier Report (AC Form 203). Same distribution as AC Form 203 if required by occurrence of aircraft accident. e. Sick and Wounded Report: Form 51 MD and Form 52 MD - 4 copies of Form 51 MD* - report cards accompany original of Form 51 MD. Mailed by the 5th day of the following month for the preceding month (AR 40-1025 and FM 8-45). Original of Form 51 goes direct to the Surgeon General accompanied by original report cards; 2 carbon copies (Form 51 only) to the Surgeon, Nth Air Force Base Command, who forwards one to the Service Command Surgeon; carbon copy retained. L Sanitary Report: (For form and instructions see AR 40-275 and Circular Letter No. 114, War Dept., dated June 13, 1941) - 4 copies; prepared as of the 1st of the following months and mailed within 3 days. Original and one carbon copy of Air Base Report through the Air Base Commander to the Service Command Commander; carbon copy to Headquarters, Nth Air Force Base Command; and carbon copy to file. 5. Reports by Tactical Unit Surgeons: (Group and Separate or Independent Squad- rons) (See appropriate references for rendition of these reports in Par. 4, this memorandum). Distribution and additional instructions for Tactical Unit Surgeons are as follows: a. Weekly Statistical Report: Form MD 86 ab - 4 copies and mark “SPECIAL”. Original mailed each Saturday to the Surgeon; Nth Air Force Base Command, Tampa, Florida; one copy mailed each Saturday direct to the SGO; one copy sent to Air Base Surgeon; one copy to Group or Squadron file. (1) All cases admitted to the Base Hospital, to Quarters or Carded for Record only will be accounted for under sections (E) and (F). (2) All cases sent to the Base Hospital and admitted will be disposed of by transfer (formal or informal as the case may be) - dispose of by Section (I). (3) Cases Carded for Record Only and not admitted to Hospital or Quarters status will be disposed of by Section (K). (4) The only cases which can remain to be accounted for on the next report will be: Those in other than an Army Hospital (e.g, in civilian hospital in case of a Squadron on maneuvers acting independently) and those on a quarters status. (5) Reference section on communicable diseases - see Par. 72, K, FM 8-45. An entry will be made here only if the communicable disease is treated in quarters. Otherwise the entry should be, “NONE”. b. Monthly Report of Medical Department Personnel and Equipment; Form MD 8(Tc - 4 copies - marked “SPECIAL”. The use of mimeographed lists of Air Corps field medical equipment on this report will be discontinued. Original mailed within 3 days after period ending the last day of each month - to Surgeon, Nth Air Force Base Command, Tampa, Florida; carbon copy to SGO; carbon copy to Post Surgeon and carbon copy to file. c. Care of Flier Report: Form AC 203 - 4 copies. Mailed each Saturday. Original direct to Air Surgeon; carbon copy to Surgeon, Nth Air Force Base Command, Tampa, Florida; carbon copy to Air Base Surgeon and carbon copy to to file. d. Report of Aircraft Accident: Form AC 205 - mailed when indicated, with Care of Filer Report (AC Form 203). Same distribution as AC Form 203 If required by occurrence of aircraft accident. e. Sick and Wounded Report: Form 51 MD and Form 52 MD - 4 copies of Form 5FMD - report cards accompany original of Form 51 MD. Mailed by the 5th day of the following month for the preceding month (AR 40-1025 and FM 8-45). (See Par. 4ef of this memorandum). Original and report cards will include; originals (Form 52 MD) for all Quarters and Carded for Record Only cases, and Report Cards prepared from formal trans- fer cards. These are not numbered, but should be submitted in sequence of ad- mission dates; carbon copies of formal and informal transfer cards will not be forwarded. Report sheets will be folded twice (first through the middle) and with the accompanying cards in order, will be held together by an ordinary paper clip which may be removed without tearing the sheet. The report sheet will not be used as a wrapper covering for the report cards. One carbon copy of Form 51 to the Air Base Surgeon; one carbon copy to file. jf. Sanitary Report: (For form and Instructions see AR 40-275 and Circular Letter No. 114, War Department, dated June 13, 1941 and Par. 161 of text) - 4 copies; prepared as of the 1st of the following month and mailed within three days. Original and one carbon copy through command channels by Unit Commanders by indorsement noting any action taken to the Commanding Officer, Nth Air Force Base Command, Tampa, Florida; one carbon copy to Air Base Commander (for his Information only - this copy is not forwarded) and is omitted when the unit is not at the Air Base, e.g. on maneuvers; carbon copy to file. g. Venereal Report: (For form and instructions see Par. 6, AR 40-235, dated October 11, 1939) - 4 copies; prepared as of the end of each period (at midnight of last Friday in each month). Submit within 3 days after end of period. Original to Surgeon, Nth Air Force Base Command, carbon copy to Unit Command er (for his information only - this copy is not forwarded); carbon copy to Air Base Surgeon - omitted when unit is not at the Air Base, e.g. on maneuvers; one carbon copy to file. 6. Dental Reports: Group Dental Officers of the Nth Air Force will sub mi, reports as indicated by SGO Circular Letter No. 61, dated June 16, 1941. Stat- istical reports will be submitted through Corps Area channels unchanged. Group Dental Surgeons will act similarly to Divisional Dental Surgeons, even though they have no reports to “consolidate/’ as follows: a. Form 57 MD - (For the Group-4 copies with distribution as follows: 2 copies to Surgeon, Nth Air Base Command (original for the SGO and carbon for file); one copy to Station Surgeon for transmissions to the Service Command Sur- geon (this copy need not be forwarded on maneuvers); one copy to file. b. No statement of expenditures (18 b MD) is required of Group Surgeons in that they are equipped only with Chest MD No. 60. 7. Venterinary Reports: A copy of all veterinary reports rendered to any higher authority will be submitted direct to The Veterinarian, Nth Air Force, Tampa, Florida. (Specifically Form 86 c, Veterinary Statistical and MD Form 110, Meat and Dairy Hygiene Report). By command of Major Genera*al ; Colonel, G.S.C. OFFICIAL: Chief of staff- Lieut. Col., A.G.D. Adjutant General. DISTRIBUTION; “C 185. REPORT OF SICK AND WOUNDED, a. In zone of Interior (Circ. Ltr. No. 100, W. D., S.G.O., Washington, September 2, 1542) (1) Each post, camp, or station surgeon, and each port surgeon will forward all original MD Forms 52 direct to The Surgeon General with original of MD Form 51 attached. One (1) copy of MD Form 51 will be forwarded direct to the Service Command Surgeon concerned. (2) The commanding officer of each named station hospital, named laboratory, named station and general dispensary, and named general hospital Will forward all original MD Forms 52 direct to The Surgeon General with original of MD Form 51 attached. One (1) copy of MD Form 51 will be forwarded direct to the Service Command Surgeon concerned and one (1) copy to the next higher medical head- quarters. (3) The commanding officer of each exempted, named general hospital, named med- ical depot, medical section of Quartermaster depot and named medical center will forward all original MD Forms 52 direct to The Surgeon General with original of MD Form 51 attached. One (1) Copy of MD Form 51 will be forwarded direct to Service Command Surgeon. (4) The Report of Sick and Wounded will be rendered in accordance with AR 40- 1025 and routed through the channels Indicated In paragraph (1), (2), and (3) above. b. In theater of operations (FM 8-45). (1) Emergency medical tag (EMT, Form 52b, M.D.) - In the theater of operations the EMT is used as a sick and wounded record. During or after an engagement it will be attached to all sick, wounded, and dead. It is made out by the first mem- ber of the Medical Department who treats the patient previous to his admission to a hospital. (2) Entries on EMT (Circ. No. 182, W.D., Washington, June 11, 1942). (a) In combat and simulated combat (maneuvers), aid stations and collecting stations of divisional or brigade units engaged with the enemy will partially accomplish W.D., M. D. Form No. 52b to show only name, grade, Army serial number, date, hour, diagnosis, and treatment given. (b) Form No. 52b, thus partially prepared, will be signed by the person respon- sible, indicating his grade. (c) At clearing stations and other Medical Department establishments in rear of clearing stations, Form No, 52b will be accomplished completely. (d) Under all conditions of service other than indicated In b, (2) (a) above, Form No. 52b, when used, will be accomplished completely. (3) The Field Medical Record - In the theater of operations Registers of Sick and Wounded will not be maintained. Instead a field medical record Is recorded. It consists of the field medical card (W. D., M. D. Form 52c) and the field medical jacket (W. D., M. D., Form 52d) which together contain a brief history of each patient who is treated in a station, general, or convalescent hospital in the theater of operations. 186. CHECK SYSTEM FOR RENDITION OF REPORTS. In keeping a current check on the forwarding of reports, some stations have found it convenient to have a wall chart of two rows of thirty- one hooks. On the upper row, for each day of the month, properly numbered tags are placed, Indicating reports to be rendered on that day. When these reports are forwarded, the corresponding tags are placed on the lower row. 187. LIST OF FORMS COMMONLY USED, BY NUMBER. (With the reorganization of the Army, the distribution of these forms may be changed in the near future). a. WD, AGO FORMS. NO. TITLE AND DESCRIPTION 1 Company Morning Reports. One copy. A permanent record pre- pared by the commanding officer of the company or detachment and submitted to the commanding officer of the regiment, separate or detached battalion, or similar unit and in the case of separate or detached companies, to the commanding officer of the next higher administrative unit, or of the post, camp, or station. See AR 345- 100. 2 Headquarters Morning Reports. One copy. A permanent record provided for the purpose of accounting for officers and enlisted men not belonging or attached to a company or to a detachment using a Company Morning Report, and for Army nurses, warrant officers, and contract surgeons. See AR 345-400. 5 Daily Sick Report. One copy. A permanent record prepared by the commanding officer of a company or detachment and sent to the place of,holding sick call by the noncommissioned officer in charge and re- turned by the same means to organization. • See AR 345-415. 6 Duty Roster. One copy. List of officers or enlisted men by name that is kept for the purpose of recording duty performed by each per- son. See AR 345-25. 9 Monthly Roster. Four (or more) copies. Prepared monthly or at cer- taln other intervals, such as one the day the command is organized, reorganized, demobilized, or rendered Inactive. Normal disposition of copies as follows; Original to The Adjutant General, one copy to the chief of the arm or service concerned, one copy to the headquar- ters of the corps area, and one copy retained for file. See AR 345- 900. 13 Report of Enlistments. One copy. Prepared and forwarded to The Adjutant General by the recruiting officer. See AR 600-750. 15 Report of Survey. Whenever loss or destruction of, or damage to public property occurs, the responsible officer will accomplish WD. AGO Form No. 15 in triplicate within 39 days, unless prevented by explained exceptional circumstances, and send all copies to the commanding officer or appointing authority for approval, disapproval, or such, other action as he may deem pertinent. After action by ap- pointing authority, the original and one copy are forwarded to the corps area commander and the third copy to the accountable officer. See AR 35-6640. 21 Enlistment Record, Regular Army. One copy. Prepared by the re- crulting officer for every soldier enlisted, and forwarded to The Ad- jutant General. See AR 600-750. 23 Report of Enlisted Men Enlisted for, Reenllsted in, or Transferred to Certain” Arms or Services. One copy. Prepared by the command - Ing officer of the company or detachment upon receipt of soldier’s service record. Sent to the chief of the arm or service concerned. Fact of mailing with date should be entered under remarks in the service record. See AR 600-750. 24 Service Record. One copy. Prepared by the recruiting officer. Accompanies soldier until end of his enlistment. Then sent to The Adjutant General by the commanding officer of the company or de- tachment to which the soldier belongs. See AR 345-125. 24-1 to Insert to Service Record. Furnished to record data, when the space 24-7, incl. alloted in the service record is insufficient. See AR 345-125. 25 Extract from Service Record. One copy. Prepared by the custodian of the service record upon desertion, transfer, individual change of station, etc. It is filed with the records of the unit. See AR 345-125. 26 Assignment Card. One copy. Prepared by the commanding officer of the company or similar organization upon the receipt of an order assigning or transferring an enlisted man to his command. Forwarded to The Adjutant General. See AR 615-200. 29 Authorization for Allotment of Pay. Two copies. Original mailed by the commanding officer of the unit to the Finance Officer, United States Army, Washington, D. C. See AR 35-5520. 29- Authorization for Change of Allotment. Two copies. Same remark as above. See AR 35-5520. 2 9-2 Authorization for Deduction of Pay. Two copies. Original mailed by the commanding officer of unit to the Director of Insurance, Veter- an’s Administration, Washington, D. C. Duplicate retained for file. See AR 600-100. 30 Notification of Discontinuance of Allotment or Deduction. Two copies. This is a double form - Discontinuance of Allotment printed on one side and Discontinuance of Deduction on the other. Same procedure as for WD, AGO forms Nos. 29 and 29-2, respectively.. See AR 35-5520 and AR 600-100. 30- Notification of Reinstatement or Suspension of Allotment. Two copies. This is a double form - Notification of Reinstatement on one side and Notification of Suspension on the other. Same procedure as for WD, AGO From No. 29. See AR 35-5520. 31 Furlough. Two copies. Original sent to headquarters for signature of the commanding officer. Not delivered to soldier until expiration of furlough, then signed by company or detachment commander to certify date of return. Both copies sent to Finance Officer for pay- ment of furlough ration money. See AR 615-275. 32 Individual Clothing Record. One copy. In case of transfer, accom- panies soldier. True copy made and retained for file. See AR 35- 6680, 35-6720, and 615-40. 33 Individual Equipment Record. One copy. See AR 35-6680, 35-6720, and 615-40. 35 Individual Clothing Slip. Two (or more) copies. Used in the issue of clothing to individual enlisted men and in the transfer of accounta- bility for individual equipment in their possession upon change of station. See AR 35-6560, 35-6680, and 615-40. 36 Statement of Charges. Three copies. Prepared by the commanding officer of the company or detachment. Original to the accountable officer; one copy to the responsible officer; and one copy retained for file. A separate Statement of Charges will be made for property of each supply branch. See AR 35-6620, 35-6640, and 345-300. 38 Report of Physical Examination of Enlisted Man Prior to Discharge or Retirement. Two copies. Prepared by commanding officer of the company or detachment, signed by the soldier concerned. Sent to the surgeon for physical examination of the soldier. Returned to the commanding officer of the company or detachment who transmits the original to The Adjutant General with service record. One copy retained for file. See AR 40-100. 39 Notification of Discharge. One copy. Prepared by the officer who prepares the final statement and sent to the disbursing officer who is to pay the account. Used in case there is not any finance officer located where the soldier is discharged. See AR 345-465. 40 Certificate of Disability for Discharge. Three copies. Prepared by company commander. Sent to the board of medical officers through the officer convening the board, then to the corps area commander. The original is returned to the company commander, who, after dis- charging the soldier, sends it to The Adjutant General, See AR 600-500 and 615-360. 41 Designation of Beneficiary. One copy. Prepared by the company or detachment commander and sent to The Adjutant General. Prepared in case of change of beneficiary subsequent to enlistment. See AR 600-600. 42 Change in Address of Beneficiary or Next of Kin. One copy. Same remarks as above. See AR 600-600. 44 Report of Desertion. Four copies. Prepared by the commanding officer of company or detachment. Original and two copies for- warded to The Adjutant General with service record. Copy retained for file. See AR 615-300. 46 Report of Apprehension or Surrender of a Deserter. Three copies. Prepared by the commanding officer of the company or detachment. All copies sent to The Adjutant General, who pastes the original in the service record, which is returned to the commanding officer of the post, camp, or station at which the deserter is in confinement. See AR 615-300. 49 Application for Retirement. Two copies. Signed and submitted by the soldier to his organization commander who in turn forwards it to The Adjutant General through the post or regimental commander, with information in his indorsement as to whether or not soldier has lost any time under AW 107 during his current enlistment. See AR 615- 395. 52 Report of Death. Three copies. Prepared by the surgeon or by the soldier's immediate commanding officer if medical officer is not pre- sent or available, In which case it is also signed by a civilian phy- sician. Original and one copy to The Adjutant General. One copy retained for file. A fourth copy will be forwarded to soldier,s commanding officer when death occurs away from home station or post. See AR 600-550. 54 Inventory of Effects. Three copies. (See AW 112). Prepared in the case of every person whose effects are under the control of the mili- tary authorities. See AR 600-550. 55 Honorable Discharge from the Army of the United States. One copy. Prepared and signed by the commanding' officer of the company or detachment and presented to a designated field officer or the command ing officer of the post, camp, or station for his signature. Given to the soldier who must present it to the finance officer paying final statement for notation as to fact of payment. See AR 345-470. 56 Discharge from the Army of the United States (blue): One copy. Same remarks as above. See AR 345-470. 57 Dishonorable Discharge from the Army of the United States (yellow): One copy. Same remark as above, with the exception that discharge is not delivered to soldier until his release from confinement. See AR 345-470. 63 Report of Physical Examination. One copy. Used for the annual physical examination of all officers, warrant officers, and members of the Army Nurse Corps. Used to record the physical examination of the above personnel prior to discharge, dismissal, or resignation and at certain other intervals, such as promotion. See AR 40-100 and 40-105. 64 Physical Examination for Flying. Two copies. For distribution, see Table I. Used to record the physical examination of candidates for commission in the Air Corps and the transfer of officers there- to. Used for January and July examination of all pilots and rated observers. See Table I and AR 40-110. 73 Basic Strength Return. Four copies. Rendered by the commanding officer of each branch of the service represented at a post. Origi- nal to The Adjutant General. Copy to the chief of the branch. Copy to the corps area concerned and copy retained for file. See AR 345- 50, 345-55, and 345-100. 115 Charge Sheet (for Court Martial): Three copies. Any person subject to military law may prefer charges. After preparation they are signed and affidavit completed as prescribed by AW 70. All copies are submitted to the commanding officer for investigation and such action as he deems appropriate in each case. If tried by summary court martial the three copies are disposed of as follows: The original copy is filed at post headquarters, a copy sent to The Adju- tant General and a copy to the officer exercising general court mar- tial jurisdiction. See paragraph 31 and appendix 3, Manual for Court Martial. 181 Enlistment record. Regular Army Reserves. Three copies. Accom- plished by the recruiting officer or other officer authorized to accept enlistments for the Regular Army Reserve, The original copy (white) is sent to the commanding general of the corps area in which the reservist’s home is located. The second copy (pink) is sent to The Adjutant General. The third copy (green) is given to the reservist. See AJR 155-5. b. F. B. I. Military Fingerprint Card. One copy. Prepared by the recruiting officer or other officer designated for the purpose for every soldier en- listed, and forwarded to The Adjutant General. See AR 345-120. c. WD, MD FORMS. 16a Issue Slip-Expendable Medical Property. Made out and signed by the officer in charge of ward or department. Names of articles desired will be written as they appear in the Medical Department Supply catalog. Slip will be completed by the officer in charge, who will in- sert the date and receipt same. Filed at the medical supply office. See AR 40-1Y05. 16b Issue Slip-Nonexpendable Medical Property. Made out and signed in duplicate by the officer in charge of the ward or department. Names of articles will be written as they appear in the Medical Department Supply Catalog. Both the original and duplicate slip will be com- pleted by the receipt of the officer in charge, who will insert the date. Original will then be filed at the medical supply office and the duplicate returned to the requesting officer for file with his retained memorandum receipt. See AR 40-1705. 16c Credit Slip-Nonexpendable Medical Property. Made out and signed in duplicate by the officer in charge of the ward or department where the property has been In use. Names of articles will be written as they appear in the Medical Department Supply Catalog. If property to be turned in is unserviceable from any cause other than fair wear and tear in the military service, a statement to that effect will be attached showing what action has been taken to fix responsibility. Both the original and duplicate slip will be completed by the receipt of the storekeeper, who will insert the date. The original will then be returned to the officer turning in the property for file with his retained memorandum receipt, and the duplicate will be filed at the medical supply office. See AR 40-1705. 16d Exchange Slip-Nonexpendable Medical Property. Made out and signed by the officer in charge of the ward or department for which the ser- viceable property is needed. Names of articles desired will be writ- ten as they appear in the Medical Department Supply Catalog. If property to be turned in is unserviceable from any cause other than fair wear and tear in the military service, a statement will be at- t ached showing what action has been taken to fix responsibility. The slip will be completed by the receipt of the officer in charge, who will insert the da.te. It will then be filed at the medical supply office. See AR 40-1705. 21 Hospital Laundry List. Copy sent to The Surgeon General, with the voucher for laundry service in case the service is being accomplished by a civilian laundry. A copy sent to The Surgeon General as a month- ly report in case the service is being accomplished by a Government- owned laundry. One copy retained. See AR 40-590. 42 Contract for Laundry Work (with appendix sheet “A”). Six copies. Three copies sent to The Surgeon General or corps area surgeon for approval. Three authenticated copies prepared and distributed as follows: One copy for the contracting officer, one to the Returns Offi- cer, General Accounting Office, and one to the disbursing officer. See AR 5-160 and 40-590. 4 9 Statement of the Hospital Fund. Two copies. Original to The Sur- geon General through the SC surgeon. Retained copy for file. See AR 210-50. 49a Employee’s Certificate of Indebtedness for Hospital Service. Three copies. Marked “Original,” “Duplicate,” and’’Triplicate.” Two copies to the officer under whom the employee is serving. One copy retained by the commanding officer of the hospital. See AR 40-590. 51 Report Sheet for Report of Sick and Wounded. Two copies. Original with report cards and other records to the Surgeon General for checking and then forwarded to The Surgeon General. Copy to SC Surgeon and one filed. See AR. 40-1025 and par. 185. 52 Register Cards. Two copies. Original to the SC surgeon along with WD, MD Form No. 51. Copv filed. See above and AR 40- 1025. 52a Index Record of Patients (Card); Register index. One copy. Kept in the hospital and prepared by alFhospitals in peace or wax, wherever located. Also used for keeping the “diagnosis index” and other indices at fixed hospitals in addition to its use as a nominal index of patients. See AR 40-1025. 52b Emergency Medical Tag. Used only in the field. Two copies. Origi- nal attached to all sick, wounded, and dead, as soon as practicable. See FM 8-45. 52c Field Medical Card. One copy. Started at the first hospital in the field where treatment is furnished. Accompanies the patient until return to duty, death, or arrival in zone of the interior. Removed and sent with the monthly report of sick and wounded to the chief surgeon, or corps area surgeon, as the case may be, for transmit- tal to The Surgeon General. See FM 8-45. 52d Field Medical Record Jacket. For field use. Used for inclosing the field medical.'card, emergency medical tag, and any other clini- cal record of value. See FM 8-45. 54 Surgeon’s Request for Service Record. Used by the commanding officer of hospital to make direct call upon the proper organisation commander for the soldier’s service record in the event of failure to receive same in due time. See AR 40-590. 55a Clinical Record Brief. A clinical record will be kept by fixed hospi- tals in time of peace or war, excepting those serving in a theater of operations. This form and 55 j are used for every patient treated in hospital and for serious cases treated in quarters. See AR 40-1025. NOTE: The other lettered blanks of the 55 series will be used as the nature or importance of the case may warrant. 56 Malarial Register. One copy. Prepared for every case or carrier of malaria and should be kept up to date until patient is definitely cured or terminates his military service. In the event of transfer, accompanies the patient to Ms new station. In the event of termina- tions of Ms military service, will be l nt to The Surgeon General. See AR 40-230. (No longer required). 57 Report of Dental Service. Rendered monthly from every station and separate command~where a dental officer has been on duty dur- ing the month. If post is under the immediate control of the War De- partment, report is sent direct to The Surgeon General. One copy re tained. If forwarded through the corps area surgeon, two copies are forwarded and one retained. See AR 40-1010. 72 Morning Report of Ward, Rendered each morning by ward officer. Sent to the registrar along with clinical records, etc., of completed cases. Not a permanent record. See AR 40-590. 72a Consolidated Morning Report of Wards. Kept by the Registrar of the hospital. See AR 40-590. 73 Diet Card. Made out daily by the ward officer and sent to the hospi- tal mess. Not a permanent record. See AR 40-590. 74 Mess Account. Kept by noncommissioned officer in charge. Filed at the end of every month with retained hospital fund papers for that month. See AR 40-590. 75 Patient’s Property Card. Made out in duplicate. Original filed with hospital records; duplicate given to patient. See AR 40-590. 76 Patient’s Property Tag. Used for identification of patient’s property stored while hospitalized. See AR 40-590. 78 Syphilitic Register. Maintained for each person in active military service who has syphilis. Kept on file in the office of the surgeon. On “cure” or separation from the service, the register will be for- warded to The Surgeon General. See AR 40-235, C.L. No. 1, SGO, each year. 7 9 Register of Dental Patients (Card). Made for every person admitted to a dental clinic for dental treatment. See AR 40-1010. 81 Immunization Register. Made out in duplicate. Original in cases of officers, warrant officers, and nurses to the person concerned. Original in cases of enlisted men to the organization commander for entry in soldier’s service record: Duplicate copy will be filed in an alphabetical immunization file of the medical department records of the station or command to which the individual belongs. See AR 40- 215. 86ab Statistical Report (first and second sections). Rendered by the sur- geon of every separate station or command. Made out in triplicate. See AR 40-1080, and par. 184. 86c Statistical Report (third section). See above remarks. 95 Report of Bacteriological Examination of Water. Accompanies monthly sanitary report; one copy for each analysis made. d. WD, QMC FORMS. 22 Statement of Clothing Charged to Enlisted Men. One copy. Used by company commanders to list the names and amount charged to cloth- ing allowance of men to whom clothing has been issued. Sent to offi- cer designated for keeping service records. See AR 35-6560, 35- 6720, and 615-40. 364 Weekly Collection and Delivery Sheet. Three copies. Shows names of each enlisted man sending laundry. Original and duplicate to laundry each week; triplicate retained for file. See AR 30-2135. 365 Monthly Roster and Statement. Three copies. Shows names of en- listed men of the organization who have signified intention to have quartermaster laundry service during the month. Original and dupli- cate to laundry on first day of month; triplicate retained for file. See AR 30-2135. 374 Enlisted Men’s Laundry Slip. One copy. A list of laundry sent by enlisted men to accompany each bundle. Sent to laundry. See AR 30- 2135. 400 Requisition. Three copies. Used in requisitioning all supplies except those for which special forms are provided. Original and duplicate to commanding officer for approval and in turn to quartermaster for issue. Triplicate retained. See AR 35-6540 and 35-6720. 409 Requisition and Receipt for Clothing in Bulk. Three copies. Nor- mally submitted by organization quarterly for clothing charged against clothing money allowance. Original and duplicate to commanding offi- cer for approval and in turn to quartermaster for supply. Triplicate retained for follow-up purposes. See AR 35-6540, 35-6560, and 35- 6720. 411 Requisition and Receipt for Brooms, Brushes, Matches, Mops, Toilet Paper, Soap, etc. Three copies. Quarterly requisitions by organizations for items appearing thereon but not exceeding in money value of budget credit allotted to organizations. Original to command- ing officer for approval and in turn to the quartermaster for supply. Triplicate retained. See AR 30-3010, 35-6540, and 35-6720. 412 Requisition and Receipt for Stationery and Office Supplies. Three copies. See remarks about WD, QmC Form No. 4ll. 413 Requisition and Receipt for Cleaning and Preserving Materials. Three copies. See remarks about WD, QMC Form No. 411. 414 Requisition and Receipt for China and Glassware. Three copies. See remarks about WD, QMC Form No. 411. 424 Stock Record Card for Loose Leaf Binder, Organizations or Posts and Stations. One copy. Used for keeping stock records. See AR 35-6560 and 35-6720. 431 Receiving Report. Three copies. Used as voucher to stock record account to cover receipt and acceptance of articles purchased. Original and duplicate to finance officer designated to make payments Retained copy, voucher to stock records. See AR 35-6560 and 35- 6720. 434 Shipping Ticket. Five copies. Used when property accountability is transferred from one accountable officer to another. Original and duplicate to consignee, who, upon receipt of property, will sign one copy and return to consignor. Third and fourth copy to finance officer of the corps area where consignee is located. Retained copy, credit voucher, to stock record account of consignor. See AR 35-6560 and 35-6720. 445 Over, Short, and Damaged Report. Three copies. See AR 35-6560, 35-66407 and ■'SEUffm 460 Ration Return. Three copies. A requisition on the quartermaster for rations. Signed and submitted by officers under whom persons entitled to these are serving. After approval by the commanding officer, original and duplicate sent to quartermaster sales officer. Third copy retained. See AR 30-2210 and 35-6720. 487 Memorandum Receipt. Three copies. Used by accountable officer who issues property to individuals or organizations, who in turn assume responsibility used as credit or debit voucher to memoran- dum receipt account. Original and duplicate to organization or in- dividual to whom property was issued, who will sign original and re turn to accountable officer. Retained copy used for follow-up pur- poses. See AR 35-6520 and 35-6720. 488 Account of Property on Memorandum Receipt. One copy. Used by property officer to show where property is located for which he is accountable. Postings are made from WD, QMC Form No. 487. See AR 35-6520 and 35-6720. e. WD, IG FORMS. 1 Inventory and Inspection Report. Responsible officer will prepare and sign two copies, listing the property to be inspected. Action of the inspector will be final. See AR 20-35. 2 Inventory and Inspection Report of Public Animals. Unserviceable public animals will be listed on this form. Prepared whenever needed. See AR 20-35. THE FLIGHT SURGEON'S OFFICE SECTION n Types of examinations 188 Instructions for completing W.D., A.G.O. Form No 64 189 Care of flier report 190 Locator chart- - - - - 191 Transfer of records 192 Grounding, relief, clearance, and restoration of flying personnel 193 Procedure in case of crash death 194 Reports following hospitalization 195 Paragraphs 188. TYPES OF EXAMINATIONS. Many types of examinations besides those for flying may be done in a Flight Surgeon’s office. The following list indicates the most common of these: Examination Form Used (1) Original examination for training as Air WD, AGO~Bi Crew (Pilot, Bombardier, Navigator), Service Pilot, Liaison Pilot. (2) Enlistment and reenlistments WD, AGO 21, 22, 165 or 181 (3) Discharges WD AGO 38 WD AGO 21 (4) Prisoners (5) Preliminary, for applicants for West Point None (6) Foreign service Certificate (7) Semi-annuals Certificate (8) Annuals WD, AGO 64 for flying officers WD, AGO 63 for non-flying officers (9) Combat crew (enlisted) WD, AGO 64 (10) Civilian flying instructors and Trainee WD, AGO 64 Instructors (11) Promotion WD, AGO 63 (12) Flying Personnel WD, AGO 64 (13) Army nurse corps WD, AGO 63 (14) Service school Certificate (15) Government insurance (National Service Vet. Adm. Ins. Form 350 Life) (16) Civil Service U.S. Civ. Ser. Form 2413 (17) Officer Candidate (non-flying) WD, AGO 63 If possible, it is better to have the organization of the office arranged so that all fly- ing examinations will be done by one unit and the remainder of the examinations perform- ed by a separate unit. 189. INSTRUCTIONS FOR COMPLETING W.D., A.G.O. FORM No. 64. (Physical Examin- ation for Flying), a. General Remarks. The following discussion of certain points in the completion of the “64" examination form is an attempt to standardize the manner of fill- ing out this form and to furnish a ready reference for all examiners. Because of frequent changes and additions, especially in the purpose of examination for which this form is used, all examiners should help in keeping this reference up to date by revision whenever indi- cated. b. General Instructions. (1) Fill in every entry. If a heading is not applicable, use dashes. (2) The term “normal" will be used whenever possible to Indicate Usual, average, qualifying findings. If abnormalities are present describe in detail. If these are not symptomatic, indicate by the use of the abbreviation N.S. If abnormalities are des- cribed which are not considered disqualifying indicate by use of the abbreviation N.D. JSjNegative will not be used except to report the results of laboratory tests and X-rays. (( „ (4) “None” will be used where indicated. Example: Varicose none . (5) If there is insufficient space for remarks, write: “See Par. 37’ , and continue the remarks in that paragraph. If additional sheets are required they will be consi- dered In an extension of paragraph 37 and should be permanently attached, preferably by pasting, to Form “64* . c. Special Instructions for Individual Items of “64”, by Paragraph (Obvious entries will not be discussed). Par. 1. (a) Give full name, including full middle name. If there is only a middle initial, give the initial followed in parenthesis by “(initial only)”. If there is no middle name or initial, write in parenthesis “(none)”. (b) If no military status, write “civilian” over grade and arm of ser- vice. Grade means rank as Pvt., Sgt., 1st Lt., etc. Arm means Combat Troops ast Air Forces, Cavalry, Infantry, Coast Artillery Corps, etc. Services are Medical Department, Finance, Q.M.C., etc. (c) Age. Nearest birthday. (3) Years of service. Indicate only whole years completed. Where there has been less than one year, state service in nearest twelfth, example: 5/12. Par._2. (a) If in service, give service address. Otherwise, give a detailed home address (where Individual habitually receives mail). (b) Purpose of examination. L TAC (Air Crew). This is used for all applicants for Air Crew Training. 2. Officer training in grade, (Pilot), (Navigator), (Bombardier), (Aerial) Observer). 3. Other purposes: Service Pilot, Liaison Pilot, Flexible Gunnery Training, Other Combat Crew (Radio or radar operator, airplane mechanic, etc.) 4. Foreign Student. F. Non-rated Observer. For officers of other branches applying for flying status. 6. Semi-annual. Indicate in parenthesis (pilot), (navigator), (civilian instructor), etc. 7. Special (after hospitalization or after sick leave, or after head in- juries, etc.). (c) Date and result of last examination applies examinations for flying.'"If this is original examination, enter “original”. This entry is to be supported by accompanying certificate. (Form W-3766, AC, revised). (d) Aeronautical Ratings are Army Ratings only. (e) Flying time refers to Army flying time only. Par. 4. In this paragraph should appear* remarks concerning any of the conditions called for in small print. On the original examintaion a comprehensive history of personal Illness (childhood and adult), of familial illness if relative to selection, and of personal surgery, injury, or abnormality will be recorded. On subsequent examination the medical history since the last examination will be obtained and recorded. Physical findings as scars, deformities, etc., properly belong in the par- agraph concerning that part of the physical examination, and not in this paragraph. In recording the history, give dates (year) rather than the age at which the disease occurred. Wordage should be limited. Negative statements should be limited to amplifying Illnesses, e.g,, “no complications, no sequelae”. In the event the ex- aminee denies any history, the following statement should appear in paragraph 4; “Denies any Illnesses, injuries, or operations”. JPar. 5. Inspection, use “normal”. For nystagmus, use “none”. Par. 67 For associated parallel movements, use “normal”. For equality, use “iquaT*. For reaction, use “normal”. Par. 7. Visual acuity will always be Indicated in positive values, e.g. 20/20+2, not 20/30-6. The acuity 20/25 will not be used because it does not appear on all Snellen charts. Par. 10. Red Lens Test. - Record as “normal” if no defect found. If suppression is found give distance and direction in which the light was moved and distance from the neutral point at which the suppression occurred, e.g., “Suppression, right eye, 20 cm. up and to left”. If diplopia is found, list as crossed or uncrossed diplopia and the direction and distance at which it occurs from the neutral point, e.g., “Crossed Diplopia, 25 cm. up and to the right”. , Angle of Convergence. Record PcB or Pd in mm. but do not compute angle. Qualification is determined on basis of PcB - Pd = 25 or less. Par. 11. Addition required for 50 cm - filled in when accommodation falls below 3D. (This refers to rated pilots or service pilots over 40 years old and ordinarily does not apply to the applicant for Air Crew training). Jaeger type. Reported on all aviation cadet applicants, and when form “64” is used in place of ‘63” and is to be reviewed in Office of Surgeon General (Com- missions, promotions, annual physical). J-l-13 refers to J-l type legible at 13 inches, without glasses. If glasses are worn, near vision is determined without glasses and with glasses (corrected), and the prescription given. Par. 12. Color vision will be designated as follows: /a) If applicant misses no plates, either American Optical Company or Ishihara; ‘ Normal” is recorded. (b) If applicant misses less than 25% of plates record as “misses 3 A.O.” or “misses 2 Ish.”. (c) If applicant misses more than 25% of plates record as “Fails Ishi- hara” (or Fails A.O.), Perm. Disq”. (d) In the classification center the adjunctive tests may be used in the event an individual misses more than 25% of the plates. Depending on the results of these tests the individual is listed as “safe (or unsafe) for Air Crew (or Combat Crew) training as indicated by (give name of test or tests used)”. Par. 15. Use “Denies”, if no history of ear trouble is admitted. If history of ear disease is admitted, record the diagnosis, the ear involved, date of occurrence, operative procedure, if any, and sequelae, if any. Par. 17. Hearing loss by the audiometer test will not be recorded in percentages, but will be recorded as average decibel loss computed from the practical conver- sational range of hearing. Par. 18. Deviations of the septum will be recorded in terms of obstruction. For example: “Septum deviated to right; 40% obstruction, NSND.”, or “Septal spur on left, interfering with ventilation and/or drainage of the middle meatus, Temp. Disq. . Tonsils: “Enucleated”, if they have been removed. Do not describe the tonsils unless they have, or may have in the future, some pathological significance. Do not use the term “present”. Record “normal”, if such is the case. Par. 19. (b) Remarks including other defects - State “no teeth missing” if this is the case. Enter gingivitis, stomatitis, etc. if present. Also enter irregularities which may be of value in identification, “tooth malposed R 13 lingually”. Note type of malocclusion if present. Par. 20. Use denies, if no history admitted. Par. 23. Record height to nearest 1/4 inch, weight to nearest pound, chest measurements to nearest 1/4 inch. Par. 27. “Exercise Test’ is the standard test of hopping on one foot one hundred times. Par. 30. Use “negative”. If X-ray report contains any findings other than nor- mal or negative data, include the entire X-ray report verbatim. Par. 35. (a) If Kahn negative and Wassermann test not made put dashes after Wassermann. (b) Microscopical to be completed on all original and on final type ex- aminations; otherwise put dashes after microscopical. Par. 36. State either “Satisfactory” or “Unsatisfactory”. Follow this by “A&MA”, giving the score. In this paragraph do not put in any derogatory remarks concerning the individual which are personality evaluations, and which reflect on his intelligence, character, habits, etc. Do not put in paragraph 36 any remarks which rightly belong in paragraph 4. Par. 37. Begin continuation as: “Par. 18, cont.” Continuations should follow each other in their numerical sequence. If there are no remarks, state: “none”. Recommendations for waiver of minor defects should be placed in this paragraph. Par. 38. Qualified? Yes or No. Class? 1, 2, or 3 (if qualified). If disqualified put in a dash. If qualified, but waiver recommended, indicate as follows: “l (or 2 or 3) if waiver is granted.” List disqualifications by paragraph number only as “Par. 7, 10, 18, 36. ’. Do not enumerate the actual disqualifications. Par. 39. Dash out on original applicant only. Fill in on semi-annual. Par. 40. Dash out on original applicant only. Fill in on semi-annual. Par. 41. Use “none” or one of the following remarks: (a) “Permanently disqual- ified, reexamination not recommended.” (b) “Temporarily disqualified, reexamin- ation recommended.” For original applicants, do not include any recommendations for correction of temporary defects, (c) If the applicant Is to wear glasses while flying, a statement to that effect will appear in this paragraph, (d) other remarks as indicated. Par. 42. On original examinations only, does he meet physical requirements? “Yes, or No.” Do you recommend acceptance with minor physical defects? “Yes or No.” If rejected enumerate disqualifications, for example: “Defective color vision, hypertension, unsatisfactory ARMA,” d. iSignatures. Two on the right, and one reviewing officer. Flight Surgeons and Avia- tions Medical Examiners may sign “64”. Typewritten name will appear below the officer’s signature. 190. CARE OF FLIER REPORT, a. Instructions, general. (1) This report will be pre- pared in duplicate by a Flight Surgeon, or in the absence of a Flight Surgeon, by the Sta- tion Surgeon, for every Air Forces station on Saturday of each week and the original forwarded promptly to Air Surgeon, Army Air Forces, Office of the Commanding General, Army Air Forces, Washington, D.C. The retained copy will be filed as a permanent record in the office of the Flight Surgeon. (2) The report will cover a period of one week from midnight Friday to midnight of the following Friday. It will be dated as of the Friday closing the weekly period. (3) All personnel receiving flying training will be reported as flying students. While receiving dual instruction, flying students will be reported as passengers. (4) When an individual is removed from flying for any reason while away from his home station, he will be recorded only on the Care of Flier Report of the Air Forces station where he is under treatment or observation, and will continue to be so re- corded until he passes from jurisdiction of that station. In the event of transfer to a General Hospital, the home station Flight Surgeon will be notified and the individual dropped from the records of the station where he had been under treatment. The home station Flight Surgeon will from that time account for the flier on his Care of Flier report. Should the disability occur or be continued at a point where a Care of Flier report is not routinely made, the home station Flight Surgeon will be notified and the individual recorded on his own station report. (5) Personnel of the Navy or Coast Guard removed from flying for any reason at any Army Air Forces station will not be recorded on this form. A separate re- port by letter will be made to the appropriate authority. A copy of this letter will be attached to the Care of Flier report. (6) With reference to cases on sick leave under the provisions of par. 25 a, AR 40- 1025, dated October 12, 1940, attention is invited to the two types of sick leave pro- vided for therein. In the preparation of the Care of Flier report due distinction will be made. If the case is on sick leave on a sick status, it will be carried in the same manner as if in hospital. If the sick leave is on a duty status, the days lost will be entered in the sick leave column. (7) The report will be signed by the Senior Flight Surgeon. In the preparation of this report only those abbreviations authorized by Army Regulations or having official sanction will be used. b. Preparation. (1) The strength of command may be obtained from Headquarters of the station and should be identical with that shown on WD Form 86 ab for the same period. The breakdown into component parts will be the same as shown on Form 51, MD. (2/ Report of aircraft accidents. Only aircraft accidents resulting in injury to the occupants of aircraft or to bystanders, or as a result of which the flying status of any individual is changed, will be reported hereon. In all such cases, an aircraft accident report (WD, AC Form 205) will also be prepared and attached to this re- port. It is to be noted that the definition of “aircraft accident” differs from the de- finition used by the Air Forces. The latter includes any accident involving appreciabl damage to the plane alone. The number of aircraft accidents is that which has occured during the week covered by the report only. This will be recorded as words and not as numerals: viz., "None,” “One,” etc. Personnel involved in the accident will be tabulated in Table A on the appropriate line and in the column corresponding to their classification. In those instances where there is a pilot and a co-pilot involved, both will be recorded as pilots and explana- tion made under “Remarks.” For example, if the pilot and co-pilot are R. A. offi- cers, the figure “2” will be placed on the “commissioned” line in the first “pilot column” and followed by an (*). Under “Remarks” the statement, co- pilot,” or other suitable phrase will be used. Military personnel injured in air- craft accidents will also be tabulated under “disorders due to flying, ’ and listed un- der “Remarks” on the back of the form. Killed or uninjured military personnel and civilians will not be accounted for anywhere else on the report. The results of aircraft accidents will be tabulated in a similar manner. An extra column heading “Civilian” may be inserted in the “Total” column for this purpose. Command pilots will be tabulated as “passengers.” Civilians will be tabulated in the “Total” columns of Tables A and B. (See the second sentence of this paragraph above). Propeller accidents. Applies only to those injuries caused by a moving propeller. Remarks. The space on the front of the Form 203 is reserved for remarks per- taining to accidents only. The names of the killed or injured, together with such other data as seems pertinent will be recorded here. Complete report will be made on Form 205, and attached to this report. c. Supplemental reports. In the event that injuries prove to be more serious than origi- nally believed, or if death occurs, subsequent to first report of the appropriate remarks will be made on a later Cere of Flier report following a notation: ‘Supplemental report -- see Care of Flier report dated .” Such notations will be entered be- low the remarks for the current week. In these instances no tabulations will be made. No supplemental report need be made for civilians. d. Tabulation. (1) Tabulation of fliers on sick report or those removed from flying for “physical causes. Under “Disorders Due to Flying” all military occupants of aircraft, regardless of their crew position, who are incapacitated for flying for reasons inci- dent thereto, will be tabulated here on the appropriate line and in the correct column. (2) Under “Disorders Not Due to Flying” only classified flying personnel of the Air Corps will be tabulated. Enlisted men who do not hold military aeronautical ratings or who are not receiving training for aeronautical ratings should not be carried on the Care of Flier report. Non-rated observers (officers of other branches) should be car- ried on the Care of Flier report only when thev are injured in aircraft accidents or receiving injuries while flying. (See Table XXI). (3) In computing time lost tne aay of admission xo sick report or of grounding is al- ways counted as a day lost regardless of the time it occurs, and the day of return to duty is counted as not lost regardless of the time it is effective. In case of death or retirement for disability it is included. In the tabulations only the number of days lost by each individual for the week covered by the report is recorded. The number of days lost by an individual thus may range from none to seven. No days lost will occur when return to duty is effective the first day covered by the report. The total number of days reported as lost by any group of individuals in any column is the sum 179 TABLE XXL DATA TO BE CARRIED ON BACK OF CARE OF FLIER REPORT COLUMN A COLUMN B Disorders due to flying Disorders not due to flying 1. To be carried when injuries or diseases are due to flying: a. Officers (1) Air Crew (pilot, bombar- dier, navigator) Same personnel carried (2) Officers training in grade (air crew) as in Column A b. Flying Sergeants c. Aviation Cadets - Air Crew d. Flight Officers 2. To be carried only when injuries are received while flying: a. Officers (1) Ground Crew (photographer, armorer, engineer, meteorologist, radioman) This personnel not carried in this Column (2) Flight Surgeons. b. Aviation Cadets - Ground Crew of the days lost for that week only, by each. (4) Only individuals who have lost a minimum of 24 hours from flying will be recorded. This includes those fliers who might be removed from flying for some reason without being on sick report or sick leave. Should the physical condition of the flier b e such that intercurrent diseases indicat- ing a new or changed diagnosis change the cause of removal from flying from a dis- order due to flying to a disorder not due to flying, or vice versa, such fact will be noted by an asterisk (*) in the “Days lost” column under “A” and “b” with an ap- propriate explanation under “Remarks.” In such event, the day the change in diagnosis is made will be considered a day lost under the new diagnosis. (5) This portion of the report is accumulative as far as the number of individuals is concerned. As long as an individual is removed from flying for any reason he must be repeatedly tabulated here until final disposition is made. e. Remarks. (1) Every individual tabulated under “Disorders Due to Flying” and “Dis- orders Not Due to Flying” will be listed here and separated into R.A., Reserve, and Flying Student Components. The name, rank, diagnosis, date of admission to this re- port, date of duty and the total number of days lost for the current admission will be recorded for each. These diagnoses will necessarily be brief and need not conform stricly to regulations governing the preparation of sick and wounded reports else- where. The diagnostic table set forth in AR 40-1035 should, however, be used as a general guide for terminology. When the diagnosis is unduly long, unnecessary weekly repetition of this may be avoided by a brief mention of the nature of the disability and stating the date of Care of Flier report on which the complete diagnosis appears, as “Multiple injuries, result of aircraft accident, see report of 9/27/40.” (2) An additional sheet will be used when necessary, and attention called to this by making an appropriate remark at the bottom of the form. f. Recording of data. (1) The method used for recording necessary data for the prepara- ~ tion of the Care of Flier report varies from one station to another. The system most generally in use is that of keeping individual records (Forms 52, 55a, etc.) which at the end of the week are sorted into “Disorders Due to Flying” and “Disorders Not Due to Flying,” and the Care of Flier report prepared from these. Such a system re- quires a great deal of care to correctly determine the number of days lost for that week and the total number of days lost to date. The Flight Surgeon experiences the same difficulty in checking the accuracy of a report which is prepared from a number of different records. To overcome these difficulties a method of keeping this data on a single form is illustrated (Table XXII). Each of the dates covered by the report is placed at the head of a column provided for it. Daily disposition of each individual is recorded under the corresponding date. Under “Previously” the date of admission prior to the current report week is entered and also the total number of days lost at the end of the previous week. The column headed “Designation” is provided to indi- cate that the individual is in the Regular Army, Reserve, or is a flying student. When the Care of Flier report is to be prepared the number of days lost during current week by each individual is readily determined and recorded under “This Week.” The total number of days lost is also easily determined by adding the number of days lost under “Previously” to that lost under “This Week.” Therefore, all the Information that is necessary to complete the Care of Flier report is consolidated on one form. By re- ference to it at any time during the week the Flight Surgeon can readily see who is on sick report and the diagnosis, status, date of admission, date of duty and the number of days lost by each individual. g. Checking the report. (1) The report is checked in the following manner: ~The totals for the “Number“columnsof “Disorders Due To Flying” and “Disorders Not Due to Flying” are added. This sum should be the same as the number of names appearing under “Remarks. ” (2) Similarly the totals of the columns “Days lost” for “Disorders Due to Flying” and “Disorders Not Due to Flying” are added. This sum should be equal to the total of the days lost during the week by everyone. (3) This method of checking the report is greatly facilitated by using the single data sheet for all that is necessary is to add the column “This Week” and to count the number of names for comparison with the total shown. Name Rank Desig- nation 1st 2nd 3rd Ath 5th 6th 7th Previ- ously This Week To Date Smith, A. B. Maj. Reg. A. Psychoneurosis, anxiety type, mod. severe DNIF DNIF DNIF DNIF DNIF DNIF DNIF 3/1/39 31 7 38 Jones, C. D. Lt. Reg. A. Varicose veins, severe, left leg Hosp Hosp Hosp Hosp Hosp Hosp Hosp 0 7 7 Green, E. F. Lt. Res. Nasopharyngitis, acute, cat., mod. severe ~ — Qtrs Qtrs Qtrs Duty — 0 3 3 Brown, G. H. Capt. Reg. A. Sprain, mod., left ankle — — — Qtrs Qtrs Qtrs Qtrs 0 A A Adams, I. J. Lt. Student Nasopharyngitis, acute, cat., mod. severe — — — — — Hosp Hosp 0 2 2 TABLE XXII . DATA FOR CARE OF FLIER REPORT MONTH April DNIF - Duty Not Involving Flying Week ending April 7th. 1939 182 h. Frequent errors made on Chre of Flier report. “(1) Ommission from report of students, cadets and officers who are removed from flying status because of physical disqualifications. (2) Failure to carry on subsequent reports patients transferred to general hospitals or other station hospitals for observation and further treatment. (3) Failure to give disposition, whether on ground duty, in hospital, quarters, etc. (4) Failure to enter dates of disposition. (5) Failure to give date returned to duty. (6) Failure to carry on report when on ground duty. (7) Carrying enlisted personnel who do not hold aeronautical ratings and who are not taking such training. (8) Failure to give full name; (Last name, first name, and middle initial). Initials alone are insufficient. (9) Failure to distinguish between ground duty (DNIF) and full flight duty (Duty). (10) Failure to give diagnosis. (11) Failure to submit reports weekly (single copy^only)! (12) Failure to recognize the fact that “Days Lost” should include all flying days lost (13) Carelessness in spelling of names on reports, especially those previously re- ported. 191. LOCATOR CHART. For ready reference to the status of all flying personnel, a wall chart can be constructed, consisting of any background (conveniently imitation leather) which can be slit to receive cards for each officer. These can be arranged either by organizations or by alphabet and rank. Varicolored cards are used to indicate types of personnel involved, as officer, pilot, bombardier, navigator, warrant officer, etc. In addition, small squares of colored cards may be used to indicate the status of the individual; that is, no additional card for an officer on full duty, a small red card superimposed on one corner of officer’s name card, indicating “hospital”, a yellow card, “quarters,” a green card, “duty not involving flying”, a black card, “sick leave,” etc. Charts of this nature can also be made to indicate status by the use of golf tees or other pegs, inserted in a status hole opposite officer’s name. 192. TRANSFER OF RECORDS, a. As a flying officer’s records must be sent to the Flight Surgeon of his next station, on transfer (see par. 12, AR 40-110) it will be found convenient to have the officers’ clearance slip made with a space for checking by the Flight Surgeon. The pilot on receiving his clearance, will notify the Flight Surgeon of his change of station and his records can then be forwarded with a copy of the pilot’s orders attached. b. When flying personnel are transferred to overseas commands or when their orders indicate that such may be their disposition, their records will be sent to the Air Surgeon, OCGAAF, Washington, D. C. c. In case of death of any flying personnel records will be sent to the Air Surgeon. 193. GROUNDING, RELIEF, CLEARANCE, AND RESTORATION OF FLYING PERSONNEL, a. Definitions. (1) Flying - Moving in the air in an aircraft. (2) Flying Status- a Status in which an individual has been ordered to participate in regular and frequent flights. (3) Grounding - The prohibition of an individual from flying, usually for reasons of a temporary or minor nature. (4) Relief - The issuance of a legal order by the Commanding General, A.A'.F., terminating the participation of an individual in regular and frequent flights. (5) Clearance - Clearance is the authority to fly. In the case of grounding local permission is sufficient. In relief the OCGAAF must grant the authority. In other words, the authority to remove is the same as the authority to restore. (6) Restoration - The issuance of an order by the Commanding General, AAF, to permit a flyer who has been removed to again participate in flight. (7) Serious Illness or Injury - In relation to flying any illness or injury that requires major surgical procedure or absence from full military duty for a period of over one month; fractures, and especially fractures Involving the cranium or vertebral column; injuries or interference with function, or diseases of the eye; neurological, mental or neuropsychic conditions; cardiovascular and renal conditions of an organic nature; encephalitis lethargica or any condition accompanied by diplopia or lethargy; and syphilis, malaria, paroxysmal tachycardia, recurrent attacks of any of the rheumatic group, renal calculus, pneumonia, typhoid, and any other debilitating diseases. (8) Differentiation of Ground and Relief - Grounding has a dual meaning. In the broad sense it means staying on the ground. In the more narrow sense it is used to define a non-flying status of less than 30 days and for minor causes. To a degree the terms “grounding’’ and ’’relief from flying’’ are synonymous. This is to say while clear, relief from flying is a formal procedure requiring the action of the Commanding General, A.A.F., and is only recommended in case of prolonged removal from flying for serious conditions and for a period greater than 30 days. In “grounding” there is no loss of flying pay or flying status. In “relief” both are indefinitely suspended. In grounding the final action is local; in relief the OCGAAF takes final action, b. Indications. - (1) Grounding - Personnel on flight status are temporarily prohibited from flying usually because of some minor illness or injury which in the opinion of the Flight Surgeon is sufficient to interfere with proper control of the airplane or which might become aggravated by flying. (2) Relief. Relief from flight status is indicated in the following conditions: (a) For serious illness or injury in relation to flying, (b) Whenever A.G.O. waivers are required. (3) Clearance. Clearance of fliers must be obtained after grounding for minor ill- ness or injury, after relief from flight status, upon return from leave of 30 days or more, after all aircraft accidents and upon reporting to a new station. Reserve officers with pilot ratings who apply at Air Forces stations to pilot aircraft are required to obtain a clearance before flights are authorized. (4) Restoration. At any time following relief from flying status and subject to the condition causing this relief the individual may request an examination to determine whether he is physically qualified to fly. c. Procedure. (1) Grounding. Whenever a Flight Surgeon finds an individual on flight status physically incapacitated for such duty, he will promptly inform the Commanding Officer of his station and at the same time submit appropriate recommendations. Upon the receipt of such notification from the Flight Surgeon, the Commanding Officer will at once ground or suspend the flying training of any individual reported physically incapa- citated without reference of the case to the CGAAF. (2) Clearance. When the Flight Surgeon upon examination has found the individual physically fit to fly, he so notifies the Commanding Officer and makes appropriate recommendations. The Commanding Officer upon receipt of this notification may authorize the resumption of flight duty, if the Flight Surgeon so recommends and the incapacity was for a slight or temporary disability, without reference of the case to the CGAAF. (3) Relief. When relief from flight status is indicated, the Flight Surgeon notifies the Commanding Officer by letter and makes appropriate recommendations. Upon receipt of the notification, the Commanding Officer will promptly remove the in- dividual from flying status and at the same time notify the CGAAF of the action taken. The CGAAF will then radio the Commanding Officer of his approval or dis- approval of this action. When the relief from flight status is affected because a waiver is required the Commanding Officer will initiate a report from the local Flying Evaluation Board, and the Flight Surgeon will forward a report of the phy- sical examination with appropriate recommendations on Form 64. The request for waiver will be initiated by the individual concerned and returned to the Flight Sur- geon for attachment to the Form 64, Upon receipt of these records in the OCGAAF, appropriate action will be taken by the Central Flying Evaluation Board. (4) Restoration - Upon recovery from a serious illness or injury or return from sick leave, a physical examination will be made and reported on WD AGO Form 64 with appropriate recommendations. The CGAAF will act upon these recommenda- tions and notify the Commanding Officer, usually by radio, that the individual has been restored to flying duty. On the basis of this, the flyer is cleared for duty in the air. (5) Return of Aviation Cadets to flying duty - . viation Cadets who have been relieved from flight duty for serious illness, or injury that requires major surgical proce- dure or absence from full military duty for a period of over one month, will not be allowed to resume any duty in the air until authorized by the general offficer having immediate supervision of his training. Such cases will not be referred to the OCGAAF. (A. G. 221.99 (2-3-41).). d. Forms Used. - (1) Grounding and Clearance - The Forms used for this purpose are for local use only, and vary from station to station, depending upon the wishes of the Commanding Officer. In general, they may be divided into (a) individual forms, and (b) consolidated forms. Either or both may be used at a station. Individual “Grounding Forms” are generally used at smaller stations where this procedure is relatively infre- quent, or at larger stations when the flyer for some reason was not entered on the “Con- solidated Form ’, which is used where the number of flyers on sick report, or who are otherwise disqualified for flying, is relatively great. (2) The number of copies and their disposition will also vary from one place to anotherUsually one goes to the Commanding Officer and one is filed in the Flight Surgeon’s Office, preferably in the individual’s 64 file. In addition, the Commanding Officer may require a copy to be sent to the Finance Officer, the Post Operations’' Officer or other persons designated by him. Grounding and Clearance of personnel of the Navy, National Guard, and Coast Guard. When it becomes necessary to re- move personnel of the Navy, National Guard, or Coast Guard from flying at any Army Air Forces Station, the Flight Surgeon notifies and makes appropriate recom- mendations to the Commanding Officer who will take the necessary action to inform the Department having jurisdiction over the individual. When the individual is re- ported by the Flight Surgeon as physically fit to resume flying, the Commanding Officer will take appropriate steps to clear him for flying. (3) Relief and Restoration. See Par. 193c.(4). 194. PROCEDURE IN CASE OF CRASH DEATH. A medical officer is always detailed as a member of the aircraft accident Investigation board which inquires into the circum- stances surrounding the crash. This medical officer is the logical one to sit as member of the line of duty board if one is concerned. It is therefore desirable that he should be the one to fulfill all the functions required below except such as are specifically delegated to the Station Surgeon. a. Upon Arrival at the Scene of the Accident. (1) Establish the fact of death at a specific and exact time. (2) Notify Station Commander by radio or telephone at once giving positive identifi- cation. If this is not possible, give all available information obtained including the number of the plane and any data obtainable from the Form 1. (3) If the crash has occurred on a military reservation the body may be moved to the Station Hospital. If it occurred off the military reservation authority to remove the body must be obtained from the Coroner. Laws vary in each State and must be complied with even though the death involves only military personnel. Blanket authority to remove any and all crash victims may often be obtained from the local Coroner so that notification to that office only is required. (4) Remove the body, or bodies, to the Station Hospital morgue. If bodies have been badly mutilated or cremated a special bag is often useful for this purpose. A can- vas bag 6-1/2 feet long, 2-1/2 feet wide, lined by rubber sheeting and closed by a long zipper has proven to be valuable. Under any circumstance, wrap the remains in a sheet or blanket. Be sure all fragments of dismembered bodies are coHected. b. After arrival at the Hospital. (1) When a body has not been positively identified because of mutilation or cremation a dental officer can often determine the individual’s identity from the dental records. (2) The body should be completely disrobed in the presence of a medical officer who will personally remove all valuables. These items will be turned over to the Summary Court Officer and a receipt obtained for them. Items of clothing or equipment issue are turned over to organization commander. (3) A complete diagnosis of the cause of death must be established either by com- plete external examination or by necropsy. A specimen of cardiac blood is taken as soon as possible following the crash and tested for the amount of carbon monoxide saturation. These specimens must be placed in a flask under oil until they can be examined. (Circular Letter to Flight Surgeon, Office Chief of the Air Corps, Aug. 1, 1932). (4) Call the Station Adjutant by telephone and confirm the identification of the body. (5) Place 2 tags on the body. One tied firmly to the right great toe, and the other to the left wrist. This tag must show the Individual’s full name, rank, branch of service, and serial number. (6) Release the body to the contracting Undertaker. If one is not available a local Undertaker may be employed (AR 30-1830). A copy of the contract between the Quartermaster and the local contracted undertaker should be on file at the hospital as a guide to the medical officer in making arrangements with undertakers not under contract. (7) Write a letter to Station Commander as shown below. SUBJECT Report of Death. TO: The Commanding Officer, Randolph Field, Texas. 1. In compliance with paragraph 2 b, AR 600-550, dated March 6, 1936, and changes thereof, the following report of death is submitted: a. Full Name of Decedent: b. Army Serial Number: c. Rank and Branch: d. Date, Place, and Cause of Death: e. Death Occurred in Line of Duty and Was or Was Not the Result of His Own Misconduct: SURGEON ♦(Statement of line of duty determined ordinarily by a conference with the deceased’s immediate Commanding Officer. If the Surgeon and Command- ing Officer agree on the line of duty the statement in this letter will ordinar- ily be accepted. If the Surgeon disagrees with the immediate Commanding Officer, or feels that the line of duty is doubtful, he will so state here and re- quest that a Line of Duty Board be appointed. (AR 345-415 as amended by W. D. Circular Letter 226-1941).) (8) Complete the following records: (a) Death Certificate (State Form - original to Undertaker) Death Certificate (Bureau of Census Form) (b) Report of death (WD AGO Form No. 52). “Command” or “Casual Station - Field” as case may be. (c) M. D. Form No. 52 “Carded for record only, not currently on the register”. (d) Report of Aircraft Accident ( W. D. Form No. 205 A. C. ) (e) Proper notation on “Care of Flier Report (W. D. Form No. 203, A. C.)” (f) Entry is made on organization sick book. c. After the body has been embalmed. (1) The body must be inspected by a Medical Officer to determine that it has been properly embalmed. (19 c, AR 40-590). This inspection is usually made with the Quartermaster who inspects the casket and clothing. In the case of mutilated or burned bodies which cannot be embalmed, sawdust saturated with formaldehyde is used. In order to comply with State laws such bodies are placed in a sealed casket (Par. 10, AR 30-1820). When a sealed casket is desired a certificate is furnished the Undertaker by the Surgeon establishing the reason for this type of casket. The Quartermaster is advised at the completion of the inspection that the body is proper ly embalmed and ready for shipment. It is his function to see that it is properly shipped. (2) The Medical Officer making the inspection completes a certificate to the effect that he has Inspected the body and that it has been properly embalmed. One copy of this certificate is filed with the clinical record of the case, and the original is given to the Quartermaster. 195. REPORTS FOLLOWING HOSPITALIZATION, a. When an individual has been hospi- talized in a general hospital for conditions which have necessitated his appearance before a Board of Officers - a copy of the hospital board proceedings, or an extract of clinical history if no board proceedings were prepared, will accompany the Form 64 prepared after his return to a duty status. b. When Forms 64 AGO are submitted on an individual after admission to hospital for quarters for serious illness or injury the following information will be entered on the Form: (1) Date of admission to hospital or quarters. (2) Name of hospital. (3) Diagnosis. (4) Hospital or quarters if so admitted. (5) Date of return to duty. CHAPTER 9 MEDICAL PROPERTY AND SUPPLY SECTION I CLASSIFICATION General 196 Standard supplies 197 Medical service and supply within the tactical units of the Army Air Forces 198 Paragraphs 196. GENERAL. The Medical Department Supply Catalog lists those items the issue of which is the responsibility of the Medical Department. Items listed in the Medical Depart- ment Supply Catalog constitute “standard medical supplies,” and those not listed in the Supply Catalog but procured by the Medical Department as required are designated as “nonstandard.” Insofar as practicable, medical equipment and supplies will be provided to the Army Air Forces and Army Ground Forces by the Army Service Forces. Requirements in excess of those authorized by Tables of Allowances and Tables of Basic Allowances plus normal maintenance will be estimated by Army Air Forces and Army Ground Forces and reported to the Army Service Force. The Air Surgeon shall establish Medical Supply Platoons, Aviation, in Air Forces de- pots. They shall be stocked with initial and small maintenance stock for the supply of tactical medical units attached to the Air Forces. Replenishments wiH be drawn from Army Service Force depots. 197. STANDARD SUPPLIES. The standard medical supplies are divided into classes and subclasses as foHows: a. Class 1. Drugs, chemicals Biological stains Biological products b. Class 2. Surgical dressings c. Class 3. Surgical instruments, surgical appliances, misceUaneous diagnc. !c instruments, and surgical supplies d. Class 4. Laboratory equipment and supplies e. Class 5. Dental equipment and supplies f. Class 6. X-ray equipment and supplies g. Class 7. Furniture Physiotherapy equipment Hospital linen and bedding Mess equipment and supplies Cleaning and preserving equipment and supplies Stationery and miscellaneous office equipment and supplies Miscellaneous hospital equipment and supplies h. Class 8. Veterinary equipment and supplies _i. Class 9. Field equipment and supplies j. N.S. Class 10. Professional books 198. MEDICAL SERVICE AND SUPPLY WITHIN THE TACTICAL UNITS OF THE ARMY AIR FORCES, a. General. As a preliminary to an understanding of the chain of service and supply in the A.A.F., it is necessary to understand the functions of the Air Depot and Air Service Groups. The Air Depot Group corresponds to the Air Depot within the Zone of the Interior. As such it is charged with fourth echelon maintenance of military aircraft and the storage and issuance of supplies which are peculair to the Air Forces. It consists of a Headquarters and Headquarters Squadron, a Repair Squadron, and .a Supply Squadron. Ordinarily one Depot Group is behind two Service Groups. The Medical Section of the Depot Group has a total of four Medical officers, one Dental Officer, one MAC Officer, and 35 enlisted men. They perform the usual sanitary functions of attached medical personnel and operate a dispensary for the unit. The equipment differs from that in a combat group in that a certain amount of second echelon hospitalization is provided for; the moderately sick and less severely impaired may be treated within the unit so that evacuation and replacement are unnecessary. The Air Service Group corresponds to the air base sub-depot, and is the intermediate unit between the Depot Group and the combat units. Generally the Service Group serves two combat groups of four dispersed squadrons each. It consists of two Service Squadrons, Ordnance Section, Chemical Section, Signal Section, two Quartermaster Truck Companies, a Light Maintenance Company, and a Medical Section. Two functions of the Service Group are to furnish third echelon maintenance to the combat units and to supply and distribute aH classes of supplies to the dispersed combat units. The Medical Section of the Service Group has practically the same composition and equipment as the Depot Group. There are three additional men who are provided for hand- ling medical supplies for distribution to the dispersed units. The Section operates a dis- pensary which is identical with the dispensary in the Depot Group. b. Distribution of Medical Supplies. Normally, medical supplies are drawn by Medical Supply Platoons, Aviation, from medical supply depots established by the Army Service Force in depots of armies or theatres. The Medical Supply Platoons, Aviation, are attached directly to the depots, to Air Depot Groups, or elsewhere as needed. This function is to procure the supplies to maintain a 10-day stock, and to distribute supplies automatically or upon requisition to medical detachments of the combat squadrons. When the Army Service Force does not operate a medical supply point in the vicinity of the group and its combat units, a Medical Supply Platoon, Aviation, is attached to the Depot Group. This platoon consists of two Medical Administrative Corps Officers and 19 enlisted men, and is charged with storage and issuance of replacement medical supplies. Normally these supplies are forwarded to the Service Group by truck or train. c. Evacuation and Hospitalization. The chain of medical services with the tactical units of the A.A.F. provides no facilities for hospitalization or evacuation. All hospitali- zation within the theatre of operations is the responsibility of the theatre Commander. The Army Service Forces are charged with furnishing the required facilities. The Air Force will request the required hospital facilities from the theatre commander. Evacuation and hospitalization are usually accomplished by means of the evacuation system which is func- tioning in the area in which the airdrome is situated. If no such facilities exist, separate facilities for the Air Force must be provided. However, the supply chain from Depot Group to Service Group to advanced airdrome would provide in reverse a very natural chain of evacuation. SECTION n PROCUREMENT Paragraphs Requisitions 199 Shipping ticket 200 Purchase Order 201 199. REQUISITIONS, a. Requisitions for supplies and equipment pertaining to any of the supply arms are ordinarily prepared on WD, QMC Form No. 400 and 401 (extra sheet). b. Designation: (1) Semi-annual - March 31 and September 30, AR 40-1705 (2) Quarterly (deteriorating items), AR 40-1705 (3) Emergency requisitions c. All requisitions are now sent to the designated depot of issue without reference to the"Surgeon of the Service Command. 200. SHIPPING TICKET (QMC FORM 434), a. Lists supplies shipped; b. Signed shipping ticket acknowledges receipt; c. Serves as voucher for picking up supplies. 201. PURCHASE ORDER (QMC FORM 308). Used for local purchase. SECTION m PROPERTY RECORD Paragraphs Stock record cards 202 Vouchers 203 Memorandum receipt 204 Annual report 205 202. STOCK RECORD CARDS. A complete record of all articles of public property for which accountability is required is maintained on stock record cards. WD, QMC Form No 424 or an authorized modification is used for this purpose. This record will show the quantities on hand, received and Issued. 203. VOUCHERS. Vouchers to the stock record account, namely, shipping tickets, reports of survey, and inventory and inspection reports, are numbered serially for each fiscal year. Only one series of numbers is used. Credit vouchers are designated by “C” pre- ceding the voucher number and debit vouchers by “d” preceding the voucher number. These records are filed numerically for the fiscal year. 204. MEMORANDUM RECEIPT, a. Nonexpendable property issued by an accountable offi- cer for use within the command is carried on memorandum receipt (WD, QMC Form No. 487), bearing signature of the responsible officer. Accountability for such property re- mains with the property officer. This record may be termed an “individual account/’ b. In order that the quantity and location of all property on memorandum receipt may be known at any time, each property officer maintains a general record or account of the quantities and location of articles issued to individuals and organizations. WD, QMC Form No. 488 is used for this purpose. This record may be termed a “general account.” 205. ANNUAL REPORT, a. Medical supply officers are required to submit to the Surgeon General on December 31a report showing the quantity of all medical department supplies on hand as of that date. b. All property accounts are audited once each fiscal year by a property auditor who issues certificates of audit showing status of the account concerned. One copy is forward- ed to the corps area commander, one copy to the chief of finance, and one copy to the accountable officer. SECTION IV MISCELLANEOUS PROCEDURES Over, short, and damaged report 206 Inspection and inventory report 207 Report of survey 208 Transfer of property 209 Paragraphs 206. OVER, SHORT, AND DAMAGED REPORT (QMC FORM NO. 445). Used when supplies received are over, short, or damaged (see AR 35-6560, 35-6640, and 35-6720). 207. INSPECTION AND INVENTORY REPORT (WD, IGD FORM 1). Used in instances of unserviceable and obsolete property (see AR 20-35.) 208. REPORT OF SURVEY (AGO FORM 15). Used to investigate and report facts, and submit opinions and make recommendations as to the question of responsibility and the disposition of property found unserviceable, short, or damaged (see AR 35-6640). 209. TRANSFER OF PROPERTY. Relief from accountability for property by appointment of a new supply officer is illustrated on the following certificate which is attached to the statement of balances: (station) (date) I certify that the balances shown on the stock record account of the (state organization and station), as of the above data, last Voucher Number , dated , are true and correct to the best of my knowledge and belief, and that the property has this date been turned over to (state name of officer, organization, etc.) pursuant to Order No. , dated , (station) , and that all property found in excess of that shown on the stock record account has been taken up (Voucher Nos. ) and all shortages have been surveyed (Voucher Nos. ). (signature) (rank and department) I certify that I have this date received from (state name of officer, rank, and department), Predecessor, all property pertaining to the above designated stock record account for which my said predecessor is accountable, as shown by the list of balances from last audit, plus all proper charges against and less all authorized credits to my predecessor’s account to the time of transfer, last Voucher Number , dated , and that I have this date assumed accountability for the property pertaining to this account. (signature) (rank and department) APPROVED: (Signature) (Rank and department) (Commanding) One copy of the list of balances, certified as above, is retained by the officer relieved of accountability; one copy is filed with the property records; the original, together with the order directing the transfer is sent immediately to the Service Command finance officer for the auditor's file; and one copy is sent to the Service Command surgeon. CHAPTER 10 MILITARY MEDICINE PERIPHERAL CIRCULATORY FAILURE (Primary shock, collapse, secondary shock) SECTION I Paragraphs Definition 210 Symptoms 211 Signs 212 Classification of acute peripheral circulatory failure 213 Principles of therapy of peripheral circulatory failure, hematogenic type 214 References 215 210. DEFINITION. A type of circulatory failure which may be caused by: a. A diminished blood volume. b. A diminished blood pressure as a result of processes in the nervous system which cause vasodilatation. c. A diminished blood pressure resulting from vasodilator substances acting on the peripheral blood vessels. 211. SYMPTOMS. a. Weakness (apathy to asthenia). b. Retardation of mental processes even to syncope or prolonged unconsciousness. c. Dizziness. d. Subjective coldness. e. Thirst. f. Restlessness. 212. SIGNS. a. Diminished temperature. b. Cold, clammy, ashen (pallor plus cyanosis) skin. The skin is dry in gross dehydra- tion. c. Rapid, feeble pulse. Sometimes the pulse is normal until just before death. The volume of the pulse is said to be more valuable than the rate, but this is questionable. d. Blood pressure. The systolic and diastolic pressure may be elevated early. Later, the systolic falls initially, then the diastolic. The blood pressure is probably the most reliable guide to the progress of the case in the field. It should be recorded every 15 minutes, and must be carefully correlated with the extent and the nature of the injury. e. Distant heart sounds. f. Respiration is unchanged or deeper. There may be rales in “tissue shock.” g. Vomiting and diarrhea. h. Urinary changes with elevation of blood NPN. The last two signs are common in shock of traumatic origin. The most reliable guides to the severity of the syndrome so far as signs are concerned are: (1) The condition of the skin, especially pallor; (2) the mental state, though alertness may persist to the end; (3) the blood pressure if the mechanism is clearly understood. 213. CLASSIFICATION OF ACUTE PERIPHERAL CIRCULATORY FAILURE, a. Hema- togenic type (secondary shock), caused by reduction of the circulating blood volume. (1) Acute hemorrhage. (2) Plasma loss (in burns, at site of trauma including crush injury)i (3) Gross dehydration (prolonged diarrhea, diabetic acidosis, adrenal insufficiency). b.(Neurogenic and psychogenic type (primary shock, collapse), cuased by reflex vaso- dilation of peripheral vessels which is acute and less serious than the hematogenic type. (1) Traumatic (solar plexus blow, direct injury to nervous system). (2) Emotional (inhibition of vasoconstrictor center - vasovagal syncope of Gowers, Lewis). (3) Postural hypotension - failure of the postural vasoconstrictor reflex (in tabes, in syringomyelia, in other diseases of the central nervous system, of unknown cause). (4) Carotid sinus syncope - reflex vasodilatation type. c. Vasogenic type - caused by agents acting directly on peripheral vessels, such as histamine, nitrites, and mecholyl. d. Unclassified (toxemic) - seen with peritonitis, gas gangrene, during and after sys- temic infections (typhoid, pneumonia, influenza). 214. PRINCIPLES OF THERAPY OF PERIPHERAL CIRCULATORY FAILURE, HEMA- TOGENIC TYPE. A reduction of the circulating blood volume is the most common cause of “shock" encountered in military medicine. Since it is a serious form, details of ther- apy are given. a. General. (1) Head down except in penetrating wounds of the cranium or of the chest. (2) Warm blankets. Care must be exercised not to overheat the patient. In the early stages of shock there is marked vasoconstriction in compensation for the reduced blood volume. A sudden release of this vasomotor activity by overzealous application of external heat may result in rapid exitus. (3) Warm drinks, except when the patient is vomiting or when the abdomen is wounded, (4) Anoxia of all tissue occurs in shock. It is treated by inhalation of high concentra- tions of oxygen. Every case should receive oxygen, but if equipment is limited, it should be used for the cyanosed patients particularly. (5) Pain is relieved by opiates and barbiturates. (6) Classify the case. (7) Record blood pressure frequently (every 15 minutes). b. Specific. Specific therapy is concerned with the restoration to the circulation of fluid, of cells, of both, or of sodium chloride. The type of treatment that will be used will depend on the type of loss - whole blood for hemorrhage, plasma for burns, saline for de- hydrating diseases. Early in shock the most urgent need is for fluid in any form. The type used will often be at first dictated by the type available, but as soon as possible the correct fluid should be administered. Whole blood must be avoided for the early treat- ment of burns, for this ultimately further increases the viscosity of a blood already great- ly concentrated by plasma loss. Most often the clinical condition met with in the field will be one due to combined hemorrhage and plasma loss. The relative amount of cells and plasma can easily be determined. The hemoglobin, red blood cells, and hematocrit determination will be increased in the hemcconcentration caused by loss of plasma; the reverse will occur in the hemodilution following a hemorrhage. In a base hospital the course of the shock may be further followed by determination of the serum proteins and the specific gravity of the blood. The preferred route of giving fluid is by vein, but this should be augmented by enteral administration except in patients who are vomiting or who are wounded in the abdomen. The sub-cutaneous or intramedullary routes may be used. The amount, to be used will depend on the amount of blood lost or upon the degree of hemcconcentration, and upon the clinical condition and the level of the blood pressure. A crude guide in this regard is that 500 cc. of fluid will cause a rise in blood pressure of 10 to 20 mm. of Hg. The amount of plasma from the Army-Navy Standard Package that can be given in a 24-hour period should never exceed four liters, because of the small amount of free mercury present in the form of preservative. The rate of giving the fluid will again largely depend on the clinical condition of the pa- tient. In young sub! : vts who were healthy just before the injury which brings them to the medical officer, it is usually possible to give 500 cc. safely in the first 15 minutes. (1) Whole blood. Blood may be used fresh or after storage. Blood which has been stored should not be used after ten days, and preferably not after days, due to the hemolysis which occurs. Plasma may be prepared from this blood. (a) The indirect method of giving a transfusion is the preferred one in the Army. Vacuum bottles of 600 cc. capacity, which contain 70 Cause/ smerr M Wash eyes. keep guiet and warm Do not use bandages YELLOW OILY Liquid Colorless Oos Open \1 HOUtl Harassing ft re Ml SO, - Sodium Su/ite in alco- hol solution DP Di~Phos DPHOSGENE Gat 41 *&ar Cause/ eouq/mf braadnnf hurts eye/ mater. Loan M Keep guiet and warm Cure coffee as a stimulant COLORLESS LIQUID Colorless Gas 30 MM Harassing fire Alka/i CG Choky-Gas PHOSGENE Oat „li iV Musty hay Green cam Irritates fungi doped fee/ing. M Keep guiet and warm 6ire coffee as a Stimulant COLORLESS LIQUID Colorless Gas (0 to 30 MINUTES Surprise attacks .protectlies Gas cJood release Aorqu/ck phyt'oaf affect Alkali go «as Cry Hoa CLORACETO- PHENONE Gat Sai/fior -.11 itr ML. 4x3 Notes eynsnur shut flaw remp>ury M Wash ayes m/th mater or bent and Donat mb or bandage Shut.HsCOt sol* BROWN CRYSTALLINE POWDER Ooudof small, sol id particles 10 HIN Training. Mob control. CHS used m counter-battery to force mas1 wear Strong,hot Solution of Sodwm carbonate CA Cry Aiv/eys 8R0MBENZYL- CYANI8E Oat 1 % DQur fruit Cats smsft.sbu i*an flow 'ns- fa/t* some ttrn M Wash eyes ruth bone oca Do not bandage DARK MOWN LIQUID Slowly evaporates SEVERAL DAYS. (MM ,n WmCei) To neutralise areas Counter-battery Alcoholic Sod- ium hydro rude spray DM Mlir. ADAMSITE Got a 8»c*> Coal Smoke 4r.&. Cau/at snatsms, feeling. M Pernor* to pure aw and keep warmandgmet TELLOWrLiPUN GRANULAR SOLID Yellow 10 MIN Gas Cloud Attacks Mob control- Bleaching Powder Solution. DS SNEEZE GAS Snake m Shoe pc/ith 4x3: Tau/at.saenmg f fare of tears M Remote to pureatrand keep warmand guiet BLACK VISCOUS MASS sZn 5 MIN Harassing and screening. Hone needed HC Harmless Cloud HC MIXTURE Srdtt m 1 n. Sharp arrid H*mku NONE. Produces no effect requiring treatment ORLY SOLID Grey Smoke BURNING To screen small operations in own lines and for trammg purposes. Hone needed FS Fuming Syrey SilPHLR TSIOXBE — Smaka 33 SBE Burning matches Causa/ pnckhaq nf skin, ftow of tears M Wash with Soda solution CLEAR LIQUID Vense white Smoke 510 MIN Airplane seray for screen on broad front - Alkaline Solution FM Floating M ant'd TITANIUM TETRACHLORIDE J*ola V. 1 nil Acrid Harm NONE. Produces no effect requiring treatment YELLOWISH LIQUID White Smoke 10 HIN Screening operations None needed DA Dopey Ach* OPHENYL- CHLORARSiK Smoke ■ Nat pronounced Causes tick feeling and headache M Rtmort to pureair, keep guiet Sniff chlorine Not* bteachmg powder bottle Summer 10 MIN. Harassing fire Bleaching Pow- der Solution WP ffhitt Pktu WHITE PHOSPHORUS Smoke ,,l 111' Burning Matches Bum mg piece/ adhere to ik in. clothing. NONE. AVAILABLE Plunge in mud to smother PALE YELLOW SOLID Burns to white smoke in Air 10 MIN. To screen adrancinatnoops Cause incendiary effect*, fosse* Harass enemy observers ■ Burns out. TH THERMIT — incm diary ■11 Sooo degree heat ignites Cover with oath.sand Treat hr severe bum 5 MIN destruction of MaOene! - Quick/y cover with earth or sand CL Oil or in e CHLORINE Gas ~4 i + f t CO Sj&t «ca Lung Irritant M Re more from gassed am Keep qutec and worn Coffee as stimulant YELLOW LIQUID Tellowgreen gas 10 MIN. Surprise attacks (thud) A/ka/fne Solution A CJCMCAL A«HTiU.fR» AMCu.TSml *' nowrital pielo .-.smoke /incendiary DU CAS fT| GAS PROOF CACMTV A. MASK HIP UODi,HC mtm&esa TABLE XXKt 212 SECTION V SULFONAMIDE THERAPY General 236 Use in treatment of gonorrhea 237 Use in hemolytic streptococcal infections 238 Use in meningococcal meningitis 239 Use in purulent meningitis 240 Use in penumonia 241 Use in gas bacillus infection 242 Use in staphylococcal infections 243 Use in peritonitis 244 Use in urinary tract infections 245 Use in bacillary dysentery 246 Local use 247 Toxic manifestations 248 Laboratory control of sulfonamide therapy 249 Regulations on use of sulfonamide in flying personnel 250 References 251 Paragraphs 236. GENERAL. (Ref. Circular Letters, SGO, No. 17, February 23, 1942; No. 74, July 25, 1942). The rapid development of chemotherapeutic agents will necessitate modification from time to time in the recommendations concerning the use Of the sulfonamides. It is not intended that the sulfonamides be used to the exclusion or neglect of other indicated therapeutic or nursing procedures (see also Ch. 10, Sections VI and VH on Venereal and Tropical Diseases). Therapeutic sera are to be used in patients sensitive to chemothera- peutic agents when it is believed that they may advantageously be treated with such serum. Although sulfadiazine may have some definite advantages over sulfathiazole, it is at present not as generally available and it will be frequently necessary to substitute another sulfonamide, usually sulfathiazole. The present distribution of powdered sulfanilamide and tablets of sulfathiazole to mem- bers of the armed forces other than the medical personnel in a combat area makes it im- perative that as much information as possible be obtained by a Flight Surgeon regarding the use of the sulfonamides. 237. USE IN TREATMENT OF GONORRHEA (see par. 253). 238. USE IN HEMOLYTIC STREPTOCOCCAL INFECTIONS. a. Mild or moderately severe such as erysipelas, mild cellulitis and tonsillitis. (1) Specific treatment. (a) Sulfanilamide: Initial oral dose, 2 grams; subsequent doses, 1 gram every four hours, day and night, until five days of normal temperature have elapsed. (b) Sulfadiazine: Initial oral dose, 4 grams; subsequent doses, 1 gram every four hours, day and night, until five days of normal temperature have elapsed. b. Otitis media. Usually caused by hemolytic streptococci. Other causes are penumo- coccus, staphylococcus, streptococcus faecalis, and influenza bacillus. (1) Therapy should be continued in small doses of 0.5 gram four times a day for at least ten days after clinical cure has been effected. The treatment should be started as outlined in a. above. Bacteriologlc cultures should be taken. c. Severe hemolytic streptococcal infections, such as meningitis, septicemia, severe cellulitis, acute osteomyelitis, acute mastoiditis, and so forth. (1) Specific treatment. (a) Sulfadiazine: Initial oral dose, 4 to 6 grams; subsequent doses, 1 gram every four hours, day and night, until temperature is normal for seven days, and continu- ed in small doses of 0.5 gram four times a day for at least ten days after clinical cure. If not available, use sulfanilamide in the same dose by mouth. Special conditions: In acute streptococcal mastoiditis or osteomyelitis, sulfadia- zine or sulfanilamide should be continued in small doses of 0.5 gram four times a day for at least ten days after a clinical cure has been effected. Intravenous administration: Intravenous solutions erf the sulfonamides should be prepared as follows: Sodium salts: Intravenous solutions are made up with the sodium salts of the sulfonamides except In the case of sulfanilamide. There is no sodium salt of sulfanilamide and the method of preparation erf this drug is different The sodium salts are given In 5-per cent solution. To make such a solution 5 grams of the selected salt should be measured In a sterile container and transferred with a sterile spatula to 100 cc. of sterile freshly distilled water. These solutions must not be boiled or autoclaved. The alkalinity of the solutions will kill all bac- teria except spores. When given Intravenously they should be administered slowly (15 minutes), care being taken not to get the alkaline material outside the vein since this may cause a slough. For this reason solutions of the sodium salts of the sul- fonamides should not be administered by hypodermocylsls or intrathecally. They should never be added to transfusion blood, saline, glucose, or other Intravenous fluids. Sulfanilamide: To prepare a 1-per cent solu- tion of sulfanilamide, 1 gram of crystalline sulfanilamide should be measured In a sterile container and transferred with a sterile spatula to 100 cc. of freshly pre- pared normal saline solution which has been brought to a boll. This solution Is practically always given by the subcutaneous route, rarely by the Intravenous route. Sodium sulfadiazine, intravenously, may be used In severe hemolytic streptococc- al infections. If it is used, the initial dose is 0.10 grams per kilo of body weight. Following the initial Intravenous dose of sodium sulfadiazine it is generally suffi- cient to continue therapy with 1.0 gram of sulfadiazine by mouth every four hours day and night until the temperature has been normal for seven days. If, following the initial intravenous dose of sodium sulfadiazine, it is desired to continue therapy by the intravenous rather than the oral route, subsequent doses of sodium sulfadia- zine based on 0.05 grams per kilo of body weight should be administered at 12-hour intervals. It is always advisable to shift to oral administration of sulfadiazine as soon as possible. Blood concentration: A blood concentration of sulfadiazine of 15 milligrams per cent should be maintained during the febrile phase of serious hemolytic streptococc- al infections. d. Scarlet fever. Associated complications: Sulfanilamide and sulfadiazine: This has no therapeutic effect on the toxic stage. It may be used for prophylaxis of septic compli- cations in dosage of 0.5 gram four times a day for the period of quarantine. 239. USE IN MENINGOCOCCAL MENINGITIS. a. Specific treatment. ~ (1) Sulfanilamide or sulfadiazine: Initial oral dose, 4 grams; subsequent doses, 1 gram every four hours day and night, until temperature is normal seven days. (2) Sodium sulfadiazine: Initial dose (intravenous only): 0.10 gram per kilo of body weight. Subsequent doses (usually sulfadiazine orally): 1.0 gram every four hours day and night until the temperature has been normal for seven days. If it seems de- sirable to continue treatment by the intravenous rather than the oral route subsequent doses of sodium sulfadiazine based on 0.05 grams per kilo of body weight should be administered at 12-hour intervals. It is always advisable to shift to oral therapy with sulfadiazine as soon as possible. Blood concentration: A blood concentration of sulfadiazine of 15 milligrams per cent should be maintained during the febrile period of the disease. 240. USE IN PURULENT MENINGITIS. a. Specific treatment. If etiology is not established, sulfadiazine or sulfathiazole may be instituted at once. b. Sulfadiazine, or if not available, sulfathiazole. Initial dose (oral); 4.0 grams. Sub- sequent doses: 1.0 gram every four hours day and night. If response is not satisfactory increase to 1.5-2.0 grams every four hours until improvement is definite, then reduce dose to 1.0 gram every four hours and continue until temperature has been normal for seven days. Sodium sulfadiazine, or if not available, sodium sulfathiazole intravenously should be SECTION V SULFONAMIDE THERAPY Paragraphs General 236 Use in treatment of gonorrhea 237 Use in hemolytic streptococcal infections 238 Use in meningococcal meningitis 239 Use in purulent meningitis 240 Use in penumonia 241 Use in gas bacillus infection 242 Use in staphylococcal infections 243 Use in peritonitis 244 Use in urinary tract infections 245 Use in bacillary dysentery 246 Local use 247 Toxic manifestations 248 Laboratory control of sulfonamide therapy 249 Regulations on use of sulfonamide in flying personnel 250 References 251 236. GENERAL. (Ref. Circular Letters, SGO, No. 17, February 23, 1942; No. 74, July 25, 1942). The rapid development of chemotherapeutic agents will necessitate modification from time to time in the recommendations concerning the use of the sulfonamides. It is not intended that the sulfonamides be used to the exclusion or neglect of other indicated therapeutic or nursing procedures (see also Ch. 10, Sections VI and VH on Venereal and Tropical Diseases). Therapeutic sera are to be used in patients sensitive to chemothera- peutic agents when it is believed that they may advantageously be treated with such serum. Although sulfadiazine may have some definite advantages over sulfathiazole, it is at present not as generally available and it will be frequently necessary to substitute another sulfonamide, usually sulfathiazole. The present distribution of powdered sulfanilamide and tablets of sulfathiazole to mem- bers of the armed forces other than the medical personnel in a combat area makes it im- perative that as much information as possible be obtained by a Flight Surgeon regarding the use of the sulfonamides. 237. USE IN TREATMENT OF GONORRHEA (see par. 253). 238. USE IN HEMOLYTIC STREPTOCOCCAL INFECTIONS. a. Mild or moderately severe such as erysipelas, mild cellulitis and tonsillitis. - (1) Specific treatment. (a) Sulfanilamide: Initial oral dose, 2 grams; subsequent doses, 1 gram every four hours, day and night, until five days of normal temperature have elapsed. (b) Sulfadiazine: Initial oral dose, 4 grams; subsequent doses, 1 gram every four hours, day and night, until five days of normal temperature have elapsed. b. Otitis media. Usually caused by hemolytic streptococci. Other causes are penumo- coccus, staphylococcus, streptococcus faecalis, and influenza bacillus. (1) Therapy should be continued in small doses of 0.5 gram four times a day for at least ten days after clinical cure has been effected. The treatment should be started as outlined in a. above. Bacteriologic cultures should be taken. c. Severe hemolytic streptococcal infections, such as meningitis, septicemia, severe cellulitis, acute osteomyelitis, acute mastoiditis, and so forth. (1) Specific treatment. (a) Sulfadiazine: Initial oral dose, 4 to 6 grams; subsequent doses, 1 gram every four hours, day and night, until temperature is normal for seven days, and continu- ed in small doses of 0.5 gram four times a day for at least ten days after clinical cure. If not available, use sulfanilamide in the same dose by mouth. Special conditions: In acute streptococcal mastoiditis or osteomyelitis, sulfadia- zine or sulfanilamide should be continued in small doses of 0.5 gram four times a day for at least ten days after a clinical cure has been effected. Intravenous administration: Intravenous solutions of the sulfonamides should be prepared as follows: Sodium salts: Intravenous solutions are made with the sodium salts of the sulfonamides except in the case of sulfanilamide. There is no sodium salt of sulfanilamide and the method of preparation of this drug is different. The sodium salts are given in 5-per cent solution. To make such a solution 5 grams of the selected salt should be measured in a sterile container and transferred with a sterile spatula to 100 cc. of sterile freshly distilled water. These solutions must not be boiled or autoclaved. The alkalinity of the solutions will kill all bac- teria except spores. When given intravenously they should be administered slowly (15 minutes), care being taken not to get the alkaline material outside the vein since this may cause a slough. For this reason solutions of the sodium salts of the sul- fonamides should not be administered by hypodermocylsis or intrathecally. They should never be added to transfusion blood, saline, glucose, or other intravenous fluids. Sulfanilamide: To prepare a 1-per cent solu- tion of sulfanilamide, 1 gram of crystalline sulfanilamide should be me amir ed in a sterile container and transferred with a sterile spatula to 100 cc. of freshly pre- pared normal saline solution which has been brought to a boil. This solution is practically always given by the subcutaneous route, rarely by the intravenous route. Sodium sulfadiazine, intravenously, may be used in severe hemolytic streptococc- al infections. If it is used, the initial dose is 0.10 grams per kilo of body weight. Following the initial intravenous dose of sodium sulfadiazine it is generally suffi- cient to continue therapy with 1.0 gram of sulfadiazine by mouth every four hours day and night until the temperature has been normal for seven days. H, following the initial intravenous dose of sodium sulfadiazine, it is desired to continue therapy by the intravenous rather than the oral route, subsequent doses of sodium sulfadia- zine based on 0.05 grams per kilo of body weight should be administered at 12-hour intervals. It is always advisable to shift to oral administration of sulfadiazine as soon as possible. Blood concentration: A blood concentration of sulfadiazine of 15 milligrams per cent should be maintained during the febrile phase of serious hemolytic streptococc- al infections. d. Scarlet fever. Associated complications: Sulfanilamide and sulfadiazine: This has no therapeutic effect on the toxic stage. It may be used for prophylaxis of septic compli- cations in dosage of 0.5 gram four times a day for the period of quarantine. 239. USE IN MENINGOCOCCAL MENINGITIS, a. Specific treatment. (1) Sulfanilamide or sulfadiazine: Initial oral dose, 4 grams; subsequent doses, 1 gram every four hours day and night, until temperature is normal seven days. (2) Sodium sulfadiazine: Initial dose (intravenous only): 0,10 gram per kilo of body weight. Subsequent doses (usually sulfadiazine orally): 1.0 gram every four hours day and night until the temperature has been normal for seven days. If it seems de- sirable to continue treatment by the intravenous rather than the oral route subsequent doses of sodium sulfadiazine based on 0.05 grams per kilo of body weight should be administered at 12-hour intervals. It is always advisable to shift to oral therapy with sulfadiazine as soon as possible. Blood concentration: A blood concentration of sulfadiazine of 15 milligrams per cent should be maintained during the febrile period of the disease. 240. USE IN PURULENT MENINGITIS. a. Specific treatment. If etiology is not established, sulfadiazine or sulfathlazole may be instituted at once. b. Sulfadiazine, or if not available, sulfathlazole. Initial dose (oral); 4.0 grams. Sub- sequent doses; 1.0 gram every four hours day and night. If response is not satisfactory increase to 1.5-2.0 grams every four hours until improvement is definite, then reduce dose to 1.0 gram every four hours and continue until temperature has been normal for seven days. Sodium sulfadiazine, or if not available, sodium sulfathlazole intravenously should be used If oral treatment Is Impossible. If it is used, the initial dose is 0.10 gram per kilo of body weight. Subsequent doses should be based on 0.05 gram per kilo of body weight, and should be given by the intravenous route at 12-hour intervals. Oral administration of sulfadiazine should be started as soon as it is practicable. 241. USE IN PENUMONIA. a. Caused by pneumococcus, streptococcus hemolyticus, staphylococcus, Friedl undents bacillus, and Hemophilus influenzae, streptococcus viridans (1) Pneumococcal pneumonia. (a) Chemotherapy. 1. Sulf athiazole: Initial oral dose, 4.0 grams; subsequent doses, 1 gram every four hours, day and night, until seventy-two hours of normal temperature have elasped. 2. Sodium sulf athiazole: Intravenously; 5% solution in sterile, distilled water; initial dose, 4 grams; subsequent doses, 2 grams every six hours. Change to oral dose as soon as possible. 3. Sulfadiazine: Initial oral dose, 4 grams; subsequent doses, 1 gram every four hours, day and night, until seventy-two hours of normal temperature have elapsed. 4. Sodium sulfadiazine: Initial dose: 0.10 gram per kilo of body weight adminis- tered by the intravenous route. Subsequent doses: 0.05 grams per kilo of body weight administered at intervals of 12 hours by the intravenous route. Change to oral dosage as soon as possible. (2) Hemolytic streptococcal pneumonia and Friedlander’s bacillus pneumonia. Sulf athiazole and sulfadiazine: Initial dose (oral), 4,0 grams. Subsequent doses (oral); Begin with 1.0 gram every four hours. If response is not satisfactory in- crease to 1.5-2.0 grams every four hours until improvement is definite, then reduce dose to 1.0 gram every four hours and continue until temperature has been normal for five days. Sodium sulfadiazine: Dosage the same as in pneumococcal pneumonia. (3) Staphylococcal pneumonia, Sulf athiazole: Initial dose (oral), 4,0 grams. Subse- quent doses (oral): Begin with 1.0 gram every four hours. If response is not satis- factory Increase to 1.5-2.0 grams every four hours until improvement is definite, then reduce dose to 1.0 gram every four hours and continue until the temperature has been normal for five days. Sodium sulf athiazole. Initial dose: 4.0 grams. Subsequent doses: 2.0 grams every six hours. Sodium sulfathiazole is given by the intravenous route as a 5 per cent solution. It is advisable to change to oral dosage as soon as possible. b. Secondary pneumonia. Prophylaxis: The possible value of chemotherapy with sul- fonamide compounds in the prevention of bacterial penumonia complicating influenza, measles, etc., is not known at present. Specific recommendations are, therefore, not justified. c. Postoperative pneumonia. Methods of treatment, dosage, and precautions are the same as in primary pneumonia. d. Comment. Chemotherapy with sulfonamide derivatives is of no demonstrated value in many bronchopneumonias of indeterminate (virus?) etiology; also of no demonstrated value in streptococcus viridans or Hemophilus influenza pulmonary infections. Results in secondary pneumonias, which are often mixed infections, will, therefore, be variable, often disappointing and difficult to evaluate, even when bacteria known to be susceptible to the sulfonamide compounds are present in the sputum. 242. USE IN GAS BACILLUS INFECTION, a. Prophylaxis, Sulfanilamide at present is recommended as the drug of choice. Initial dose (oral): 6.0 grams. Subsequent doses: 1.0 gram every four hours day and night. This should be continued for seven days or until definitive treatment is available. This period of therapy almost always eliminates the possibility of gas bacillus infection. Crystalline sulfanilamide should be used locally. It should be distributed evenly over the surface of the wound, approximately 0.1 gram being used per square inch but not over 10 grams for any one person. b. Treatment. Sulfathiazole: Recommended at present as the drug of choice. Initial dose (oral): 6.0 grams. Subsequent doses: 1.0 gram every four hours day and night until temperature has been normal for 48 hours. Then 0.5 gram every four hours day and night until convalescence Is completely established. (1) Local therapy. Crystalline sulfathlazole or sulfanilamide should be used locally. It should be distributed evenly over the surface of the wound, approximately 0.1 gram being used per sonare Inch but not over 10 grams for any one person In a single 24- hour period. It is recognized that If this amount is used locally and the above oral dosage is given the total dosage of sulfathlazole may be considered high. However, the severe nature of the infection warrants heavy dosage and local absorption from open surface Is variable depending on the amount of tissue fluid present, as well as other factors. 243. USE IN STAPHYLOCOCCAL INFECTIONS, a. Large boils and carbuncles. Administer sulfathiazole or sulfadiazine in a 4.0 gram initial dose followed by 1.0 gram every four hours thereafter for seven days. Apply hot fomentations. Incise as necessary after fluc- tuation develops in order to encourage evacuation of necrotic slough. Avoid incision of uninfected tissue or of diffuse cellulitis. The local application of crystalline sulfathiazole is of definite value in the treatment of large boils and carbuncles which has been incised and drained. b. Diffuse cellulitis, lymphangitis and acute osteomyelitis. (1) Sulfathiazole: Initial oral dose, 4 grams; subsequent doses, 1.5 grams every four hours, day and night, until localization of infection becomes evident, then 1 gram every four hours for at least seven days. Employ surgical treatment for any areas of localized infection which may develop and insufflate powdered form into the wound. c. Staphylococcic bacteremia. (1) Sulfathiazole: Initial oral dose, 4 grams; subsequent doses, 1.5 gram every four hours, until temperature has been normal for forty-eight hours, then 1 gram every four hours for fourteen days. (2) Sulfadiazine : Initial oral dose, 4 grams; subsequent doses, 1 gram every four hours, until temperature has been normal for forty-eight hours, then 1 gram every six hours for fourteen days. 244. USE IN PERITONITIS : Sulfanilamide therapy is recommended as a procedure sup- plementary to appropriate surgical treatment. a. Local treatment: Sulfanilamide crystals, in an amount between 4.0 and 8.0 . ~ams, should be applied to the peritoneum in the immediate area exposed at operation, aud to the layers of the abdominal wound, during its closure. b. Systemic treatment: Parenteral sulfanilamide: 150 cc. of 1 per cent solution (1,5 grams) should be given every 6 hours by hypodermocylsis starting before, or imme- diately after, operation. Continue this dosage for two days. If the patient shows satisfac- tory progress at that time the dose may be reduced to 120 cc. (1.2 grams) every 6 hours. As soon as the patient is allowed oral feedings the sulfanilamide may be given by mouth in dosage of 1.0 gram every four hours. It is usually unnecessary to continue treatment beyond the 6th postoperative day. If no sulfanilamide is implanted locally, the initial dose of the solution by hypodermoclysis should be 400 cc. 245. USE IN URINARY TRACT INFECTIONS, a. General considerations. It has been de- finitely shown that obstruction due either to renal or bladder calculi or any other type of pathological obstruction of the urinary tract greatly militates against the successful use of sulfonamide and other compounds in the treatment of urinary tract infections. Hence, when such pathological conditions are present, good results in the treatment of urinary tract infections are usually not obtained and every effort should be made to eradicate the obstruction. It is advisable in the therapy of urinary tract infections to adjust the fluid intake of the patient so that his urine output is in the neighborhood of 1,000 cc. per day. If signs of renal impairment (lowered PSP) are present, doses of the drug should be de- creased in size and the concentration (both free and total) of the drug in the blood be de- termined daily in order that concentrations of more than 10 milligrams per cent of the drug in the blood be avoided. Bacteriological cultures designed to determine the sterility of the urine should always be employed. It is desirable to include in the bacteriological procedures a culture made by placing 5 cc. of urine on a blood agar slant containing 2 milligrams per cent of para-amino-benzoid acid. This should be incubated for five days before being discarded as sterile. b. Infections due to E. coli, A. Aerogenes, Shigella dispar, and other gram negative or- ganisms belonging to the so-called coli-typhoid paratyphoid group: (1) Specific treatment: Sulfadiazine is the drug of choice. If sulfadiazine is not avail- able, sulfathiazole is the second drug of choice, sulfanilamide the third. Dosage (oral): 1.0 gram every four hours day and night until definite clinical improvement has been noted. Then decrease the dosage to 1.0 gram four times a day until the urine is clear and two negative cultures have been obtained in medium containing para-amlno-ben- zoid acid. Then stop the drug, wait one week, and reculture the urine. The dosage is the same for all these drugs. c. Infections due to Staphylococcus aureus or Pseudomonas aeruginosa (B. pyocaneus), (1) Specific treatment: Sulfathlazole is the drug of choice. Dosage (oral): 1.0 gram every four hours day and night until definite clinical improvement has occurred. Then, decrease dosage to 1.0 gram 4 times a day and maintain this until two negative urine cultures have been obtained in medium containing para-amino-benzoic acid. Then stop the drug and reculture the urine one week later. d. Infections due to B. proteus, Sulfathlazole is the drug of choice. Dosage (oral): Same as for staphylococcal urinary tract infections. e. Infections due to entepococcal organisms (Streptococcus fecalis). These infections do not respond to sulfonamide drugs, and hence such drugs are not used. f. Miscellaneous urinary tract infections. If organisms other than those already des- cribed are the etiological s of the urinary tract infection, either sulfathlazole or sul- fadiazine should be used in dosage as outlined above 246. USE IN BACILLARY DYSENTERY, a. Both su aguanidine and succinylsulfathiazole are used in the treatment of bacillary dysentery. T isy are not effective against amoebic dysentery. Their effectiveness depends upon the fact that they are absorbed to a very slight extent and it is possible to maintain a large concentration of the free drug in the gastrointestinal tract. b. Treatment. Sulf aguanidine or succinylsulfathiazole. Dosage (oral) 0.20 gm. per kilogram per day, divided into 4 equal doses, for 10 to 14 days. 247. LOCAL USE. Sulfanilamide, sulfadiazine, and sulfathiazole may be used locally in wounds supplemented by systemic sulfonamide therapy. Crushed tablets should not be substituted for the powdered form. A suspension of microcrystalline sulfathiazole is available. Approximately 1 gm. to 4 sq. cms. of wound surface Is desirable. Blood levels should be determined every other day when practicable. 248. TOXIC MANIFESTATIONS OF SULFONAMIDES (TABLE XXIV). a. Patients receiving sulfonamide compounds should be seen at least once a day and should be questioned as to the presence of headache or malaise. These are frequently important early symptoms of toxic reaction. Patients should be inspected at each visit for the presence of jaundiced sclerae (acute hemolytic anemia or hepatitis), pale mucous membranes (acute hemolytic anemia), or rash. The temperature should be carefully recorded. With recurrent fever after normal temperature in the course of sulfonamide therapy, the drug should be discontinued immediately, or, if recently discontinued, should not be resumed unless it has been demonstrated that the fever is due to a recurrence of the Infection. Whenever therapy with the sulfonamide drugs is shopped because of a drug re action, fluids should be forced to 5,000 cc. per day in order to wash out the drug. b. Agranulocytosis is extremely rare before the 14th day of therapy. It is imperative that total and differential white blood cell counts be made in patients still under treatment after the 14th day , every two days from the 14th to the 40th days. Stop the drug imme- diately if the polymorphonuclear leukocytes fall to 50 per cent 8r less in adult patients. Granulocytopenia without agranulocytosis may occur. c. Any patient who has had a toxic reaction to one of the sulfonamide group of drugs may have a second and more severe toxic reaction if one of these drugs is prescribed again. In such individuals a small test dose of the drug (0.1 to 0.3 grams) should be given and the patient observed for 12 hours before intensive therapy is started following which the patient must be carefully observed and the drug immediately stopped on the the first appearance of any toxic manifestation. 249. LABORATORY CONTROL OF SULFONAMIDE THERAPY, a. It should be constantly borne in mind that laboratory measures should be utilized as an adjunct In the effort to avoid complications from the administration of sulfonamide compounds. In view of the relatively smaller doses of sulfonamides prescribed in the treatment of uncomplicated gonorrheal urethritis or prostatitis, laboratory control may not seem indicated under these conditions. However, careful clinical observation must be carried out and hospita- lization must be resorted to in case of complication. b. Determination of the concentration of the sulfonamide compounds in the blood, body fluids, and urine. (1) In patients who are receiving one of the sulfonamide compounds determination of the concentration of the particular drug in the blood of the patient should be made on the morning of the day following the expiration of a full twenty-four (24) hour period of sulfonamide therapy and should be repeated subsequently when in the opinion of the surgeon such a determination will aid in the clinical conduct of therapy in the patient. (2) The method of Bratton and Marshall will be employed for the determination of sulfonamide compounds in the blood, body fluids, and urine of patients (See SGO Circular Letter No. 17, dated February 23, 1942.) c. Blood counts and hemoglobin determinations. (1) Red blood cell and hemoglobin determinations. (a) Each patient to whom a sulfonamide compound is to be administered should have his hemoglobin determined before sulfonamide therapy is started, and once a week thereafter as long as sulfonamide therapy is continued. If, in the opinion of the ward surgeon, more frequent determinations of the patient’s hemoglobin are advisable, these should be done. (b) Red blood cell counts should be ordered at the discretion of the ward surgeon. (2) White blood cell counts. (a) The total white blood cell and differential count of the patient should be deter- mined before therapy with sulfonamide compounds is started. Subsequent total white blood cell counts should be done on the 3rd, 6th and 9th days of therapy. If sulfona- mide therapy is continued beyond 10 days, total white blood cells counts should be done every other day thereafter until therapy is discontinued. (b) If, in the opinion of the surgeon, sulfonamide therapy is producing a leukopenia of 4,000 white cells or below and this leukopenia is not due to the infection from which the patient is suffering, a second total white blood cell and differential count should be done immediately in order to check the supposedly low count. d. Urine examinations. (1) The urine output should be measured and recorded dally upon the chart of all patients receiving sulfapyridine, sulfathiazole, or sulfadiazine compounds. (2) Patients receiving sulfathiazole, sulfapyridine or sulfadiazine should have their urine examined every two days for the presence of red blood cells and albumin. The drug should always be stopped if any degree of microscopic hematuria develops in the course of sulfonamide therapy. The appearance of microscopic hematuria does not necessarily contraindicate a continuance of chemotherapy. When it is present the urine output should be carefully followed and dally urine examination performed. If the urine output falls noticeably the drug should be stopped. The finding of sulfo- namide drug crystals in the urine of patients receiving these drugs does not in itself constitute an Indication for stopping the drug. e. Bacterial studies. ~ (1) An attempt should be made to establish in every patient, in whom sulfonamide therapy is contemplated the etiological diagnosis of the infection by bacteriological methods. However, this does not mean that sulfonamide treatment should be delayed until the bacteriological diagnosis is established. If the clinical diagnosis is that of an infection known to respond to sulfonamide therapy, then the appropriate drug should be used at once. 250. REGULATIONS ON USE OF SULFONAMIDES IN FLYING PERSONNEL, A.A.F. Re- Reaction Sulfanilamide Sulfapyridine Sulfathiazole Sulfadiazine Nausea or vomiting, or both 10-20% 40-55% 23-40% 5-9% Mental disturbances * including toxic psychoses 0.5-1% 0.3-5% 0-2% Uncommon Skin eruption * 2-5%, may take any form, generally 5th to 9th day, may oc- cur 1st to 30th day 4-5%, may take any form, 5th to 9th day. may occur 1st to 30th day 8-10%, nodular type, common, may take any form 5th to 9th day 2-3% Fever * 10%, generally 5th to 9th day, may oc- cur 1st to 30th day 2-5%, generally 5th to 9th day, may occur 1st to 30th day 5-6%, generally 5th to 9th day 1% Mild hemolytic anemia 2%, early and late 2% Uncommon Uncommon Acute hemolytic anemia ♦* 2%, occurs 1st to 5th day 2%, occurs ls+- to 5th day Rare Rare Hematuria * Not reported 8% 3% 1% Anuria with nitrogen retention ** Not reported 0.3% 0.7% 0.7% Leukopenia with granulo- cytopenia 0.1% 0.1-0.5% Rare 1% Cyanosis Common Uncommon Uncommon Uncommon Sulfanilamide administration is also occasionally associated with an acidosis or hepatitis. Sulfaguanidine administration is occasionally associated with nausea and vomiting. TABLE XXIV. TOXIC MANIFESTATIONS OF SULFONAMIDES * Best to stop drug and force fluids. **Imperative to stop drug and force fluids. 219 gulation No. 25-13, December 3, 1942. a. The administration of these drugs may occasion' ally result in temporary mental confusion, visual disturbances, impaired sensory percep- tions, coordination defects, and other insidious manifestations. b. No rated officer, flying officer, aviation cadet, enlisted man, or member of an air- crew or combat crew will be permitted to participate in aerial flights while receiving sul- fonamide therapy or for six days following the last dose of the drug. Physical examina- tion will be accomplished with special reference to symptoms resulting from the adminis- tration of the sulfonamide group of drugs, and return to flying status will be in accordance with AR 40-110. Copy of WD, AGO Form No. 64 need not be forwarded to higher authority unless so specified in AR 40-110. Removal from flying status need not apply where sulfo- namides have been used for local application on flying personnel. c. The instructions and provisions of this regulation will not apply to passengers or patients being transported or evacuated by air, nor to the emergency use of sulfonamides as supplied in the individual first-aid kits. 251. REFERENCES. a. Articles. (1) Flippin, H.F., Rose, S.B., Schwartz, L. and Dourm, A.H.: Treatment of Pneumo- coccic Pneumonia with Sulfadiazine and Sodium Sulfadiazine, War Med. 2; 284, 1942. (2) Keefer, C.S.: Toxic Reactions Following Sulfonamide Treatment, New Eng. J. Med, 226; 266, 1942. (3) Kirby, W.M.M. and Rantz, L.A.: The Treatment of Typhoid and Dysentery Carr- iers with Succinylsuflathiazole, J.A.M.A, 119; 615, 1942. (4) Kline, E.F. and Ryan, T.C.: Suliathiazole Prophylaxis in Prevention of Gonococcus Infections, U.S. Naval Med. Bull. 40; 360, 1942. (5) Peterson, O.L. and Finland, M.: The Effect of Food and Alkali on the Absorption and Excretion of Sulfonamide Drugs After Oral and Duodenal Administration, Am. J. Med. Sci, 204; 581, 1942. (6) Saitterthwaite, R.W., Hill, J.H., and Huffer, V.: Sulfadiazine in the Treatment of Gonorrhea Laboratory and Clinical Studies, Vener, Dis. Inform. 23; 249, 1942. b. Texts. (1) Goodman, L. and Gillman, A.: The Pharmacological Basis of Therapeutics, New York, The Macmillan Co., 1941. c. Letters. (1) SGO, Circular Letter No. 17, February 23, 1942, Subject: Chemotherapy in In- fectious Diseases and Other Infections. (2) SGO, Circular Letter No. 74, July 25, 1942, Subject: Diagnosis and Treatment of the Venereal Diseases. d. Regulations. (1) AAF Regulations No. 25-13, December 3, 1942. SECTION VI THE VENEREAL DISEASES Paragraphs Prophylaxis 252 Gonorrhea 253 Syphilis 254 Chancroidal infection 255 Lymphogranuloma venereum 256 Granuloma inguinale 257 References 258 252. PROPHYLAXIS. Instruction in individual prophylaxis must be given. The Flight Surgeon must make material available both for officers and for enlisted men. For the former, who are too often neglected, individual prophylactic units of various types may be recommended after investigation and determination cf the local supply (see SGOI Cir- cular Letter No. 80, July 31, 1942). It may be desirable to set up a prophylactic station for the officers in addition to the one for enlisted personnel. The following is the procedure to be followed at the station (TM 8-220, par. 264 (c): The prophylaxis should be administered or closely supervised by a trained attendant. It is most effective when given within an hour of exposure. a. The exposed subject urinates and washes his hands. E. He washes his penis, scrotum, and adjacent area of the body thoroughly with liquid soap and warm water. These parts are dried and then flushed with a 1-1000 solution of bichloride of mercury. c. With a urethral syringe the attendant gently injects 5 c.c. of a 2% solution of protar- gol%prepared fresh once a week) into the anterior urethra. The subject retains this so- lution for five minutes by the clock by compressing the urethral orifice with his thumb and forefinger. Small amounts of the protargol are permitted to escape at brief intervals in order to keep the meatus well bathed. d. The subject retracts the foreskin, then thoroughly rubs into the penis and surrounding body area about 4 grams of 30% calomel (mercurous chloride) ointment for a period of at least 3 minutes. The penis is then wrapped in paper or gauze. The subject should not urinate for 4 hours. 253. GONORRHEA, a. Diagnosis in the male. (1) A diagnosis of gonorrhea must not be made in the absence of laboratory confirm- ation. Treatment for gonorrhea should be started at once if the patient has an acute purulent urethral discharge, but material should be obtained before treatment is be- gun for subsequent laboratory study (smear and/ or culture). (2) Acute gonorrhea. The detection of gram-negative intracellular diplococci in smears of the urethral exudate, or smears of the centrifuged sediment of the first glass of urine, or fluid from conjunctival sac or joints, establishes the diagnosis of gonococcal infection. In competent hands cultures yield a high percentage of posi- tive results and are of particular value in cases in which no gonococci are found in the smear. (3) Chronic gonorrhea (posterior urethritis, prostatitis, seminal vesiculitis, epididy- mitis and arthritis). The detection of gram-negative intracellular diplococci in smears of the exudate obtained by digital stripping of the prostate, Cowper’s glands, and the urethra, or in smears of the centrifuged sediment of urine passed after strip- ping the prostate, Cowper’s glands, and the urethra, or the demonstration of gonococ- ci in cultures of material so obtained, establishes the diagnosis of gonococcal infec- tion. b. Diagnosis In the female. (1) A diagnosis of gonorrhea must not be made in the absence of laboratory confirm- ation. (Treatment for gonorrhea should be started at once in women who have eviden- ce of this disease, even though laboratory studies are negative or not available. If laboratory facilities are not available, material for subsequent laboratory studies should be obtained before treatment is begun.) (2) The detection of gram-negative intracellular diplococci in smears of material obtained from any of the following; the urethra, Skene’s glands, or the cervix (or from Bartholin’s glands or the rectum, when clinical symptoms exist); or positive cultures of such material establishes the diagnosis of gonococcal infection. (Caution; The normal genital bacterial flora and the flora of nonspecific infections may contain organisms that in smear closely resemble gonococci. Therefore, cultural methods should be utilized when possible.) c. Gonorrheal ophthalmia. The diagnosis is made on the basis of an acute purulent conjunctivitis, pus containing gonococci, and rapid involvement of the external coats of the eye. (Sulfonamide therapy should be instituted immediately. Prompt pphthalmologlcal consultation is imperative.) d. Serologic tests for syphilis. All patients with gonorrhea should be given a serologic test for syphilis on admission, a test before being discharged to duty, and if possible a final test two months after discharge. e. Treatment of gonorrhea in males and females. (1) Local treatment of any kind (injections, irrigations, massages, instrumentations) is contraindicated in uncomplicated acute gonorrhea. (2) Treatment should consist of not more than two courses of chemotherapy. A care- ful inquiry should be made as to previous sulfonamide therapy, recent seif-adminis- tered chemotherapy for gonorrhea, and for previous drug reactions. (See note 1, page 1; paragraph 14, and table 1, Chemotherapy in infectious diseases and other infections, SGO Circular Letter No. 17, February 25, 1942.) (a) Sulfathiazole and sulfadiazine are each highly efficient, and In the doses recom- mended cause toxic manifestations very infrequently. Either of these compounds is recommended. Sulfapyridlne, although nearly as efficient as sulfathi azole or sulfa- diazine, is more toxic and should be used only if the other compounds are not avai- lable. Sulfanilamide is far less effective than the other sulfa compounds in gonor- rhea and is not recommended. (b) The recommended dosage for sulfathi azole and sulfadiazine Is 1 gram Q.5 grains) four times a day for five days. The recommended dosage for sulfapyridlne is 1 gram (15 grains) three times a day for five days. (c) A second course of the drug, in the same dosage, should be given if there is evidence of persistence or recurrence of the disease. There should, however, be a lapse of five days between the two courses of medication. (d) Patients in whom the gonococcus is present after the second course, or tuo have not made a satisfactory clinical response, generally should be transferred to a gen- eral hospital. (e) In males, local treatment to the urethra generally should be administered only in a general hospital. (f) In the female, hot vaginal douches (under no more than 2 feet of water pressure) afford comfort and promote cleanliness. Acute pelvic Inflammatory disease is an indication for bed rest, ice bags to the abdomen, and analgesics. If enemas are ne- cessary, preliminary bathing of the perineum is indicated before Inserting the rec- tal tube in order to avoid inducing gonococcal proctitis. f. Treatment of sulfonamide-resistant gonorrhea in males and females (general hospi- tals). (1) It is recommended that carefully selected patients with sulfonamide-resistant in- fections be given ten hours of sustained fever therapy, where such therapy is availa- lable, preceded by chemotherapy consisting of sulfathi azole, 1 gram every six hours for eight doses. This program should be preceded by one week of freedom from sulfo namide therapy. Patients who are not subjected to this form of treatment, and those who are not cured by this means, should be placed upon local treatment. (2) Local treatment in the male (sulfonamide-resistant cases only). (a) When the infection is confined to the anterior urethra, an anterior urethral In- jection, once daily, of not more than 6 cc. of a 5-percent solution of mild protein sli- ver or 0.5 percent of strong protein silver is advised. (Retain for five minutes.) It should be kept in mind that prolonged use of chemicals tends to perpetuate urethral discharge. Discharge caused by overtreatment of this type may be recognized by the presence of many epithelial cells. (b) All urethral injections are to be administered by a medical officer or a trained attendant; not by the patient. (c) Stop all local treatment ff the patient develops acute symptoms of posterior ureth- ral infection, such as urgency, painful or marked frequency of urination, or perineal or rectal pain; and confine treatment to hot Sitz baths. When acute symptoms have subsided, resume anterior urethral injections and continue until prostatic stroking is begun. (d) Extremely gentle prostatic stroking should be tried when the second glass of urine has been clear, and the first glass nearly so, for two weeks. If gentle massage is painful or causes a recrudescence of other symptoms, it should not be repeated for one week, or until the symptoms have subsided. If it is not painful and if no recrudes- cence of symptoms occurs, the gland should be gently stripped at three or four days intervals, and smears of the prostatic secretion examined every two weeks. (When prostatic massage is instituted too soon or applied too vigorously it often induces com- plications and retards cure.) (e) Infections of Cowper’s glands should be searched for in resistant cases. If these glands are palpable, they should be gently kneaded. This can be accomplished at the time prostatic massage is practiced, by placing the thumb against the perineum and gently massaging first one and then the other gland with the index finger. (f) No instruments of any type should be passed into the urethra while gonococci are present. (3) Local treatment in the female. (a) (See e(2) (f) ) } (b) The persistence of infection in Skene s glands, Bartholin s glands pr the endocer- vical glands in spite of the use of measures recommended above constitutes a special problem beyond the province of this handbook. Such patients require skilled gyneco- logical treatment. g. Determination of cure in the male (uncomplicated cases). (1) Cure is determined by the inability to demonstrate gonococci in any of the uro- genital fluids including prostatic secretions, by smears or cultures. (2) Patients whose symptoms have disappeared as the result of sulfonamide medica- tion may have the first test of cure on the third day after disappearance of symptoms. Thus, for example, patients clinically well on the third day of chemotherapy, whose urethral cultures or smears are negative for gonococci, may have on the sixth day prostatic massage and may then be discharged to duty if smears of the urogenital fluids are normal. When feasible these patients should return to the hospital for two subsequent examinations at weekly intervals and should be discharged as cured after three negative examinations. h. Determination cf cure in the male (sulfonamide-resistant cases). (1) Cure is determined by the inability to demonstrate the gonococcus in any of the urogenital fluids by repeated smears or cultures. Material for these studies should be obtained in the manner previously described in a.3 . The prostatic secretion should be included in the study of all types of infection. Three successive negative studies at weekly intervals constitute practical evidence of cure. Tests for cure may be car- ried out after the patient has returned to duty. (2) Patients whose symptoms disappear as the result of fever therapy may have tests of cure started on the second day following the treatment. i_. Determination of cure in the female (uncomplicated canes). (1) Patients whose symptoms have disappeared as the result of chemotherapy may have tests cf cure begun on the third day after disappearance of symptoms. (2) Cure is determined by: (a) Absence of tender masses or points of tenderness in the pelvis. (b) Inability to demonstrate the gonococcus by smears or cultures in material ob- tained from the urethra, Skene’s glands, Bartholin's glands, or the cervix. Such tests should be repeated every two weeks for three months, and if all are found to be nega- tive, the patient should be discharged from observation. These tests should be car- ried out on an ambulatory basis. (c) To obtain material for smears and cultures, massage the urethra, Bartholin’s glands, and Skene’s glands, obtaining secretion with small cotton-wrapped applicator or a platinum loop. Pass bivalve vaginal speculum without lubricant, expose cervix clean vagina and cervical canal, squeeze cervix between ends of speculum blades, and obtain expressed fluid on cotton applicators or platinum loops for smear and culture. j_. Determination of cure in the female (sulfonamide-resistant cases). (1) Patients whose symptoms have disappeared as the result of prolonged artificial fever may have tests of cure begun on the second day after treatment. The tests of cure are the same as those recommended for female patients in uncomplicated gonorrhea. (2) Patients under local treatment should have smears and cultures done at least every two weeks. If these tests remain consistently negative for three months, and if there are no demonstrable complications-,the patient should be discharged from observation. 254. SYPHILIS, a. Diagnosis of syphilis. (1) It is of the utmost importance that the diagnosis in early syphilis (primary and secondary stages) be established at the earliest practicable moment and that treat- ment be instituted as soon as the diagnosis is made. (2) All ulcerative genital lesions, extragenital lesions characterized by indolence, in- duration, and regional lymphadenopathy, and cases of urethritis accompanied by in- dolent enlargement of related lymph glands are to be regarded as probable cases of syphilitic infection until this possibility has been excluded by repeated darkfield examinations and repeated serologic tests. In these cases routine serologic tests will be done not less often than: On admission to sick report. Second week. About the end of the first month. About the end of the second month. (3) Routine serologic tests will also be made in all cases of gonorrhea at least as often as follows: On admission to sick report. Before return to a duty status. About the end of the second month. (4) Antisyphilitic treatment will not be started until the diagnosis of syphilis is defi- nitely established. The demonstration of the Treponema pallidum by darkfield exa- mination is conclusive as to the necessity for the immediate institution of treatment. A persistent completely positive serology even in the absence of confirmatory clinical signs or a history of infection is also diagnostic of syphilis, and usually is an indica- tion for treatment. Positive serologic tests on a single specimen should never be made the basis of treatment in the absence of unmistakable clinical evidence of syphi- lis. A completely positive precipitation or complement-fixation test (Kahn or Wasser- mann) confirmed by a positive complement-fixation test (Wassermann) on a second specimen indicates syphilis provided no negative reactions have been obtained. Acute infections, particularly malaria and possibly vaccination procedures, are believed to give rise at times to transient false positive serologic tests. The presence of these complicating factors should be excluded before making a definite diagnosis of latent syphilis. In the event of incompletely positive or contradictory serologic reactions the test should be repeated until the possibility of technical error is excluded. b. Treatment of syphilis. (1) General principles of treatment. (a) No treatment is to be given for suspected early syphilis until the diagnosis is made either by darkfield examination or confirmed serologic tests. No therapeutic tests are to be used. (b) Arsenoxide (mapharsen) will be used as the standard arsenical. Neoarsphena- mine or other arsenicals cannot be substituted in the treatment schedule outlined in Table XXV. (c) If it is necessary to use neoarsphenamine, because of the nonavailability of arsenoxide, the former drug should be given only at weekly intervals in courses of not more than eight consecutive weekly doses. (d) Tryparsamide and fever therapy are not to be used outside of a hospital. (e) Each treatment is to be recorded on the syphilis.register of the patient or if for any reason a syphilis register (Form 78 MD) is not available, a written record is to be kept and transferred to the standard form as soon as possible. Each entry will include date, drug, dose, and reaction. (f) It cannot be too strongly emphasized that regularity of treatment schedule without long or short time variations or lapses is critically important to both infection control and cure. Every effort must be made to impress this fact on enlisted men and officers as well as medical personnel. (g) Emphasis should also be placed on thecompletionby each patient of the full sche- dule of treatment in the time called for regardless of early serologic reversal. (2) Treatment of early and latent syphilis. (a) In view of recent advances in knowledge regarding the toxicity and therapeutic efficiency of arsenoxide, the following recommendations regarding the treatment of early and latent syphilis have been prepared by the Subcommittee on Venereal Diseases of the National Research Council and approved by the Surgeon General. (b) Early (primary and secondary) and latent syphilis of any duration should be trea- ted by an identical treatment system. This treatment may be completed within twenty- six weeks. (See Treatment Schedule - Table XXV) (c) Patients with syphilis, early or latent, should, as a rule, be hospitalized initial- ly to the end that a careful examination may be made and antisyphilitic treatment star- ted. The period of hospitalization ordinarily need not be prolonged more than five to seven days. Thereafter, treatment should be continued by unit medical officers; or, in areas where concentration of patients is feasible, in centralized ambulatory clinics established in hospitals. Whenever possible and to minimize loss of time from duty, treatment of nonhospitalized patients should be given after duty hours. (d) At reception centers vaccinations and other procedures incident to induction may be carried out, during the initial period of hospitalization for syphilis, by local ar- rangements between the commanding officers of the reception center and the station hospital. (3) Technical suggestions. (a) Discard discolored drugs and solutions and damaged ampules. (b) Dissolve arsenoxide in sterile distilled water in the proportion of 10 mg. of drug per 2 cc. of water; a dose of 60 mg. will then be contained in 12 cc. of solution, 50 mg. in 10 cc., and 70 mg. in 14 cc. (c) Shake and aerate arsenoxide; do not shake or aerate the other arsenicals. (d) Inject arsenoxide rapidly to avoid thrombosis; there is little danger of speed shock or nitritoid crisis. Other arsenicals should be injected slowly to avoid speed shock or nitritoid crisis. (e) Thoroughly shake oily suspensions. (f) Attempt aspiration after insertion of needle before making any injection, especial- ly intramuscularly. (g) Inject bismuth intramuscularly into upper outer quadrant of buttock. Alternate sides. (h) Massage firmly after withdrawing needle from buttock and have patient prolong massage to three minutes. (i) Advise rest if practicable after arsenicals. (j) Warn patient to report his reactions. (k) Watch mouth and gums for bismuth stomatitis. (4) Treatment is to be stopped and the patient hospitalized if the following appear; (a) An itchy dermatitis of the face or flexures. (b) Jaundice (c) Petechial or other hemorrhagic lesions. (d) Evidence of cerebral injury, even though slight. (5) General antireaction therapy. (a) Epinephrin solution 1:1000, 1/2 - 1 cc. subcutaneously for speed shock or nitri- toid crisis. (b) Glucose 500 cc. 5-percent solution intravenously supplemented with thiamine chloride 5 mgm., for jaundice. (See Notes on the treatment of jaundice, SGO Circular Letter No. 55, June 11, 1942.) (c) Vitamin B complex is recommended in suspected liver damage. TABLE XXV. TREATMENT SCHEDULE: EARLY AND LATENT SYPHILIS Week 1 2 3 4 5 6 7 8 9 10 ( Bismuth subsalicylate Arsenoxide (mapharsen) r intramuscularly once intravenously twice \ weekly, 5 doses wppkly total 20 IrjpotinnK J \ Omit bismuth - 5 weeks 11 12 13 Omit arsenoxide Bismuth subsalicylate - 14 (mapharsen) - 6 weeks intramuscularly 15 Once weekly - 6 doses 16 17 18 19 V Omit bismuth - 5 weeks 20 Arsenoxide (mapharsen) C 21 as in first course, twice j 22 weekly total 20 injections \ 23 ( 24 V Bismuth subsalicylate 25 \ intramuscularly once 26 J weekly, 5 doses Arsenoxide (mapharsen) dosage: Adjusted approximately to body weight; average dose 60 mg., minimum dose 50 mg., maximum 70 mg. Bismuth subsalicylate in oil dosage: The standard dose is 0.2 gm. of bismuth sub- salicylate intramuscularly (not 0.2 gm. of elemental bismuth metal). (d) In cerebral vascular accidents measures to be considered are venesection, and hypertonic saline solution intravenously (500 cc. of a 1.5 percent solution.) (e) In blood dyscrasias, transfusions. (f) Sodium thiosulphate for any type of treatment reaction is considered valueless. (6) Serologic control of treatment. In patients with early syphilis a serologic test will be done at the beginning and end of the schedule of treatment outlined in Table XXV, but treatment may be stopped whether the serologic test for syphilis (STS) is positive or negative. After the completion of treatment the STS should be repeated three and six months later. If the test is negative after six months, the case may be classified as “Result Satisfactory” and the Syphilis Register may be closed. If the test is posi- tive after six months, the patient should be referred to a station or general hospital. Jn patients with latent syphilis the STS should be repeated at the completion of treat- ment outlined in Table XXV, but the Syphilis Register may be closed when this treatment is completed, regardless of the result of serologic test. (7) Spinal fluid examination should be performed in a hospital in patients with early syphilis at the end of the course of treatment outlined in Table XXV, or as soon as pos- sible thereafter; but in any event before the Syphilis Register is closed. In apparent latent syphilis, spinal puncture should be performed in a hospital before treatment or as soon as possible thereafter, but in any event before the Syphilis Register is closed. (8) Control of relapse and infectiousness. (a) Early syphilis is to be regarded as infectious until the second injection of arse- noxide has been given. (b) Physical inspection of skin (including palms and soles), mucosae, anus, and ge- nitalia should be performed as often as circumstances permit during treatment and and at each probationary inspection. (c) The involution of the chancre or secondaries should be watched to detect treat- ment-resistant cases. (d) Patients should be warned to look for and report mouth, skin, and genital lesions. Darkfield examination is of great help in recognizing relapsing lesions of the skin, mucosa, and genitalia. (9) Complications or relapse. In the event of any complication of treatment (serious treatment reactions) or any evidence of relapse, clinical or serologic, the patient should be at once transferred to a station or general hospital. (10) Cardiovascular, visceral, and neurosyphilis require special treatment in hospital. For additional details see standard texts. (11) Treatment of precocious late syphilis (tertiarism). As soon as possible preco- cious late syphilis (early gummatous and rupial lesions and bone lesions) should be hospitalized for combined fever and arsenical therapy. (12) Treatment of congenital syphilis. On recognition or on appearance of active lesions, congenital syphilis should be treated on the schedule for early and latent syphilis. (13) Separation from the service. When practicable, the physical status of every patient with syphilis, whether the disease was acquired before or after induction into the service, will be completely reevaluated when discharge from the Army is contem- plated. c. Diagnostic nomenclature for syphilis in the Army. ~ Syphilis, primary. Syphilis, secondary. Syphilis, early latent (less than four years since infection) Spinal fluid negative. Spinal fluid not performed (diagnosis tentative). Syphilis, late latent (four or more years since infection). Spinal fluid negative. Spinal fluid not performed (diagnosis tentative). Syphilis, tertiary - otherwise unclassified. Mucocutaneous. Osseous. Ocular (except optic atrophy). Visceral (except cardiovascular). Cardiovascular - other. Aneurysm (saccular). Aortic regurgitation (insufficiency). Aortitis (uncomplicated). Neurosyphilis - otherwise unclassified. Asymptomatic. Acute syphilitic meningitis. Diffuse meningovascular. Optic atrophy. Tabes dorsalis. Taborparesis. Psychosis with syphilitic meningoencephalitis (general paresis). Psychosis with neurosyphilis other than paresis or taborparesis. Syphilis, type undetermined - to include cases in which accurate diagnosis has not been made. Syphilis, congenital - include all manifestations. Arsenical poisoning. Bismuth poisoning. Iodine poisoning. Mercury poisoning. Spinal puncture for diagnosis or progress. Special therapeutic practices. Fever therapy (malaria, artificial). (1) Definition of terms and explanations of their use. Primary. To include those cases presenting the primary lesion cf syphilis (the chancre), which have not yet developed secondary manifestation. This diagnosis must be confirmed by darkfield examination, serologic test of the blood, or both. If blood serologic test is negative, the diagnosis of primary syphilis is not permissible without the demonstration of T. pallidum by darkfield. Secondary. To include only those cases of early syphilis which show one or more of the manifestations of systemic dissemination of the spirochete; for example, gen- eralized enlargement of lymph glands, cutaneous eruption, mucous patches, condylo- mata lata, patchy alopecia, largyngitis, bone pains, febrile reaction, and so i rth. The chancre may or may not be present and if present may be in any stage of evolu- tion. In early secondary cases the manifestations of systemic spirochetal dissemina- tion are increasing, have attained their maximum, or are waning. This diagnosis must be confirmed by darkfield examination, serologic test, or both. In early secondary syphilis and in addition to the manifestations listed above, ocular or neurologic complications (iritis, neuroretinitis, acute syphilitic meningitis) should be specially recorded as: “Syphilis, secondary, manifested by ” Latent. Secondary symptoms have subsided and the active manifestations of late syphilis have not yet supervened. There are no evidences of syphilis other than a positive serologic test of the blood. Cases will be classified as : “Latent (early or late) - spinal fluid negative” or “ Latent (early or late) - spinal fluid not performed (diagnosis tentative) . The date of the negative examination of the spinal fluid will be stated in all cases. Tertiary. - This classification is to be limited to cases that show active lesions of late syphilis. The lesion may be a gumma, or it may be a diffuse process and may involve any organ or tissue of the body. The majority of all patients with tertiary syphilis will fall within six categories: Mucocutaneous. Late syphilitic gummatous lesions of skin or mucous membrane. Osseous. Periostitis, osteomyelitis, arthritis, synovitis. Ocular. Iritis, uveitis, keratoiritis, keratitis, choroiditis, but not including optic atrophy. Visceral. Hepatic, gastric, etc., but not including cardiovascular. Cardiovascular. To include all lesions of the heart and great vessels. Classify as follows: Aneurysm (Saccular). Do not use for a fusiform dilation of the aorta. Specify artery involved. Aortic regurgitation (aortic insufficiency). Specify whether with or without cardiac decompensation. Aortitis, uncomplicated. To be used only for those patients with symptoms and physical or x-ray signs of syphilitic aortic involvement in the absence of aneurys- mal sacculation or aortic regurgitation. Neurosyphilis. To include all cases with involvement of the central nervous system, classified as follows: Asymptomatic. To be used only for those patients with early or late syphilis who have no symptoms or detectable physical signs of central nervous system involve- ment, and in whom the diagnosis is based on the routine finding of abnormalities in the spinal fluid. Acute syphilitic meningitis. Usually occurs within the first two years of the disease most commonly as a relapse phenomenon (neurorecurrence), manifested by the usual signs of low grade meningeal involvement, with or without cranial nerve palsies. Diffuse meningovascular. This is a catch basket category to include all patients with neurosyphilis who do not fit into other diagnostic categories enumerated. Manifestations to be stated in each instance. Optic atrophy. Primary of secondary. Tabes dorsalis. Manifestations to be stated. Taboparesis. To be used only in patients with definite psychiatric signs of paresis complicated by definite clinically demonstrable evidence of damage to the posterior columns cf the spinal cord. Psychosis with syphilitic meningo-encephalitis (general paresis). To be limited to cases which show psychic changes in addition to neurologic signs and the charac- teristic changes in the spinal fluid. Cases with paretic type spinal fluid but without psychic changes will be reported as: “Syphilis, diffuse meningovasucular, mani- fested by 5 Psychosis with neurosyphilis. To include neurosyphilis with psychosis other than cases of paresis and taboparesis. If tertiary manifestations occur which do not fit into one of these categories, diagnose as: “Syphilis, tertiary, otherwise Qjiclassifed” - Specify. Type undetermined. To include cases in which accurate diagnosis has not been made. Every effort should be made to make a complete examination and proper diagnostic classification in all cases. Congenital. To be limited to cases that show definite evidence of the former existence of the characteristic changes of congenital syphilis, such as inter- stitial keratitis, Hutchinson’s teeth, saber shins and other bone changes, saddle nose, eighth nerve deafness, and so forth. The congenital origin of syphilis is not to be as- sumed merely because the time and the circumstances of the infection cannot be as- certained and there is no scar of a primary lesion. The suggested terms for various drug poisonings are inteHigible as they stand . Spinal puncture for diagnosis or progress. This should be used in all cases (syphi- litic or otherwise) routinely hospitalized for purpose of a spinal puncture. Special therapeutic practices. This diagnostic grouping has been included for it seemed desirable to indicate special therapeutic practices which necessitate hospi- talization. 255. CHANCROIDAL INFECTION, a. Definition. Chancroid is a venereal disease trans- mitted only by direct contact and characterized by single or multiple genital ulcers. The latter possess irregular crater-form margins, are usually not indurated, and exhibit a tendency toward the formation of complicating suppurating inguinal adenitis. The incuba- tion period is usually three to fourteen days. b. Diagnosis. It is important to rule out the presence of mixed syphilitic and chancroi- dallnfection. For this purpose at least three darkfield examinations should be made on successive days; a blood serologic test for syphilis should be made on admission to the hospital, during the second week, and at monthly intervals for two months following heal- ing of the chancroidal lesions. Laboratory tests for the diagnosis of chancroid (Ito- Reenstierna skin test or the staining or cultural isolation of the Ducrey bacillus) ara not recommended, c. Treatment. (1) Chemotherapy. (a) Local. Accessible lesions should be cleansed with soap and water and dried. They should then be completely covered with powdered sulfanilamide and a loose, dry dres- sing applied. This should be repeated at dally intervals until the lesion heals. Other local medication is not recommended. In patients with tight phimosis and underlying ulcerative lesions, the phimotic preputial cavity should be irrigated twice dally with 1-5000 potassium permanganate solution. (b) Systemic. Administer sulfathiazole or sulfadiazine 1 gram (15 grains) four times a day for five days. Sulfanilamide 1 gram (15 grains) three times a day for five days, may be utilized instead of sulfathiazole or sulfadiazine, but is less well tolerated. Practically all chancroidal infections will respond to the above routine. In fact, if the lesion does not heal, doubt is cast on the correctness of the diagnosis of chan- croid, and the patient should be restudied from the diagnostic standpoint, and, if neces- sary treated surgically. (2) Surgical therapy (a) Surgical procedure designed to relieve phimosis or paraphimosis should be ted to only on the basis of sound clinical judgment. (b) Chancroidal bubo. Most of these will subside with systemic sulfonamide therapy. If extensive suppuration is present, the bubo may be opened by a small incision, the pus aspirated, and the cavity packed with sulfanilamide powder. 256. LYMPHOGRANULOMA VENEREUM, a. Definition. TMs disease concept includes the conditions formerly known as lymphogranuloma inguinale, lymphopathia venereum, climatic bubo, esthiomene, and inflammatory rectal stricture. b. Etiology. A filtrable virus, probably multiple strains. c. Geographic distribution. World-wide. 3. Clinical picture. A systemic disease of the lymphatic system, usually originating in a trivial and transitory lesion of the penis, vulva, vagina, or rectum, which frequently escapes the patient’s notice. The Invasion of the lymphatic glands usually occurs from ten to thirty days after infection, occasionally is delayed months. Inguinal adenitis is often bilateral, and occasion naly subsides without suppuration. During this stage, constitutional symptoms may be observed. Lymph nodes may fuse to skin, resulting in multiple areas of softening, fol- lowed by numerous fistulae. Extensive scarring accompanies healing. The anorectal syndrome usually is found only in the female, and is characterized by rectal pain, dis- charge of blood and pus from the anus, a tendency toward extreme chronocity, and the production of rectal stricture. e. Differential diagnosis. Differentiate from malignant tumors, Hodgkins disease, tularemia, tuberculosis, pyogenic infections, chancroidal bubo, and syphilis. Mixed ve- nereal infections should be ruled out by the darkfield examination of material from geni- tal lesions for the causative organism of syphilis. Frequent serologic examinations should be continued for at least two months after the disappearance of the lymphatic symptoms. f. Laboratory tests in lymphogranuloma venereum. (1) Only one diagnostic procedure for lymphogranuloma venereum, the intradermal test of Frei, has as yet come into general use. Other methods used in confirming the diagnosis are either impractical (animal inoculation, artificial cultivation of the virus), nonspecific (alterations in serum protein), or their value not yet esta- blished (complement fixation). (2) Frei antigens. (a) Chick embryo antigen. This is the preparation recommended for Frei testing. Nonspecific reactions occur, so that simultaneous inoculation of control material must always be made. (b) Human bubo-pus antigen. Pus is obtained from an unruptured bubo from an acute case of lymphogranuloma venereum. This pus must be diluted 1:5 or 1:10, cultured for sterility, heated for 1-2 hours on consecutive days at 58° C, following which a preservative is added. This material is placed in sterile rubber stoppered vials and is then tested upon known positive cases and known negative controls to determine its potency. Pus from different patients differs in antigenic potency. When human bubo-pus antigens are locally available they may be used, but are not general- ly recommended for use by the armed forces because of the uncertainty of sources of supply and the variability of antigens. (c) Mouse brain antigen. This preparation is commercially available. However, it is not recommended for use because it yields a high proportion of nonspecific results. (3) The Frei test. (a) Method of use of chick-embryo antigen. This preparation is supplied in two am- pules, one of which is the virus containing antigen, the other the nonvirus containing yolk sac control. For use in Frei testing, 0.1 cc. of antigen and 0.1 cc. of control material are injected intradermally into different areas on the flexor surface of the forearm. These areas chosen should be at least 4 cm. apart, or the virus antigen and control may be injected in opposite forearms. Separate tuberculin syringes and 26-gauge needles should be used. Cb) Reading of results. The injected areas must be inspected forty-eight and seven- ty-two hours later. A positive reaction consists in a more or less indurated papule 7 mm. or more in diameter (disregarding the surrounding zone of erythema) with or without central vesiculation or ulceration. A doubtful reaction consists in a pa- pule roughly from 5 to 7 mm. in diameter, without central ulceration or vesiculation. A negative reaction consists in no change at the injected site, or erythema only, or a papule less than 5 mm. in diameter. If the control material likewise yields a posi- tive papule (7 mm. or over), the Frei test should be repeated with human bubo-pus antigen if it is available. The test may be read as positive or doubtful if the papular reaction described occurs only with the virus-containing antigen, the control remain- ing negative. (4) Interpretation of results of Frei test. The Frei test is of greatest value in pa- tients with the acute bubonic form of lymphogranuloma venereum where a negative test may be observed to develop gradually into a positive one. There is reason to believe that in certain instances there are nonspecific cross- reactions in the presence of other venereal diseases, e.g., chancroid, granuloma inguinale, syphilis; and a positive Frei test with any antigen must be interpreted with caution when suspected lymphogranuloma venereum coexists with these diseases. Moreover, a positive Frei test cannot be relied upon absolutely to establish the lymphogranulomatous nature of any clinical condition, since it is known that, in un- treated infections with lymphogranuloma venereum, skin sensitivity persists for many years, probably for a life time. A positive test may, therefore, mean only that the patient has had lymphogranuloma venereum at some time in the past, rather than that his presenting symptoms are caused by this disease. In short, the Frei test is of most diagnostic value when it is negative, since under these circumstances lymphogranuloma venereum, past or present, may be excluded with reasonable certainty. A diagnosis of lymphogranuloma venereum should not be made on the basis of a positive Frei test in the absence of clinical signs, g. Treatment. - (1) Local. Patients with acute inguinal adenitis should be hospitalized whenever .pos- sible. The fluctuant nodes may be aspirated, but incision and drainage should be de- layed until the effect of chemotherapy has been observed. Radical excision is inadvi- sable because of the risk of elephantiasis of the scrotum or vulva. (2) Chemotherapy. (a) The value of the sulfonamide compounds in lymphogranuloma venereum has not been definitely established, but preliminary reports indicate that they may be effec- tive. Sulfathiazole and sulfadiazine are probably the drugs of choice, although sulfa- nilamide may be used. 1. Sulfathiazole or sulfadiazine should be administered in doses of 1 gram (15 grain; four times daily for five days. It may be necessary to prolong this medication to ten to fourteen days, in which case the dose should be reduced to 0.5 grams four times a day. 2. Sulfanilamide, if used, should be administered in doses of 1 gram (15 grains) three times a day for five days, followed by a reduction to 0.5 - 0.75 gram three times daily for an additional five to seven days. (b) The acute anorectal syndrome should be treated in the same manner as the in- guinal manifestations. Stricture or otherlater complications should receive special consideration. 257. GRANULOMA INGUINALE, a. Definition. Granuloma inguinale is a chronic disease due to infection with a filterable virus. It involves primarily skin and mucous mem- branes, rarely with coincident adenopathy; it is characterized by vivid-hued, shining ver- rucous, vegetating nodules of granulating tissue with a hemorrhagic surface surrounded by a thin, easily excoriated epidermis. The condition spreads by peripheral extension and autoinfection, often involving the entire genital area. It may involve large adjacent areas of the lower abdomen and thighs. The lesions show little or no tendency to spontaneous healing and may persist for months or years. b. Diagnosis. The clinical appearance of a chronic process involving the groin and geni- tal areas with little involvement of the lymph nodes is characteristic of the disease. The finding of Donovan bodies by Wright stain in deep tissue scrapings or biopsy of a periphe- ral area of diseased tissue (including a section of normal adjacent skin) confirms the dia- gnosis. Lymphogranuloma venereum, chancroid infection, and syphilis should be considered in the differential diagnosis, and appropriate diagnostic tests should be performed. c. Treatment. (1) Tartar emetic administered intravenously in doses of 0.03 to 0.12 gram . Patient should remain recumbent for one hour following an injection. Drug intolerance is in- dicated by nausea, vomiting, cough, tachycardia, hypotension. Initiate treatment with 3 cc. of a freshly prepared 1-percent solution. Each subsequent dose, freshly pre- pared, should be increased 3 cc. if tolerated until the maximum dose, 12 cc., is at- tained. The maximum tolerated dose is given three times weekly for fifteen treat- ments. (2) Fuadin 1-3 cc. (0.06-0.18 grams) or anthiomaline 1-3 cc. (0.06-0.18 grams) (both of these are complex antimony compounds) may be given intramuscularly two or three times weekly for twenty to twenty-five doses when the patient has difficulty in taking tartar emetic, or when the lesions have not improved satisfactorily under the former drug. (3) Courses of tartar emetic, fuadin, or anthiomaline, separated by ‘‘rest periods” of two weeks, should be continued for at least four months after all lesions are com- pletely healed, otherwise relapse is almost certain to occur. (4) Local treatment of the lesions may be limited to dally dressings, or surgical ex- cision of the entire area may be necessary. Large areas may be treated with solid carbon dioxide pencils. Deep x-ray therapy in expert hands has yielded promising 3T0 Suits, 258. REFERENCES, a. W. D. Directives. (1) S.G.O, Circular Letter No. 74, July 25, 1942, Subject: Diagnosis and Treatment of Venereal Diseases. (2) S,G.C. Circular Letter No. 80, July 31, 1942, Subject: Individual Venereal Disea- se Prophylactic Packets. (3) S.G.O, Circular Letter No. 17, February 23, 1942, Subject; Chemotherapy in Infectious Diseases and Other Infections. (4) S.G.O, Circular Letter No. 32, February 1, 1943, Subject; Duty Status Treatment of Gonorrhea. b. Manuals. (1) TM 8-220, Medical Department Soldier’s Handbook. c. Regulations. (1) AR 35-1480, Aviation Pay - Officers and Enlisted Men. (2) AR 40-235, The Prevention of Communicable Diseases of Man - Venereal Diseases. d. Texts. (1) Moore, J. E„,: Modern Treatment of Syphilis, 2nd Ed, Springfield, C.C. Thomas, 1941 SECTION vn TROPICAL MEDICINE Paragraphs Subject matter 259 Health in the tropics 260 Diet in the tropics 261 Disease in the tropics 262 Effects of heat - 263 Plant poisonings 264 Animal poisonings 265 Virus infections 266 Rickettsial infections 267 Bacterial infections 268 Spirochetal Infections 269 Protozoal infections 270 Helminthic infections 271 Military problems 272 References 273 259. SUBJECT MATTER. Tropical medicine deals with diseases which occur in warm climates. These diseases are not confined to the geographic tropics, but tend to origin- ate or have greater prevalence there. Certain clinical aspects of tropical medicine are dealt with in the present outline. Further information will be found in the references cited In par. 273. 260. HEALTH IN THE TROPICS. The general health of those from temperate zones has a tendency to deteriorate in the tropics. Resistance to infection is lowered at the same time that exposure occurs to diseases against which the newcomer has little or no natu- ral or acquired immunity. Inadequate standards of public health and sanitation expose the resident of many parts of the tropics to further dangers, while diseased natives, animals, and insects provide large reservoirs of infection. 261. DIET IN THE TROPICS. Fresh meats, fruits, vegetables and dairy products are frequently unobtainable, of poor quality, and of doubtful cleanliness. Synthetic vitamin supplements are often, although not inevitably, needed. Chloride depletion from excess- ive sweating is common in the tropics and at least one well-salted dish should appear in each day’s dietary. One-tenth per cent saline solution is not briny in taste and can be used as drinking water. Alcohol is particularly harmful to residents of the tropics and its use should be discouraged. Many Americans have an equal or greater preference for carbonated beverages, and these should be made available. 262. DISEASE IN THE TROPICS. Many common diseases of the temperate zones occur frequently in the tropics and are major health problems there (influenza, meningitis, tuberculosis, pneumonia, diphtheria, typhoid, syphilis, neoplastic disease). Some diseases once common but now rare in northern zones are much more often encountered in warm climates (smallpox, rabies, tetanus). Other conditions, many of parasitic origin trans- mitted by arthropods, have become known as tropical diseases. Some of these are wide- spread (malaria, filariasis) while others occur only in more or less well defined endemic areas (yellow fever, leishmaniasis, trypanosomiasis). 263. EFFECTS OF HEAT. a. Heat exhaustion. (1) Cause: Vasomotor collapse. (2) Occurrence: General. (3) Diagnosis: Unconsciousness; moist skin; weak pulse; low blood pressure. Differ- entiate from malaria. (4) Treatment: Horizontal posture. Mild stimulants. (5) Prevention: Good general hygiene. Avoidance of alcohol. Protection from sun. b. Heat cramps. (1) Cause: Excessive loss of sodium and chloride in sweat. (Same syndrome may develop in cholera or dysentery from chloride loss in bowel discharges). (2) Occurrence: General. (3) Diagnosis: Gradual onset of symmetrical cramps in extremities. (4) Treatment: Physiological or hypertonic saline solution by mouth. (5) Prevention: Add 1 Gm. NaCl to each liter of drinking water. c. Heat stroke. (1) Cause: Inefficiency or failure of heat dissipating mechanism of the body. (2) Occurrence: Common among troops or in hospitals in the tropics and among ur- ban populations in certain temperate zone areas. (3) Diagnosis: Fever developing into hyperpyrexia. Unconsciousness deepening into coma. Dry skin. Examine blood for plasodium of malaria. (4) Treatment: Wrap patient in sheet. Dash with cold water every fifteen minutes. Use fans to promote evaporation during intervals. Dextrose 10 per cent solution in physological saline 500-1000 cc. intravenously, repeated as necessary. (5) Prevention: Good general hygiene. Caution in the use of atropine. Anticipatory treatment of patient with abnormally dry skin. 264. PLANT POISONINGS, a. Ackee poisoning; vomiting sickness of Jamaica. (1) Cause: Ingestion of unripe fruit of ackee tree. (2) Occurrence: Jamaica and other islands of the West Indies. (3) Diagnosis: Abdominal pain and vomiting about two hours after ingestion. Coma and death may supervene after brief remission. (4) Treatment: Symptomatic. (5) Prevention: Avoidance, b. Mandioca poisoning: (1) Cause: Ingestion of improperly prepared sweet and bitter cassava root. (2) Occurrence: West Indies, South America and Africa. (3) Diagnosis: Severe gastroenteritis following ingestion. (4) Treatment: Symptomatic. (5) Prevention: Avoidance. 265. ANIMAL POISONINGS, a. Snake bite. (1) Cause; Implied. The danger of snake bite in the tropics is overrated, except for agricultural workers, and for soldiers engaged in jungle fighting. (2) Occurrence: Colubrine snakes predominate in Australia and India. Viperine snakes of the United States Include the rattlesnake, copperhead, and water moccasin, (3) Diagnosis: Fang marks. Local edema. (4) Treatment: Colubrine or viperine antlvenin 100-300 cc. Intramuscularly or venously. Local suction through rubber dam, cruiciate incisions, local antivenin. (5) Prevention: Wear appropriate footgear or puttees when unusual exposure can be anticipated. b. Spider bite. (1) Cause: Implied. Large, hairy tarantulas are harmless. Black widows can be re- cognized by red hourglass on ventral surface of abdomen. (2) Occurrence: General. Many instances of bites occurring on genitalia during use of outdoor privies, the spiders lurking under seats. (3) Diagnosis: Severe generalized myalgias half hour after bite. Pain and muscular rigidity may suggest acute abdominal accident, but pulse slow, shock not manifested, (4) Treatment: Calcium gluconate 10% sol. 10 cc. intravenously. Deaths chiefly among children. Latrodoctus antivenin (Sharp and Dohme). (5) Prevention: Inspection prior to use of facilities where spiders may lurk. c. Scorpion sting. (1) Cause: Implied. (2) Occurrence: General. (3) Diagnosis: Immediate burning, local pain lessening in about fifteen minutes. Nausea and vomiting. Profuse sweating. (4) Treatment: Symptomatic. Deaths chiefly among children. (5) Prevention: Shake out shoes and clothing before dressing. 266. VIRUS INFECTIONS, a. Yellow fever. (1) Occurrence: Endemic in Amazon basin and adjacent areas and in central Africa. Epidemic in Anglo Egyptian Sudan, 1940. (Figure 32). (2) Transmitting agent: Endemic form: Aides leucocelaenus, Haemagogus capricorni. Epidemic form: Aides Aegypti. (3) Diagnosis: Abrupt onset. Prostration. Initial tachycardia followed by fall in pulse while fever rises (Paget’s sign). Albuminuria second day. Jaundice fourth day. Bloody vomit. Differentiate from malaria, Weil’s disease. Mouse inoculation before fifth day for -recovery of virus; protection test after second week for demonstration of Immune bodies in serum of convalescents. (4) Treatment; Nonspecific and supportive. (5) Prevention: Screening of sick. Vaccination of non-immunes. Mosquito control. Quarantine of exposed personnel in screened quarters for 10-day period of observa- tion. Anti-amaryl measures applied to airdromes and planes. b. Dengue. (1) Occurrence: Widespread in tropics and subtropics, particularly in Far East and Australasia. (Figure 33). (2) Transmitting agent: Aedes aegypti, Aedes albopictus. (3) Diagnosis: Sudden onset. Fever. Backache. Ocular pain. Remission fourth day. Characteristic eruption sixth day with febrile relapse. Differentiate from influenza, yellow fever. (4) Treatment: Analgesics and sedatives. (5) Prevention: Mosquito control. c. Sandfly fever. (1) Occurrence: Widespread, especially in Near and Middle East. (2) Transmitting agent: Sandfly (Phlebotomus). (3) Diagnosis: Resembles dengue except for shorter course without febrile relapse or eruption. (4) Treatment: Nonspecific. (5) Prevention: Sandfly control. 267. RICKETTSIAL INFECTIONS, a. Rocky Mountain spotted fever group. (1) Occurrence: United States; Colombia, S.A.; Sao Paulo, Brazil; Western Mediterr- anean basin; East and South Africa. (2) Transmission: Bite of wood tick or dog tick (Dermacentor). (3) Diagnosis: Abrupt onset. Headache, malaise, prostration. Myalgias. Eruption first on ankles and wrists third or fourth day, macolopapular becoming petechial, spreading over body. Coalescence of hemorrhagic areas. Necrosis of skin of ank- les or elbows. Fever persists about three weeks. Weil-Felix positive (0X19). (4) Treatment: Care of mouth and skin. Maintain nutrition and fluid balance. Intra- venous treatments contraindicated. Serum treatment still in experimental stage. (5) Prevention: After exposure to infestation remove ticks with tweezers. In highly endemic areas, prophylactic vaccination. b. Old World typhus group. (1) Occurrence: Epidemic: Highlands of South America; Central Europe; North Africa; Asia. Endemic: Southeastern United States, Africa, Near East, Far East (Figure 34). (2) Transmission: Epidemic: body and head louse; endemic: rat flea. (3) Diagnosis: Sudden onset. Prostration. Headache. Macular eruption fifth or sixth day appearing first on chest or abdomen, in epidemic disease becoming pete- chial, spreading to back, arms, and legs. Fever continues about 2 weeks. Weil- Felix positive (0X19). (4) Treatment: As for Rocky Mountain spotted fever. (5) Prevention: Epidemic; Louse control. Endemic: Rat control. c. Japanese river fever group. (1) Occurrence: Japan, Federated Malay States; Sumatra; Australia. (2) Transmission: Bite of hereditarily infected larval mite. (3) Diagnosis: Sudden onset. Macular or maculopapular rash fifth to seventh day appearing first on face (Strong) or trunk (Dyer). Local ulcer at site of bite with re- FIGURE 32. YELLOW FEVER POTENTIAL YELLOW FEVER AREA APPEARED IN THE PAST K) YEARS SEVERE OUTBREAK 1940 - 15,000 CASES APPEARED DURING 1941 DISTRIBUTION OF MOSQUITOES CAPABLE OF TRANSMITTING YELLOW FEVER PREPARED BY THE MEDICAL INTELLIGENCE DIVISION. PREVENTIVE MEDICINE SERVICE. OFFICE OF THE SURGEON GENERAL. FIGURE 33. DENGUE PREPARED BY THE MEDICAL INTELLIGENCE DIVISION, PREVENTIVE MEDICINE SERVICE. OFFICE OF THE SURGEON GENERAL. U.S. ARMY TYPHUS FEVER FIGURE 34. LOUSE-BORNE OR EPIDEMIC TYPHUS FEVER FLEA-BORNE OB ENDEMIC TYPHUS FEVER (AREAS WHERE INFECTED BAT FLEAS HAVE MEN < REPORTED DOBING THE PAST TEN YEARS. (HUMAN DISEASE PROBABLY PRESENT. TYPHUS FEVER REPORTED WITHIN THE LAST YEAR INTENSE WOMBAT ELY INTENSE MODERATE 238 gional lymphadenitis and later general glandular enlargement. Fever lasts about 2 weeks. Weil-Felix positive, (OX19). (4) Treatment: Symptomatic. (5) Prevention; Avoidance of infested areas. Early removal of attached mites. 268. BACTERIAL INFECTIONS, a. Dysentery. (1) Occurrence: General. (2) Transmission; Ingestion of contaminated food or water. Flies. (3) Diagnosis: Onset may be abrupt or condition may develop insidiously over sever- al days. Bowel discharges loose, then watery, consisting only of mucus, pus and blood in later stages, without feculent material. Dehydration. Emaciation. Dysen- tery due to Shigella dysenteriae may have accompanying arthritis, iridocyclitis, due to exotoxin. Differentiate dysentery due to protozoa (Endamoeba, Balantidium), helminths (Strongyloides, Schistosoma) and dysentery accompanying systemic in- fections (malaria, typhoid, tuberculosis, leishmaniasis) or bowel neoplasm. Bacter- ial causes of bacillary dysentery: (a) Shigella dysenteriae (highly pathogenic because of exotoxin). (b) Organisms of paradysentery group. (c) Organisms of Salmonella group. Stool culture and proctoscopy important in diagnosis. (4) Treatment. (a) Nonspecific: Restore fluids and chlorides. Treat acidosis. Provide rest by flushing lower bowel 2-3 times daily with enemata of warm physiological saline solution. Adsorbents such as charcoal or kaolin 50-100 Gm. suspended in water q. 3-4 hours often helpful. Fatal perforations have resulted from use of kaolin in excessive doses. (b) Specific: Sulfaguanidine 0.05 Gm. per Kg, followed by 3.5 Gm. q. 4 h. until number of stools in 24 hrs. is 5 or less; then give 3.5 Gm. q. 8 h. continuing for 96 hours after stools become normal. Succinylsulfathiazole (Sulfasuxidine) 0.25 Gm. per Kg. initially; then give 1/6 of this dose q. 4 h. until stools in 24 hrs. 5 or less; continue dose q. 8 h. until stools have been normal for 96 hours. (c) Antitoxin: In bacteriologically diagnosed Shigella dysenteriae infections, mono- valent antitoxin, 40-80 cc. intravenously after sensitivity tests. (5) Prevention: Personal supervision of kitchen personnel. Avoidance of uncooked foods liable to contamination. Drink only recently boiled water from clean glass- ware. Acute alcoholism followed by enteritis may develop into frank dysentery. Resistant infections may respond to sulfadiazine or sulfathiazole. b. Cholera. (1) Occurrence: Endemic in India and China (Figure 35). Epidemics often follow natural disasters (flood, famine) or religious gatherings (pujas, pilgrimages). (2) Transmission: Ingestion of contaminated food or water. Flies. (3) Diagnosis; Violent onset. Diarrhea. Bowel discharges soon consist of cloudy white fluid containing epithelial cells, pus, and large numbers of V. cholerae. De- hydration and chloride loss become extreme. Suppression of urine. Differentiate from acute bacillary dysentery. Stool culture. (4) Treatment: Restore fluids and chlorides (hypertonic saline). Treat circulatory collapse, acidosis and anuria. Plasma infusions. (5) Prevention: Vaccination with killed organisms of local origin confers partial immunity lasting 6-12 months. c. Plague. (1) Occurrence: Widespread in the tropics (Figure 36). (2) Transmission: Rat to man by bite of rat flea (bubonic plague), Man to man by droplet infection (pneumonic plague). (3) Diagnosis: Abrupt onset of fever. Prostration. Buboes second to fifth day after onset. Rapid feeble pulse. Petechiae. Differentiate from typhus, severe pneumonia. Culture of gland juice, blood culture. (4) Treatment: Supportive. Sulfonamide derivatives. (See par. 108, 236, 248-251). (5) Prevention: Rat control. Rigid isolation of infected individuals. Quarantine contacts seven days. Vaccination with living avirulent strains (Often). PREPARED BY TMC MEDICAL INTELLIGENCE DIVISION. PREVENTIVE MEDICINE SERVICE. OFFICE OF THE SURGEON GENERAL. FIGURE 35. CHOLERA HIGHLY ENDEMIC AREAS SPORADIC ENDEMIC FOCI CHOLERA CASES REPORTED AUG. M. IB4I 240 PREPARED BY THE MEDICAL INTELLIGENCE DIVISION, PREVENTIVE MEDICINE SERVICE. OFFICE OF THE SURGEON GENERAL. PLAGUE FIGUEE 36. HUMAN PLAGUE REPORTED WITHIN 10 YEARS HUMAN PLAGUE REPORTED DURING 1941 SYLVATIC PLAGUE, KNOWN ENDEMIC AREAS HUMAN B SYLVATIC PLAGUE. KNOWN ENDEMIC AREAS 269. SPIROCHETAL INFECTIONS, a. Relapsing fever. (1) Occurrence: General throughout tropics. (2) Transmission: Endemic: Soft ticks (Ornithodorus) infest dwellings or caves feed- ing on successive human visitors. Epidemic: Louse. Epidemics of relapsing fever often accompany epidemics of typhus. (3) Diagnosis: Abrupt onset of fever continuing for period of 3-6 days with inter- missions of equal or greater length. Headache. Mylagias, Jaundice developing with first relapse. Signs of bronchitis. Moderate hepatomegaly, splenomegaly. Differen- tiate from malaria, typhus, other infectious diseases with jaundice. Spirochete in fresh blood or stained smear during fever; may be absent during intermissions. Mouse inoculation. (4) Treatment: Drugs of arsphenamine series in dosages 20-25% less than in syphilis. Single injection may cure, but many infections refractory and require prolonged treat- ment. Supportive measures important at time of critical fall in temperature. (5) Prevention: Avoidance of infested rest houses, caves, or native huts in endemic areas. Ticks pass infection to offspring and infectivity may be retained 8 years or longer. Rodents provide animal reservoir of infection. Louse control measures ne- cessary in epidemic relapsing fever. b. Yaws. (1) Occurrence: West Indies, Polynesia, Africa, South America. (2) Transmission: Contact, Eye flies (Hippelates). (3) Diagnosis: Initial papule followed in 2-8 weeks by secondary papular or frambesi- form eruption. Late hyperplastic lesions of skin, connective tissue or periosteum (crab yaws, juxta-articular nodules, saber shins, goundou) or ulcerative lesions where bone and skin adjacent (gangosa, n’gonde). Differentiate from syphilis, leishmaniasis, leprosy. Dark-field examination of serum from frambesia. Wassermann or Kahn test. (4) Treatment: Drugs of arsphenamine series in smaller doses for shorter period than usual in syphilis. (5) Prevention: Avoidance of infective contacts. Prevention of access of eye flies to open wounds or sores. 270. PROTOZOAL INFECTIONS, a. Malaria. (1) Occurrence: General (Figure 37). (2) Transmission: Bite of infected anopheline mosquito. (3) Diagnosis: Intermittent periodic fever. Splenomegaly. Anemia. Innumerable modifications of clinical picture. Fever may be absent. Any infectious disease or acute intraabdominal accident may be simulated. In the tropics all febrile illnesses should be regarded as malaria or associated with malaria until proved otherwise. Pernicious malaria, a clinical term applied to two dangerous types usually due to PI. falciparum: (a) malaria with coma, sometimes as initial symptom. (b) acute hemolytic anemia with hemoglobinuria (blackwater fever). Diagnosis of malaria is made by blood smear examination. May be negative in blackwater fever. Low parasite density because of recent antimalarial treatment may prevent finding organisms in first blood smear taken. Repeat blood examination at another phase in the malarial cycle. With experience, examination of thick smears is always preferable, (Thick smear technique: 1. Place four drops of blood on a clean 25x75 mm. glass slide and smear together to cover an area about 2 cm. in diameter. 2. Dry for 2 hours (more or less depending on humidity) in horizontal position, protected from dust and insects. 3. Prepare a 1:10-1:20 dilution of stock Giemsa stain in distilled water, preferably buffered. 4. Flood slide and stain for 30-45 minutes. 5. Wash briefly in tap water. 6. Dry and examine.Plasmodia in these smears will differ in appearance from plasmodia found in the usual thin blood smear, but they can be easily recognized if search is made for dots of red chromatic, bits of blue cytoplasm PREPARED BY THE MEDICAL INTELLIGENCE DIVISION, PREVENTIVE MEDlONE SERVICE, OFFICE OF THE SURGEON GENERAl U S ARMY MALARIA FIGURE 37. HIGHLY ENDEMIC AREAS MODERATELY ENDEMIC AREAS LOW ENDEMIC AREAS and the golden brown or gun-metal granules of pigment. These will be seen against a background of amorphous material representing the remains of hemolyzed cells, dotted with dark, pyknotic white-cell nuclei.) (4) Treatment. (a) Malaria, 1. Approved practice outlined in WD, SGO Circular Letter No. 135, October 21, 1942, Subject: The treatment and clinical prophylaxis of malaria: 1. In order to conserve quinine it has become necessary to substitute atabrine, in appropriate doses, for quinine, when- ever feasible. Therefore, pending revision of S. G. O. Circu- lar Letter No. 56, June 9, 1941, Subject: “Notes on the Treat- ment and Control of Certain Tropical Diseases,” and Section VI of TM 8-210, “Guides to Therapy for Medical Officers,” the following brief summary of approved methods for the chemo- prophylaxis and treatment of malaria is published for the infor- mation of all concerned. 2. Therapy, a. Malaria - uncomplicated. (Patient able to retain oral medication.) (1) Combined QAP Treatment, (method of choice). (a) Quinine sulphate, 0.64 Gm. (10 grains) three times daily after meals for 2 or 3 days, or until pyrexia is controlled. Then give (b) Atabrine, 0.1 Gm. (1 1/2 grains) three times daily after meals for 5 days. Then after 2 days without antimalarial medication give (c) Plasmochin, 0.01 Gm. (3/20 grain) three times daily after meals for 5 days, except for the debil- itated patient, who should receive only two doses daily. (Discontinue if toxic symptoms occur. Never give atabrine and plasmochin concurrently.) (2) Atabrine-plasmochin treatment. (May be used for simple vivax infections and in other infections when no quinine is available.) (a) Atabrine, as above for 7 days. Then, after 2 days without antimalarial medication, give plasmochin, 0.01 Gm. three times daily for 5 days, as above. (3) Quinine-plasmochin treatment. (Method when no ata- brine is available.) (a) Quinine sulphate, as above, for 7 days, during the last 5 of which accompany each dose of quinine with plasmochin, 0.01 Gm. three times daily. NOTE: - Quinine sulphate tablets are more quickly effective if dissolved before taken. Ten grains of quinine sulphate may be dissolved in one ounce of water which has been acidified by the addition of 10 minims of dilute sulphuric or hydrochloric acid. (U. S. P.) or 2 Gms. (30 grains) citric acid. b. Malaria with coma. Quinine dihydrochloride, 0.64 Gm. (10 grains) in at least 200 cc. sterile normal saline given intravenously very slowly every 8 hours until patient can retain oral medication; then treat as an uncomplicated case, (see 2a.) c. Malaria with vomiting (unable to retain oral medication). (1) Quinine dihydrochloride, 01.0 Gm. (15 grains) in 10 cc. sterile normal saline injected carefully into the gluteal muscles of one buttock; site of injection then massaged thoroughly for 2 minutes. Care must be taken to avoid the sciatic nerve. Dose may be repeated if necessary in 8 hours in other buttock. As soon as patient can retain oral med- ication treat as an uncomplicated case, (see 2a.) (2) Atabrine dihydrochloride, 0,2 Gm. (3 grains) in 5 cc. sterile normal saline may be substituted for intramuscular injection if no quinine dihydroch- loride is available. 3. Clinical Prophylaxis (suppressive treatment), a. Atabrine, Give 0.1 Gm. (1 1/2 grains) twice daily after meals on two days a week, allowing a 2 or 3 day interval between days of medication. Continue only while need for emergency suppressive treatment exists. (See note below). Then watch for indications of malaria, and, if required, give curative treatment as above (par. 2). b. Quinine. If no atabrine is available, give quinine sulphate 0.64 Gm. (10 grains) after the evening meal each day while need for emergency suppressive treatment exists, (see note below). Then discontinue, observe for indications of malaria, and if required, give curative treatment as above (par. 2). NOTE: - There is no drug which in safe doses will prevent mosquito borne infection with malaria. However, quinine and atabrine, in small doses, are useful in suppressing the appearance of clinical symptoms after infection. They are almost equally effective. Such suppressive treatment will enable malaria-infected troops to man- euver and fight actively in spite of an infection which otherwise would incapacitate them. When these troops stop taking suppressive treat- ment many of them may develop clinical malaria and require thera- peutic treatment. It may be wise to stagger the terminal point of prophylactic medication so that hospital facilities are not overtaxed when a large force returns from a hyperendemic area. For the Surgeon General: 2. Attention is called to the following aspects of the above treatment plan: (a) The recommended dose of plasmochin (0.01 Gm. t.i.d. for 5 days) should not be exceeded in treating air crew. Overdosage may cause methemglobinemia and lower tolerance to anoxia. A dose of 0.01 Gm. b.i.d. for 3 days may prove sufficient for the needs of Air Forces flying personnel. (b) The intravenous injection of quinine dihydrochloride is generally preferable to the intramuscular injection of the drug except in patients with myocardial disease. Inability to swallow, persistent vomiting, urgency and, in some instan- ces, a need for the application of a rigid therapeutic test constitute valid indica- tions for intravenous treatment. A fall in blood pressure regularly follows venous injection of quinine salts. (c) Atabrine dihydrochloride should never be given parenterally except in an em- ergency when no quinine salts are available. (d) If suppressive treatment is instituted, it must be given to every member of tHe exposed command. The administration of the drug must be supervised, pre- ferably by an officer with disciplinary authority. Defaulters should be exposed by testing for quinine the urine of men suspected of evading treatment, and of men selected at random from the personnel of the unit. (e) In British usage, atabrine is referred to as mepacrine or quinacrine, while plasmochin is known as pamaquln or praequine. (b) Acute hemolytic anemia. Mild cases occur without evident hemoglobinuria. Severe ones show jaundice and hemoglobinuria (blackwater fever). Anuria makes the prognosis worse. Individualize treatment considering the following needs: 1. Shock (See par. 210-215). 2. Dehydration and acidosis (buffer solutions, alkalis). 3. Anemia (transfusion). 4. Anuria (hypertonic dextrose). Specific antimalarial treatment is contraindica- ted until the acute stage is past, and renal function has returned to normal. (5) Prevention: Malaria control is mosquito control. Pernicious symptoms (coma, hemolytic anemia) can often be prevented by prompt treatment if blood smear examin ations are routinely made and malaria always suspected, whatever the patient’s com- plaint. Maintenance of normal fluid balance and alkalinization of urine are important in preventing pernicious complications. The control of malaria is outlined in the following WD, SGO Circular Letter No. 22, dated January 16, 1943, Subject: Military Malaria Control: 1. Introduction. The purpose of this letter is to provide Medical and Sanitary Corps officers with some practical details of measures for the control of malaria under military conditions. 2. Classification of control measures. Military malaria control requires the protection of troops in movement as well as in fixed positions. In each of these two situations both group and individual control measures must be considered. This is the basis for the following classifications. a. Measures applicable to fixed installations. (1) Environmental measures. (a) Protection against adult mosquitoes. (1) Selecting camp site. C5) Screening buildings. (3) Spray-killing with pyrethrum extract. (b) Control of mosquito larvae. (1) Draining. (2) Filling. (3) Using larvicides. (4) Miscellaneous. (2) Individual measures. (a) Curative treatment. (b) Sleeping nets (mosquito bars). (c) Repellents. (d) Protective clothing. (e) Malaria instruction and discipline. b. Measures applicable to field operations. (1) Individual measures. (a) Sleeping nets (mosquito bars). (b) Repellents.. (c) Protective clothing. (d) Prophylactic treatment. (e) Malaria instruction and discipline. (2) Environmental measures. (a) Protection against adult mosquitoes. (1) Spray-killing with pyrethrum extract. (2) Selecting suitable camp sites. (b) Control of mosquito larvae. (Should be carried out whenever feasible ) 3. Fixed installations. Effective control of malaria in permanent and semipermanent camps, posts, fields, and stations requires a high degree of cooperation and malaria discipline. Responsibility for malaria control is vested in the commanding officer who depends on Medical and Sanitary Corps officers for surveys, recommendations, and supervision, on Quarter- master and Engineer Corps officers for antimalaria supplies, equipment, and labor, and frequently on the latter corps for prosecution of control measures. Adequate protection in highly endemic areas is not possible without teamwork in planning, accomplishment, and maintenance of the antimalaria measures outlined below. 4. Proper selection of camps. The selection of a suitable camp site is an important antimalaria measure. Malaria is a communicable disease, with mosquitoes acting as the vectors. A native village in which there are numerous infected persons is a health hazard to troops that camps within flight distance of the malaria-carrying mosquito. So, too, a large breeding place of these mosquitoes, if located within easy flying distance of a camp is a menace. The effective flying range of malaria mosquitoes rarely exceeds a mile in the tropics but is apt to be more than this in temperate zones, or under exceptional conditions of wind or terrain in the tropics. As a rule, camps should always be located a mile from malarious villages or impor- tant breeding places of malaria mosquitoes. The importance of a breeding place depends not on its appearance or altogether on its size, but on the malaria-carrying capacity of the mosquitoes breeding on it. It is equally important, where feasible, not to allow natives to live on a military reserva- tion, or within a mile of military quarters, for they provide an active pool of gametocytes. 5. Screening, The following general principles should be observed if screening is to give its full value as an antimalaria measure. a. Suitable wire of proper mesh should be used. Many types of wire screening are made. Steel wire cloth is most common, either painted or electrogalvanized. The quality of paint and of galvanizing may vary greatly in different lots of wire. Pure copper wire, bronze wire (90 percent copper, 10 percent tin), monel wire (nickel-cobalt alloy), stainless steel, and alumi- num have all been used. In most areas a good quality electrogalvanized screen will be satisfactory but in the tropics, especially along the sea, it is better to use wire of a noncorrosive material, such as bronze or aluminum. A hard drawn wire, 99.8 percent copper, and of heavy grade (having a dia- meter of 0.015 inch) is suitable. Aluminum wire screening is also good. The diameters of wire and aperture are important. In general, it is not safe to use screening which has apertures larger than 0.0475 inch in diameter. Heavy grade copper wire screening, having 16 meshes to the inch, will have a wire diameter of 0.0150 inch and a mesh diameter of 0.0475 inch, but regular 16-mesh wire screening has an aperture of mesh measuring 0.0512 inch, which will not exclude all malaria vectors and will not keep out Aedes species. Standard 18-mesh wire screening has a wire diameter of 0.0090 to 0.0100 Inch and a mesh which is 0.0456 inch in diameter. b. The screening must be so applied that breakage will be minimal, and that the doors and windows will not facilitate mosquito passage. Screen doors should open outwards, and should be on the windward side of a building, if possible. They should be strongly constructed so that they will not sag or warp. They require springs so that they will close automatically. The places where a foot or hand would naturally be applied to open a screen door should be protected with a cross strip of wood or metal. Screen doors should shut against battens, which are strips of wood or metal, to block entry of mosquitoes through the space between door frame and door. The zinc in certain paints sometimes used on door or window screen night may be sprayed advantageously at dusk and again at midnight. It is not necessary, however, to spray native villages oftener than twice a week, since the aim here is to kill fed mosquitoes before they become infective, 9 to 12 days or more after feeding on a gametocyte carrier. b. Pyrethrum insecticides. Pyrethrum flowers contain certain ac- tive principles which are grouped under the term pyrethrins, and which are extracted by kerosene or other solvents. These pyrethrins kill all species of mosquitoes and certain other insects by destructive action on the central nervous system. The sprays are nontoxic to man and animals (although liberal application of a kerosene-pyrethrum spray to the skin may cause local irritation and inflammation). Pyrethrins rapidly disintegrate by a photochemical catalytic reaction when exposed to sunlight and oxygen. Py- rethrum concentrate and sprays should be kept in tightly stoppered, light- proof containers. Containers should never be left open or in the sun. In sealed containers pyrethrum extracts will maintain their potency for a year or more even in the tropics. If a pyrethrum spray fails within three minutes to kill all the adult mosquitoes with which it comes into contact it no longer contains the standard amount of pyrethrins and is not suitable for use. Three types of pyrethrum products are supplied by the Quartermaster. There is first a 20-1 concentrate, each gallon containing the oleoresins of approximately 20 pounds of flowers, with not less than 75 to 100 grams of total pyrethrins per gallon, or 2 to 2 1/2 grams per 100 cc. This 20-1 con- centrate in Army practice is diluted with 14 parts of a good qualify of water-white, preferably odorless, kerosene and may be sprayed from various types of mechanical sprayers, such as are described below. Secondly, in areas where there may be difficulty in obtaining kerosene for diluting the concentrate, a prepared ready-to use pyrethrum spray supplied. This conforms to Class AA rating, as defined in the Department of Commerce Standard Specifications. This rating is based on actual performance killing tests and these AA sprays will contain 150 to 180 mg. of pyrethrins or their equivalent per 100 cc. With either of the above sprays, about one-half ounce is required to spray effectively 1,000 cubic feet. Finally, pyrethrum is supplied in containers holding a mixture of 20-1 concentrate, oil of sesame; and liquid freon, as described below. c. Freon-pyrethrum aerosol. Pyrethrum may be dispersed from pressure cans or cylinders containing a mixture of 1 percent pyrethrins, 2 percent oil of of sesame, and 97 percent freon. (Freon 12 is dichloro-difluoromethane) The oil pf sesame is a synergist or activator, and enhances the killing power of the pyrethrins. The vapor pressure of the freon produces the necessary spraying pressure, which does not decrease as long as a drop of liquid is present in the closed container. As the freon containing the insecticide is sprayed it forms a fine mist from which the solvent evaporates almost immediately, leaving the pyrethrum. and sesame suspended in the air as a cloud pf fine droplets called an aerosol. The freon is nontoxic to man and mosquito and it is noninflammable. It is used simply as an expellent to disperse the pyrethrum and oil of sesame. The pressure in freon cylinders varies with temperature. For example, it is 37 lbs. per sq. in. at 40 degrees F., 84 lbs. at 80 degrees F., 116 lbs. at 100 degrees F., and 205 lbs. at 140 degrees F. Various types of freon-pyrethrum pressure cans and cylinders are available. One pound of freon-pyrethrum mix- ture is sufficient to spray about 150,000 cubic feet of space when properly used. It is liberated in 12 to 14 minutes of continuous use. To spray a room, hutment, or native dwelling, the can is carried rapidly toward all corners of roof, ceiling, or floor while the spray is allowed to escape. No direct spraying of mosquitoes should be attempted, as this wastes spray. About 4 seconds of spraying per 1,000 cubic feet is usually sufficient in military huts. Somewhat longer spraying for the same cubage is generally required for native huts. It is best to spray under the eaves of a hut before going inside. The freon-pyrethrum spray is so effective that it can be used sparingly and without wastage. frames and the iron in galvanized nails sometimes used to fasten screening to a frame will react with copper screening and cause splitting at the point of contact. In highly malarious areas it is desirable to have double screen door barriers with a vestibule between. c. Careful attention must be paid to the closing of all possible aper- tures not screened, such as cracks and knotholes, spaces where floor or wall- boards have separated, openings between flooring and walls, corner openings where joists come together, holes where window shutter prop sticks extend into a room for easy handling, ventilating pipes and shafts, etc. Holes may be covered with tin shingles or pieces cut from ordinary tin cans. A fUler for holes and cracks may be made by boiling shredded paper and flour into a fairly homogenous mass and then adding sand and cement to form a plastic which may be moulded into the holes. This filler is somewhat pliable and will retain its place fairly well. Toilet paper is a suitable tissue for use in making this filler. d. Not only sleeping quarters but also washrooms, latrines, theaters, post exchanges, and all places for evening recreation should be screened. e. So far as possible, especially in the tropics, hutments and buildings should be so constructed that there is four-way ventilation. The screened buildings must not be so poorly ventilated that occupants are driven out into the open by excessive discomfort. It is wise to provide electric fans or pun- kas where possible in the tropics because they tend to make screening less irksome. f. Proper routine maintenance of screening is essential, with prompt and effective repair of rents and tears, and discovery and blocking of new cracks and knotholes. In malarious areas the great importance of these apertures for mosquitoes is out of proportion to their seeming insignificance. The soldiers who occupy hutments and barracks should be taught to make all minor repairs. Strict supervision of screening is essential. Under some conditions it may be desirable to assign an enlisted man as mosquito-proofing maintenance orderly whose duties it would be to inspect all screening at re- gular intervals, making such repairs as are within his capabilities and re- porting others to proper authorities. 6. Spray-killing adult mosquitoes, a. General principles. One of the most important measures of malaria control is the spray-killing of adult mosquitoes with pyrethrum extracts. This measure, when used against malaria vectors which rest indoors in the daytime, will (1) immediately des- troy a high percentage of infective mosquitoes of an area, (2) destroy many potential vectors before they can become effective. The use of pyrethrum sprays will also have a repelling effect, deterring mosquitoes from entering sprayed dwellings or even circumscribed outdoor areas which have been sprayed. Finally, if applied often enough, spray-killing will reduce the den- sity of a mosquito population in an area. In malaria seasons, it is essential to spray all types of adult mos- quito resting places. Whenever possible, such spraying should be extended to native villages within a radius of a mile. Shelters may include not only barracks, houses, hutments, and tents, but also outbuildings, latrines, store- houses, stables, cowsheds, empty boxes and barrels, etc. If troops are operating in hostile areas, local villagers may abandon their homes, leaving behind infective mosquitoes. It may be even more important to spray such villages than the actual quarters of the troops. If the malaria vectors tend to leave houses, tents, and barracks at sunrise the spraying should be done either before dawn or after sunset. When applied after sunset the spray will have both a killing and repelling effect. In military installations in highly malarious areas daily spraying is advisable. Huts at road blocks, sentry huts, huts used by beach patrols, antitank gun emplacements, pill boxes, and similar places when occupied at When a mixture of freon and the usual pyrethrum concentrate freezes, a wax is precipitated which may block the tube of the dispenser. The wax goes back into solution after a few days at 70 degrees F. or higher so that this freezing effect is rarely troublesome in actual practice, especially since the dispenser is generally used in warm countries. Within a few months a wax-free concentrate will be available. d. Hand atomizers or spray guns. Small household-type spray guns are useful for casual spraying of quarters. Where mosquitoes are a nuisance small spray gun atomizers should be issued at the rate of one per 20 men. They consume relatively greater amounts of insecticide than other types of sprayers but may be used to advantage by the troops themselves for occasional spraying. e. Paint gun sprayer assemblies. Pyrethrum insecticides can be effec- tively sprayed through any ordinary paint gun if a source of air pressure of 15 pounds or more is supplied. The source of the pressure may be in tanks pumped up by hand or by gasoline or electric motor-driven compressors. Solidified carbon dioxide (dry ice) when available, in suitably constructed pressure tanks is a good expedient. 7. Drainage. It is highly important that fixed installations have suit- able antimosquito drainage, integrated with the usual system of drains de- signed to carry the normal surface water runoff. Drainage should be under- taken early, during the actual construction period. It is desirable to have it well in hand, before the camp or station is occupied. It is also important to avoid blocking an existing draining system by new constructions. No drainage scheme should be undertaken without careful preliminary surveying and planning. Drainage to control mosquitoes may be accomplish- ed by the use of surface ditches, subsurface drains, vertical drains, pumps, tide gates, and other devices. In every case the aim is to drain an area in such a way that regardless of weather or tide there will be no mosquito breeding. Ditches and drains may be unlined, lined, or rock filled. The lining may be precast sectional inverts, concrete or stone slabs, rip rap, or other material. For subsurface drains many materials have been utilitized, as for example, baked clay or concrete tile, rock, bamboo, and brush. Drains should be as few as will accomplish the purpose. Drainage requires that careful levels be run and that well-though-out plans be made as to the relation of a drainage system to existing water supplies, to other sanitary improvements, to disposal of sewage,' and to maximum amount of water to be carried in the rainiest season. In some areas, where the vector breeds in seepage or in slowly running water, open ditches may cause a greater malaria nuisance than the swamp they drain. Where a satisfactory outlet is not available, land may sometimes be graded so that surface water accumulates in one or more pools which can be periodically treated with larvicides. Ditch maintenance is a very important item for which adequate pro- vision must be made. 8. Filling. It is usually necessary to do a considerable amount of filling on the site of a new permanent installation. Frequently, there will be a man- made depressions under buildings, beside roadways, and in other places where earth has been borrowed for various purposes. When large hydraulic fills are contemplated for construction purposes, it is necessary to make adequate plans to avoid blocking natural drainage and to control with larvicides the breeding places, such as pools and cracks, created by filling operations. 9. Larvicidal oiling, a. Discussion. Suitable oils, properly applied, will kill the aquatic stages of all species of mosquitoes and will also destroy sheltering vegetation at the edges of breeding places. The chief killing factor is a toxic action following contact with the tracheal cells of larvae and pupae. Consequently, the best larvicidal oils are those which penetrate most quickly, and with the greatest toxic effect, into the spiracles and thence into the tracheae, of larvae and pupae. What is required is a cheap but toxic oil or mixture of oils of suitable toxicity and viscosity which, when sprayed on the surface of the water, spreads well in a -uniform, persistent, and stable film. The best larvicidal oils will kill in less than 30 minutes under these conditions Kerosene or gasoline may be used as larvicides and will give a good kill but they form transitory films, are expensive, and may constitute a fire hazard. Occasionally it may be desirable to kill all larvae in a well by a film of gasoline, 'which soon evaporates, leaving no taste in the water. Lead- ed gasoline should not be used in wells the water of which is used for drinking. Waste motor oils are not highly toxic to larvae, as they are relatively nonvolatile. But they are sometimes used effectively when applied as a fairly thick film. Better results are possible when waste motor oil is mixed with kerosene, generally in the proportion of 1 to 3, respectively, adding if possible about 2 percent of castor oil. However, the amount of kerosene to be added will have to be determined by experiment. Diesel Oil No. 2, as supplied by the Corps of Engineers, is preferable to a mixture of waste oil and kerosene. The ideal specifications for a larvicidal oil are the following: Specific gravity 20/4 0.83 - 0.86 Viscosity (Saybolt Universal at 100° F.) 31 - 43 Initial boiling point 297° - 414° F. (165° - .230° C.) Final boiling point Max. 800° F./(426.7° C.) Spreading coefficient Min. 17.0 b. Application of oil. General. Oil may be effectively applied to small collections of water by means of an oil-soaked broom, an oil mop, or oil-soaked waste tied to a stick. An ordinary waterpot may be used to pour oil on small collections of water. c. Sprayers. The knapsack sprayer consists of oil container, hfend pump, and spray nozzle, and is carried and operated by one man. The or- dinary sprayer has a capacity of 4 to 5 gallons and a spraying range of about 25 feet. The knapsack sprayer is a practical and economical apparatus for applying oil to ditches, small ponds, or other collections of water which can be reached by the spray. Large power sprayers may be employed to oil ex- tensive areas such as the borders of lakes, or, in some instances, swampy places. Such sprayers usually consist of a barrel or tank container and a motor activated pump mounted on a vehicle or boat. Air planes may be equipp ed to oil extensive breeding areas. d. Continuous oilers. Where oil will be dispersed by currents, as in streams or ditches, it may be better to attempt constant application of oil. There are at least three types of continuous oilers, none of which is entirely satisfactory. It must be pointed out that continuous oilers require a good deal of attention, generally use more oil than would be dispensed for the same area from a knapsack sprayer, and should not be used unless other methods are found impractical. Drip oilers consist of a tin or drum of about 5 gallons capacity, placed on supports over a stream or ditch so that oil will drip on the water surface. Size of hole will govern amount of oil dropping from the container. In home- made containers a nail hole may be used, with a nail left loosely in the hole. It may be necessary to use some string to form a washer around the nail head. The can should be several feet higher than the stream surface so that oil will spread quickly when drops strike the water. The rate of flow required to furnish a satisfactory film depends on circumstances. Generally, an average flow of from 10 to 20 drops per minute will suffice for each foot of width of water in the stream. Submerged oilers are containers having two small openings. They are designed so that when sunk to the bottom of a stream or pond their oil will escape through one opening and be replaced by water which enters through the other. These cans have the disadvantage that they are difficult to adjust so that oil will :flow properly, as the openings are easily clogged. Oil may be applied continuously by means of a weighted submerged bag of oil-soaked sawdust. Or oil-soaked sawdust may be scattered over the surface of a breeding place. Oil booms may be used to combat larval drift, which is sometimes troublesome when there is intense breeding in a stream above the area being controlled. These booms may be constructed of locally- obtained materials and placed across a water channel, supported by stakes. The booms are so built that, while holding back larvae, the flow of water is not obstructed. The larvae are killed by oil-soaked sawdust or chaff thrown on the water surface above the boom. e. Amounts of oil required. Using Diesel Oil No. 2, about 9 gallons are required per acre of water surface for complete coverage with a uniform, stable oil film. With an ordinary knapsack sprayer of the Panama type one laborer can oil about five acres of breeding area per day, if the terrain is not difficult. In usual practice the amount of oil necessary to produce a uni- form film may vary from 10 to 20 gallons per acre. The amount of floatage and vegetation will make a considerable difference. It is usually necessary to spread oil once a week. 10. Spreading Paris green on mosquito breeding places, a. Nature of Paris green. Paris green (an aceto-arsenite of copper) is a micro-crystalline powder. It should be emerald green, with at least 50 percent arsenious oxide. Its solubility should not exeeed 3 percent. Paris green should pass a 300 to 325-mesh sieve. The latter has a mesh opening measuring 0.043 mm. As mixed, ready for distribution in the field, Paris green should kill all 2d, 3d, and 4th stage larvae in a laboratory jar in two hours. It has a specific gravity greater than that of water, but certain types float longer than others. r ne longer it floats the better it is as an anopheline larvicide. The usefulness of Paris green depends on the fact that it is a gut poison for larvae. Larvae feeding at the surface will ingest Paris green particles. This is especially true of Anopheles larvae, but when Paris green floats long enough in still water it will be ingested by Aedes and some Culex larvae, which feed some of the time at the surface. Sometimes when Paris green is mixed with wet sand and taken to the bottom it will be ingested by bottom feeding larvae. Paris green, however, has its greatest usefulness against Anopheles larvae, Paris green, after sinking, is usually volatilized by various moulds in the water. As ordinarily used in mosquito control procedure, it is harmless to man, animals, fishes, and bankside or floating vegetation. Paris green does not repel ovipositing mosquitoes and in this respect is inferior to oil. b. Dust dilutions of Paris green. When dust mixtures are used it is advisable to prepare a diluent which will pass a 30-mesh screen, or finer. This diluent may be road dust, powdered charcoal, slaked lime, powdered soapstone, or some other dust. The diluent must be well mixed with Paris green, the required dilution varying from 1 to 5 percent by volume for hand operated blowers to 25 percent or more for dusting from airplanes. When lime is used Paris green may be added in the proportion of 10 percent by weight. This is equivalent to about 5 percent by volume. However distributed, it is essential to test the efficacy of Paris green in the field from time to time. This may be done by ascertaining the kill in petri dishes containing larvae and placed at strategic points in the dusted area, or by dipping for larvae 10 to 24 hours after application of the Paris green and noting the survivals. c. Types of dust distributors. Paris green mixtures can be applied to ponds, lakes, and larger streams by putting the dust into the air from the windward side so that it will form a cloud and be carried out over the water. The large hand or motor operated dust blowers ordinarily employed for dusting trees in horticultural work, may be used to throw the larvicidal dust into the air. These may be knapsack, rotary, or some other type. For large bodies of water a slowly settling dust cloud carried along by a light wind will give best results. In the case of small bodies of water where vege- tation is heavy or where ditches and streams are too narrow to be dusted by the cloud method handfuls of dust mixture should be thrown directly on or into the vegetation or onto the surface of the water. There are also automatic distributors for small canals or streams. Airplanes may be used to apply the dust over large areas, such as extensive swamps. Generally, the best results will be obtained on a sunny day after the dew has evaporated from vegetation. It should be remembered that, when special distributors are not avail- able, Paris green mixed with wet or dry sand, gravel or small pebbles, and thrown by hand is often quite effective. The amount of larvicide required to treat an area of given size will vary according to the amount of vegetation present. When the surface of the water is clear, about one-half ounce of Paris green, mixed with 99 parts of dust by volume, is sufficient for 1,000 square feet of water surface. Greater quantities of Paris green must be used where there is vegetation, such as grass or reeds. The percentage of Paris green in such places should be from 2 to 5 percent by volume, as determined by experiment. One man can usually prepare and spread Paris green mixture along about 11/4 miles of bank in one day, depending, of course, on local conditions. Since Paris green will kill 2d, 3d, and 4th stage larvae within a few hours it need be applied only at such intervals as are necessary to prevent the development of the remaining 1st stage larvae or of new broods of larvae. Under average conditions Paris green should be applied at inter- vals of from 5 to 7 days in warm weather. Dusting should be repeated with- out delay whenever examination of the water reveals the presence of 4th stage larvae. d. Dustless application of Paris green. The need for preparing and transporting dust diluents is obviated by using a dustless method with the following stock suspension: Kerosene oil 1 pint Paris green 1/2 pint Egg albumen (dry powdered) 1/4 teaspoonful (If no powdered egg albumen is available an albumen solution can be prepared by using 4 to 6 egg whites in a pint of water. Use one-fourth of a pint of ihis solution to one pint of kerosene. The egg albumen is not absolutely essen- tial but it tends to make the Paris green more evenly distributed in the final spray.) The ingredients are put into a bottle in the order named and thor- oughly shaken. This stock suspension, again thoroughly shaken, may be put into vials, each holding 6 teaspoonfuls (about 27 cc.). These stoppered vials may be taken to the field by the spraying laborer in a specially made belt. To prepare the final spray one vial, or 25 to 27 cc. of stock suspension, is mixed with 5 quarts of water. It reduces the labor of transportation If the mixing is done at the breeding place to be sprayed. The water should be strained through a sieve and the mixing may be done in the usual knapsack sprayer , which generally has about 4-gallon capacity. By using only 5 quarts of final spray at one time in this sprayer it is possible by frequent agitation to keep the spray well mixed while it is being applied. About 590 square feet can be sprayed with 5 quarts of this spray. About 2 teaspoonfuls of castor oil in 5 quarts of spray will add to the effectiveness of this dustless Paris green larvicide. When it is not possible to prepare the above stock suspension, fairly good results may be had with a simple mixture of 5 teaspoonfuls (about 22,6 cc.) of Paris green in 5 quarts of water, using an ordinary knapsack sprayer Almost continuous agitation of the sprayer while spraying is advisable. Some 500 square feet of breeding area can be sprayed with 5 quarts of this larvicide. 11. Care of equipment. Equipment for spreading oil or Paris green larvicides requires careful maintenance. It should be overhauled and thor- oughly cleaned at reasonable intervals. Full sets of replacement parts should be stocked. 12. Phenothiazine. It has been shown that phenothiazine is an effective substitute for Paris green. If available, in the absence of Paris green, it may be used. It is less stable than Paris green but lighter in weight 13. Miscellaneous measures to deal with breeding places. In some areas effective larva control may be had by shading a stream or canal, using some rapidly growing plant which will give a dense cover. In other areas, stream breeding anopheline vectors may be controlled by periodically sluicing the stream. A small dam is built to impound water which can be released by the hand or mechanical removal of a barrier, or by use of automatic siphons. Where irrigation water in rice fields or canals is at fault, effective mosquito control is sometimes possible by intermitting the supply of of water so that the fields become just dry enough each week to remove the surface film of moisture without drying the roots of the plants. Fluctuation of water level in ponds and reservoirs is sometimes very effec- tive in controlling mosquito breeding. All wet cultivation, such as sugar cane or rice, within two miles of any fixed Army installation, should be eliminated, if feasible. When larvicides such as oil and Paris green are not available, con- trol of breeding is sometimes possible by tightly packing a ditch or small pool with fresh green-cut vegetation. Unless tightly packed and renewed as required, the rotting vegetation may create conditions leading to incre sed culicine breeding. In some areas routine attention must be paid to artificial breeding places such as wells, cisterns, roof gutters, and various types of household water containers, tin cans, coconut shells and the crotch of banana leaves where they join the trunk. These may be screened, emptied, oiled, or de- stroyed, as indicated. In wells and in pools without much vegetation somehelp in larva control may be had by using larva-eating fishes, such as Gambusia affinis 14. Treatment (curative). (See par. 270a.(4)(a)l.). 15. Malaria control in the field. “Fighting” malaria, or the prophy- laxis of malaria among troops in combat or maneuver areas in the field, is one of the most difficult of all malaria control problems. It requires con- stant attention to the application of individual protective measures against mosquitoes and to the use of suppressive antimalarial drugs. There must be the greatest accent on personal prophylaxis. The soldier must himself apply measures which will protect him from malaria. Under combat condi- tions the need for freedom from malaria is greatest. Under these conditions the risk of infection is maximal. Therefore, it is highly important to apply effectively such measures as suppressive treatment and the use of sleeping nets, repellents, sprays, and protective clothing. 16. Use of sleeping nets. Nets to protect sleeping individuals are useful in preventing malaria but they must be properly employed and pro- perly maintained. They must be so adjusted and used that mosquitoes cannot feed through the mesh because the net touches the individual. The lower edge must be so tucked in that no opening is available for mosquitoes to enter. Overhead frames should be provided for bed and cot nets. These should not have sharp points which will catch and tear the netting. Nets used in small tents should be suspended from and conform to the shape of the interior of the tent. Shelter tent nets should not be used over the outside of the tents but hung Inside. Nets should be folded up by day. When the net is entered at night the interior should be inspected for stray mosquitoes. It is highly important that nets be available for use from the first night spent in malarious areas. There are places in the tropics where a single night of exposure to mosquito bites may result in a 20 percent or greater infection rate among the exposed troops. Nets should therefore be carried as items of personal equipment by all personnel proceeding to malarious zones. Even in the forward areas it is highly important to utilize this protective measure whenever feasible. The best material for nets is a stiff bobbinet. Such materials as cheesecloth, tobacco cloth and butter cloth, are not suitable because they almost completely prevent proper ventilation. The size of the holes should not exceed 0.0500 inch in any dimension to exclude all species of mosquitoes. To exclude sandflies the largest permissible diameter is 0.0334 inch. The top as well as sides should be of netting to allow for a better circulation of air. Strong reinforcing at corners is necessary and repairs should be prompt and complete. Adhesive tape, sewing, or patching may be used to repair rents in the netting. Frequent inspection is required. 17. Use of chemical repellents. Various essential oils and synthetic products have been used, as creams or lotions applied to the skin, to repel mosquitoes. Most mosquito repellents have had one or both of two major defects: (1) very transitory or weak effect, and (2) risk of toxic poisoning by absorption through the skin, especially when the repellent must be used liberally during extended periods of time. For example, diethyleneglycol is a mosquito repellent but it is reported to be toxic when absorbed through the skin and apt to damage kidney and liver tissue if used freely for a considerable time. There are three good repellents (612, indalone, and dimethylphthalate) which are being issued by the Quarter master. Of these 612 will give good protection against mosquitoes for about four hours after liberal application, even under sweating conditions. Indalone will be about as well, except under sweating conditions when it should be renewed half-hourly. Dimethy- lphthalate is slightly less effective than 612, but more effective than inda- lone. All are better than any repellents available heretofore. Certainly, very much greater use than ever before should be made of these repellents when troops are in forward areas. All exposed skin sur- face should be covered with the repellent. It is also important to apply the repelleneto to the clothes where they are so thin or so taut that mosquitoes can feed through the cloth as, for example, over the shoulders and seat. Repellents should not be applied to the lips, nor allowed to reach the eyes. 18. Use of protective clothing. Men on guard duty or'forced to re- main out after dusk where malaria-carrying mosquitoes are common, may wear approved head nets and gloves as supplementary protective measures. Head nets have certain disadvantages. They impair vision and add to dis- comfort in the tropics. Vision is least impaired by black nets. Shirt sleeves should be kept down after sunset. Slacks, not shorts, should be worn. By keeping the trouser legs encased in leggings, or tucked into high boots, mosquitoes are kept from biting the ankles. Mosquito boots of canvas, suede, or goatskin may be useful if long enough to protect the leg nearly to the knee. Such light boots are not suitable for marching, which requires service shoes with leggings. The efficiency of protective clothing varies directly with the amount of inspection and discipline which can be applied. 19. Pyrethrum sprays. (See par. 6, this letter, and par. 180 of text). 20. Instruction of personnel. The instruction of all ranks in regard to malaria and malaria control is important, and it should begin in the con- tinental training bases, even if these are not malarious. The nature of malaria, cycle of development of plasmodium, role of Anopheles mosquitoes, and the fact that the disease can be prevented only by special measures, should be explained briefly in simple terms. Full use should be made of moving pictures and of locally prepared talks, bulletins, and directives. An important point to be stressed is that malaria cannot be prevented by routine camp sanitation or personal hygiene. Specific control measures are essential. In permanent and semipermanent posts and camps a high degree of protection against malaria is afforded by employing measures outlined above. In forward or combat zones and while maneuvering or holding defense positions in the field away from fixed installations, espec- ially in tropical countries, the most feasible malaria control measures are those for which the individual soldier himself must be responsible to a very large extent. 21. Drug prophylaxis or suppressive treatment. (See par. 270a,(4)(a)1.3). 22. Miscellaneous, a. Nocturnal visits to unprotected places. In some areas a high percentage of all malaria infections is acquired while soldiers are visiting unprotected towns or villages after dark. In such areas it is advisable to consider a change in the usual leave hours whereby passes are issued which will require the soldier to return to his protected camp by nightfall. b. Malaria discipline. Malaria discipline is defined as a state of or- derly and effective conduct or action on the part of soldiers in respect to malaria control. It implies ability and readiness to practice malaria control, as outlined above, particularly the individual measures. When there is malaria discipline in a company, screens, and bed nets are in good repair and are properly used, protective clothing and repellents are employed to the fullest practical extent, suppressive treatment is faithfully taken as ordered, and men do not expose themselves heedlessly to mos- quito bites. Good malaria discipline reduces to a minimum such dangerous practices as loitering, fishing, or swimming after dusk in malarious places. Malaria discipline is developed by careful indoctrination of officers and enlisted men, and it presupposes constant supervision by those in command. Malaria control is never automatic. In highly infested areas it re- quires of the Medical and Sanitary Corps officers concerned unremitting attention to small detials. Success is possible only when there is a high degree of cooperation among all ranks and all branches in outwitting the Anopheles mosquito. For the Surgeon General: b. Amebiasis. (1) Occurrence: General, especially in hot, wet climates, (2) Transmission: Contaminated food or drink. Flies. (3) Diagnosis: Symptoms may be absent (chronic carrier) or may vary from mild abdominal discomfort to those of active dysentery with marked tenesmus. Some cases resemble acute appendicitis. Laparotomyiif performed is often fatal. In- vasion of liver by amebae leads to hepatitis, later to abscess. Pyogenic infection of abscess given signs of sepsis, in tropics often mistaken for malaria. Differen- tiate from other types of dysentery, acute abdominal conditions, fevers. (4) Treatment: (a) Asymptomatic carriers. 1. Carbarsone 0.25 Gm. b.i.d. for 10 days. 3. Chiniofon (yatren, anayodin) 1.0 Gm. t.i.d. for 10 days. The drug itself may cause diarrhea. Do not confuse this toxic symptom with relapse of the amebic infection. 3. Diodoquin 1.5-2.0 Gm. daily for 2-3 weeks. (bj Acute or chronic amebic dysentery. 1. Emetine hydrochloride 0.06 Gm. i.m. daily for 6 days unless symptoms relieved in shorter time; followed by 0.03 Gm. b.i.d. for 6 days if needed. Watch for sym- ptoms of toxicity (myocarditis, neuritis). 2. Follow emetine with one of drugs mentioned in par. (4)(a) above. Relapse is frequent and treatment must often be prolonged. (c) Liver abscess. 1. Emetine hydrochloride as above followed by other drugs if needed. Aspirate only if, despite treatment, pain or fever continues (secondary infection) or rup- ture threatens. (5) Prevention: As given under bacillary dysentery. c. Leishmaniasis. (1) Occurrence. (a) Visceral (kala-azar): Mediterranean basin, Northern Africa, Near East, India, China and parts of South America. (b) Cutaneous (oriental sore): Mediterranean basin, North Africa, Near East, but not in same areas as visceral leishmaniasis. (c) Mecocutanous (espundia): Mexico, Central and South America. (2) Transmission: Bite of sandfly (Phlebotomus). (3) Diagnosis: (a) Visceral: Insidious onset of fever. Progressive hepatosplenomegaly with anemia and marked leucopenia. Emaciation. Culture or smear of peripheral blood, bone marrow, or of material obtained by spleen or liver puncture. (b) Cutaneous, mucocutaneous: Papule developing into spreading indolent phagedenic ulcer. Culture or smear of material from ulcer margin. (4) Treatment: (a) Visceral. L Stibamine glucoside (neostam): Freshly prepared 2% solution given intraven- ously alternate days. Initial dose 0.05 Gm. Increase each dose by 0.05 Gm. to level of 0.2 Gm. 2. Antimony and potassium tartrate (tarter emetic): Fresh 2% solution intra- venously on alternate days. Initial dose 0.04 Gm. Increase each dose by 0.02 Gm. to level of 0.1 Gm. Continue at this level to a total dose of 4.0 Gm. 3. Fuadin (stibophen, neoantimosan): 6.3% sol., 1.5, 3.5 and 5.0 cc. intramus- cularly successive days followed by 5.0 cc. on alternate days for a total of 10 doses. (b) Cutaneous and mucocutaneous leishmaniasis: Local treatment; Berberine sulfate 1% solution 2 cc. injected into margins of ulcer. Systemic treatment as outlined above. (c) Toxic symptoms: Neostam:gastroenteritis, nepatitis, anaphylactoid reaction, occasionally collapse, after 6 or 7 injections. Tartar emetic and fuadin: cough, vomiting, arthralgias, late in course. Bradycardia occasionally necessitates discontinuance. (5) Prevention: Avoidance of contacts. Screening to exclude sandflies (46 count bob- binet). d. Trypanosomiasis. (1) Occurrence: Africa - South of 15° N. Lat.; South America - in Brazil and adja- cent states. (2) Transmission: (a) African type: Bite of tsetse fly (Glbssina). (b) South American type: Bite of assassin bug (Triatoma). (3) Diagnosis: (a) African type. Gradual onset of remittent fever. Tachycardia. Erythematous dermatitis. General glandular enlargement. Occipital adenopathy common. He- patosplenomegaly. Deep hyperesthesia (Kerandel’s sign). Increasing somnolence. Examine fresh blood or stained smear, gland juice or CSF for trypanosomes. (b) South American type (Chagas’ disease); Severity varies. Often seen in infants. Edema of the lids and face. Conjunctivitis and other ocular symptoms. Bradycar- dia. Myocarditis. General glandular enlargement. Examine blood (early cases only) for trypanosomes; bone marrow or tissue for leishmanla forms. (4) Treatment: (a) African trypanosomiasis: Bayer 205 (moranyl, entrypol, suramin, naphuridine Wlnthrop, germanin) 1.0 Gm. intravenously in 10 cc. of distilled water weekly for 10 weeks. Tryparsamide 0.45 Gm. per Kg. of body weight intravenously, once weekly for 15 weeks. Toxic effects of tryparsamide: hepatitis, optic neuritis. (b) South American trypanosomiasis: No effective treatment. 271. HELMINTHIC INFECTIONS. a. Filariasis. (1) Occurrence: General. (2) Transmission: Varies with species. Bancroft’s filariasis (commonest type) - Mosquito. In Central America and in Africa the small black fly (Slmulium) trans- mits onchocerciasis. In Africa, a large horse fly (Chrysops) carries infective larvae of loiasis. (3) Diagnosis: (a) Bancroft’s filariasis: Adults develop in lymph glands. Are essentially asym- ptomatic until occurrence of lymphatic obstruction (lymphocele) caused by host tissue reaction to presence of dead adults. Superimposed bacterial infection gives elephantoid fever. Microfilariae in peripheral blood during night (nocturnal periodicity). (b) Onchocerciasis: Adults in subcutaneous nodules (Guatemala nodules). Der- matitis and ocular complications (keratitis) caused by migration of microfilariae. Biopsy of nodule shows adults or microfilariae in adjacent skin. (c) Loiasis: Adult worms in subcutaneous tissue or beneath conjunctivae. Fugi- tive swellings. Microfilariae in peripheral blood by day (diurnal periodicity). (4) Treatment: Surgical removal of adult worms when accessible, especially appli- cable in onchocerciasis. (5) Prevention: Protection from bites of infected insects. b. Schistosomiasis. (1) Occurrence: Widespread, especially in great tropical river vaHeys. (2) Transmission: Viable ova in urine or feces find access to water. Miracidium hatches and enters intermediate snail host. In snail there develop cercariae which, after emergence from snail, are infective for man by ingestion or by penetration of unbroken skin. Adults develop in venules of portal system, or of urinary bladder later depositing ova which excite local fibrosis. Papillomata develop in rectum or bladder which ulcerate, releasing ova into bowel or bladder lumen. (3) Diagnosis: Dermatitis at site of entry. Fever, urticaria 2-8 weeks later. He- patosplenomegaly, ascites; rectal polyps, melena; vesical papillomata, hematuria. Diagnosis by demonstration of ova in stool or urine. (4) Treatment: (a) Antimony and potassium tartrate as described in 270c.(4)(a)2.). (b) Fuadin. (See par. 270c.(4)(a)3.). (5) Prevention; (a) Avoid swimming or wading in infected water. (b) Boil or keep water for 36 hours before drinking. (c) Copper sulfate 1:200,000 will kill snails which are obligate intermediate hosts of cercariae. 272. MILITARY PROBLEMS, a. Effective preventive measures must be taken before exposure to tropical infection actually occurs. Under ordinary conditions, success in pre vention will largely depend upon the equipment, training, discipline, and education of the military unit concerned. b. Equipment. Adequate supplies of food are necessary to the health of a military unit on duty in the tropics, more so than for units serving in temperate zones. Drugs are needed, as are nets, screens, and other items of equipment. Adequate supplies must be available, or disease will result. When circumstances of combat interrupt the regular supply lines disease occurs, as on Bataan. c. Training. Health in the tropics is in large part a matter of successful adaptation to a new environment, an adaptation which is partly physiologic, partly psychologic and to a very large degree hygienic. Previous to exposure to jungle or desert conditions troops should be rigorously conditioned by prolonged training under simulated combat conditions. The medical personnel should be included in the training program and medi- cal officers should acquire experience in preparing sanitary orders. These must be en- forced in every detail, but enforcement is not enough. For scrupulous observance of sanitary orders a high standard of discipline affecting every member of the unit is re- quired. d. Discipline. Poorly disciplined troops suffer heavily from disease and death in the tropics. Good discipline is essential to: (1) Camp sanitation. The proper disposal of waste matter as prescribed in FM 8-40 is necessary in the tropics to prevent the breeding of flies and dissemination of diseases. In the moist heat of the jungle the rate of development of the fly is so greatly accelerated that a camp will swarm with them within a few days unless adequate measures for waste disposal are taken. Mosquito breeding must simi- larly be controlled by the elimination of drainage of natural or artificial collections of water. (2) Personal hygiene. (a) Native contacts. Contact with native populations must be reduced to a mini- mum or there will be a rise not only in the venereal disease rate but in the incidence of malaria, dysentery, and other infections. (b) Skin care. Soldiers in the tropics must give particular attention to the care of the skin because of the excessive sweating which favors the development and spread of skin infections. Fungus infections are especially prevalent and tend, through exchange of clothing and towels, to become epidemic in military units. It is im- portant that the feet be completely and thoroughly dried after bathing and that clothing be frequently changed. Bacterial infections are also common and impetigo has a high incidence in the tropics when standards of personal cleanliness are low. Secondary infections of open wounds are extremely common and minor injuries such as those inflicted by leeches or ticks should receive early antiseptic treat- ment. When neglected, incapacitating ulcerations may develop, particularly on the legs. The specific cause of tropical ulcers of this type is unknown, but may be spirochetal infection of the vincenti type of may perhaps in some cases be due to a microaerophilic streptococcus. Treatment should include rest, elevation of the limb and local application of oxidizing agents such as hydrogen peroxide, zinc peroxide, or sodium perborate. Under other circumstances ulcerative lesions occur in the tropics as a manifestation of infections of known etiology, either local or systemic in nature. These must be considered in differential diagnosis of the type of tropical ulcer described above. They are: 1. Tropical sore (cutaneous leishmaniasis). 2. Veldt sore (diptheria of the skin). 3. Yaws. 4. Syphilis. (c7 Foot care. L Epidermophytosis. This condition if neglected frequently involves the nails and reaches a stage where cure becomes a matter of the greatest difficulty. It is important that all cases be treated early and dissemination within a unit be prevented by rigid enforcement of recognized methods for control through the use of foot baths, by careful drying of the skin between the toes, by frequent changes of socks and by other measures. 2. Sand fleas. These are prone to burrow into the skin particularly of the feet. They should be removed surgically by trained medical personnel. The addition of precipitated sulphur to G.I. foot powder will prevent infection. 3. Red bugs. Control of these mites is difficult but the use of standard issue in- sect repellents is indicated. The dermatitis resulting from red bugs may be a serious annoyance but it is significant principally because scratching leads to secondary infection and these infected areas may develop into tropical ulcers. (d) Dress. Rolled up shirt sleeves and shorts should not be permitted during the early or late hours of the day. Exposure to the bites of malaria carrying mosqui- toes should be reduced by requiring men to wear their sleeves rolled down to change into long trousers during the period when Anopheles mosquitoes are biting. Puttees will protect the ankles if mosquito boots are not available. Sen- tries should wear headnets and mosquitQ-proof gloves when on duty during the hours of dawn or early evening. The glare of the sun can be reduced if sun goggles are worn. Protection of the head from the sun contributes to comfort but probably has little relation to the prevention of sun stroke. In the tropics most “touches of sun” are malaria. (e) Bed nets. Bed nets should always be used whether barracks are screened or not. Men must be trained to spray beneath their beds and inside the net before getting into bed. They must then tuck the net under the entire mattress, sides, head, and foot and search the interior for trapped mosquitoes before retiring. Nets should be inspected regularly by responsible officers for holes or evidence of neglect. Barrack inspections should be made during the night to awaken men who in their sleep have rolled against the nets thus exposing themselves to in- fective mosquito bites. From a practical standpoint it is difficult to enforce the use in the tropics of nets of sufficiently fine mesh to exclude sandflies. (f) Alcohol. Use of alcohol should be prohibited during the day but permission for its moderate use after sundown is often an important factor in maintaining morale, particularly in isolated stations. (g) Anti-malarial drugs. Poorly disciplined men will attempt to evade the taking of quinine or atabrine unless closely watched during every stage of the routine ad- ministration of the drug. Some will attempt to palm the capsules because of their distaste for the drug or from a wish to sell or exchange the quinine. e. Education. Under the provision of AAF Memo 25-1, May 25, 1942, unit commanders have been ordered to institute under the supervision of unit surgeons, a medical training program which should be of the greatest value to unit stations in the tropics. Education should not stop with a single course of formal lectures but ought to continue informally during the entire period of residence in the tropics. The medical officer should train himself in the simple presentation of subjects of general concern in language easily understood by all. Adequate supplies, training and discipline will accomplish much but education of every member of the military unit is necessary to secure intelligent and spontaneous cooperation without which full fighting efficiency cannot be maintained (See par. 158-162). 273. REFERENCES. a. Manuals. (1) FM 8-40 Field Sanitation. (2) TM 8-210 Guides to Therapy for Medical Officers. (3) TM 31-20 Jungle Warfare. (4) TM 31-25 Desert Operations (Restricted). b. Memorandum, AAF Memo 25-1, May 21, 1942. c. Texts. (1) Strong’s Stitt’s “Diagnosis, Prevention and Treatment of Tropical Diseases”, 6th Ed., 2 vols. Philadelphia, Blakiston, 1942. (2) Dunham, G.C., “Military Preventive Medicine”, 3rd Ed., 1928, Carlisle, Pa., Medical Field Service School (Army Medical Bulletin No. 23). d. System. Byam and Archibald’s Practice of Medicine in the Tropics, 3 vols., London, Frowde, 1921-23. e. Letters. (1) SGO Circular Letter No. 135, October 21, 1942, Subject: The Treatment and Clinical Prophylaxis of Malaria. (2) SCO Circular Letter No. 22, January 16, 1943, Subject: Military Malaria Control. SECTION VIII BLAST INJURY Paragraphs General 274 Parts injured 275 References 276 274. GENERAL. “Blast” or explosions may be described as consisting of a wave of high pressure or compression followed immediately by a wave of low pressure or suction due to the fact that the wave of increased pressure has reduced the density of air behind it to a point below normal atmospheric pressure. Both waves last only a fraction of a second, but this is sufficient to produce instant death in many cases. A person fifteen to fifty feet from the site of the explosion will receive the maximum effect. The effect of the suction wave is always less than the wave of compression. 275. PARTS INJURED. Injuries to the brain and central nervous system, lungs and heart, and the abdomen are most common injuries found. a. Head (Blast concussion). (1) Etiology - it is thought that the action of the waves of compression and suction upon the elastic abdomen causes fluids to be instantly displaced into the skull. This causes an increase in pressure and may cause shock to the centers located in the floor of the fourth ventricle. It is believed that death in these cases is due to res- piratory paralysis. (2) Symptoms - extreme restlessness, severe headache, dizziness, altered emotion- ality, nausea, confusion, and unconsciousness. (3) Pathology - punctate hemorrhages have been demonstrated in the meninges, spinal cord, and throughout the brain substance. Because there is no evidence of external injury these cases may go unrecognized and permanent damage may be done before proper treatment has been instituted. (4) Treatment: It is the same as for any cerebral concussion due to trauma. (a) Rest in bed. (b) Limit fluids. (c) Mild sedation may be necessary. (d) Morphine should not be given. b. Lungs. (1) Etiology - after the detonation of high explosives, the lungs are most frequently involved. Earlier investigation led to the erroneous belief that sudden death follow- ing blast injury was due to carbon monoxide poisoning. It is due to the effect of sudden pressure upon the gas containing organs. (2) Pathology - necropsy shows varying degrees of congestion and hemorrhage. The lesions are usually bilateral and have a tendency to be symmetrical. The alveolar walls are torn and alveoli and bronchioles are filled with blood. Occasionally, a bronchus may be torn or the lung tissue itself may be ruptured. The three possible explanations for the pathology as suggested by Fulton are; (a) Rapid lowering of alveolar pressure by the suction wave acting through the res- piratorv passages. (b) Rapid increase of alveolar pressure acting in the same manner. (c) The impact of the pressure wave against the chest wall. (3) Symptoms - respiratory distress, cyanosis, hemoptysis, unconsciousness and even complete cessation of the respiratory movements. Bloody frothy expectoration ac- companied by varying degrees of shock and absence of external injury is practically diagnostic. (4) Treatment. (a) Prophylaxis. Covering the chest with thick covering such as an overcoat or sponge rubber jacket offers definite protection. Taking cover in a shell hole or ditch, or falling face downward on the ground offers some protection. (b) Palliative - after injury has been sustained treatment consists of complete rest, oxygen, and therapy of shock. Anesthesia and surgery should be deferred. c. Abdomen. (1) Etiology - abdominal injuries are seen after land operations, but most of the cases reported are of men swimming within one hundred feet of an exploding bomb or mine. (2) Symptoms - acute sudden onset of severe abdominal pain, similar to that seen after acute intestinal perforation. This is usually followed by board-like rigidity and collapse. (3) Pathology - the most common lesion found at operation is subperitoneal hemorr- hages over the abdominal cavity. There are a few cases on record of ruptured in- testines, and of laceration of a solid viscus. (4) Treatment: In case of doubt an exploratory laparotomy is indicated provided the associated injuries to the brain and lung are not sufficient to interfere. General treatment consists of morphine, heat, rest, and nothing by mouth until a definite diagnosis has been made. (A silent abdomen is usually a surgical abdomen). 276. REFERENCES. a. Fulton, John F., “Blast and Concussion in the Present War , in War Medicine, New York, New York Philosophical Library, 1942. b. King, J.D., and Curtis, G.M., “Lung Injury Due to Detonation of High Explosives , in War Medicine, New York, New York Philosophical Library, 1942. c. Further Experimental Studies of Blast Injuries (Editorial), J.A.M.A., 121:1220, 1943. CHAPTER 11 REFERENCE LIBRARIES FOR THE FLIGHT SURGEON Paragraphs The permanent library 277 The field library 278 277. THE PERMANENT LIBRARY, The Flight Surgeon will have need to refer more often as time goes on, to the original and newer work in Aviation Medicine. The following lists of texts and manuals has been prepared with this in mind. It will be noted that general and specialized texts, monographs and journals have been omitted. a. Texts. (1) Anderson, H.C.: The Medical and Surgical Aspects of Aviation, New York, Oxford Medical Publications, 1919. (2) Air Service Medical (Parts I and n), War Department, Air Service Division of Military Aeronautics, Washington, U.S. Government Printing Office, 1919. (3) Aviation Medicine in the A.E.F., War Department, Director of Air Service, Wash- ington, U.S. Government Printing Office, 1920. (4) Cruchet, R, and Moulinier, R.: Air Sickness: Its Nature and Treatment (trans- lated by J.R. Earp), New York, William Word Co., 1920. (5) Bauer, L.H., Aviation Medicine, Baltimore, Williams and Williams Co,, 1926. (6) The National Geographic Society - U.S. Army Air Corps Stratosphere Flight of 1935 in the Balloon “Explorer II”, Stratosphere Series No. 2, Washington, National Geographic Press, 1936. (7) Ocker, W.C., and Crane, C.J.: Blind Flight in Theory and Practice, San Antonio, Naylor Printing Co., 1932. (8) Armstrong, H.G.: Principles and Practice of Aviation Medicine, Baltimore, Williams and Williams Co., 1939. (9) Ruff, S., and Strughold, H.: Grundriss der Luftfahrtmedizin, Leiozig, J.B, Barth, 1939. (10) von Diringshofen, H.: Medical Guide for Flying Personnel (translated by V.E. Henderson), University of Toronto Press, 1940. (11) Grow, M.C., and Armstrong, H.C.: Fit to Fly; a Medical Handbook for Fliers, New York, D. Appleton-Century Co., 1941. (12) Henderson, V.E.: Air Crew in Their Element, University of Toronto Press, 1942. (13) Van Liere, E.J.; Anoxia; Its Effect on the Body, Chicago, University of Chicago Press, 1942. (14) Hoff, E.C., and Fulton, J.F.: A Bibliography of Aviation Medicine, Springfield, Charles C. Thomas, 1942. (15) Gemmill, C.: Physiology of Aviation, Springfield, Charles C. Thomas, 1942. b. Manuals. (1) Flight Surgeon’s Handbook,2nd Ed.Randolph Field, School of Aviation Medicine, 1943. (2) Field Manual for Medical Officers, Warner Robins Army Air Depot, Ga., Medical Training Section, Air Service Command, 1942. (3) War Department TM 1-705, Physiological Aspects of Flying and Maintenance of Physical Fitness. Washington, U.S. Government Printing Office, 1941. (4) Physiology of Flight, Human Factors in the Operation of Military Aircraft, Wright Field, Aero Medical Research Laboratory, 1942. (5) Outline of Course of Instruction in High Altitude Physiology, Wright Field, Aero Medical Research Laboratory, 1941. (6) War Department, TM 8-300, Notes on Eye, Ear, Nose, and Throat in Aviation Medicine, Washington, U.S. Government Printing Office, 1940. (7) War Department, TM 8-305, Notes on Cardiology in Aviation Medicine, Washing- ton, U.S. Government Printing Office, 1940. (8) War Department TM 8-310, Notes on Physiology in Aviation Medicine, Washing- ton, U.S. Government Printing Office, 1940. (9) War Department TM 8-320, Notes on Psychology and Personality Studies in Aviation Medicine, Washington, U.S. Government Printing Office, 1941, (10) War Department TM 8-325, Outline of Neuropsychiatry in Aviation Medicine, Washington, U.S. Government Printing Office, 1940. c. Journals. (1) Journal of Aviation Medicine, The Aero Medical Association, Louis H. Bauer, Editor, Hempstead, N.Y. (2) Journal of the Aeronautical Sciences, Institute of the Aeronautical Sciences, N.Y., N.Y. 278. THE FIELD LIBRARY, a. In preparing a field library for a Flight Surgeon one of the important considerations is the weight of the material, for in large part travel in the combat zone will be by air in aircraft already loaded with the accoutrements of war. The following manuals weigh less than 5 lbs. and are considered to be the most useful in the field. (1) The Flight Surgeon’s Handbook, 2nd Ed., Randolph Field, School of Aviation Medicine, 1943. (2) WD, FM 8-40, Field Sanitation. (3) WD, FM 8-45, Record of Morbidity and Mortality (Sick and Wounded). (4) WD, TM 8-210, Guides to Therapy for Medical Officers. (5) WD, FM 8-50, Splints, Appliances, and Bandages. (6) TM 12-250, Administration. (7) FM 8-35, Transportation of the Sick and Wounded. (8) AR 40-100, AR 40-105, AR 40-110 , MR 1-9 (9) Physiology of Flight, Wright Field, Aero Medical Research Laboratory, 1942. b. If space permits a text on surgical anatomy, on general surgery, and on therapeutics will be found to be of inestimable value. CHAPTER 12 APPENDIX Paragraphs Some aspects of medical care, evacuation, and supply with AAF field units 279 Tables of organization 280 Tables of basic allowances 281 Air Base group aid station equipment 282 Squadron aid station equipment 283 Contents of miscellaneous kits and cases 284 Formulae of pharmaceuticals 285 Training channels: aviation cadets 286 Training channels: officers training in grade 287 279. SOME ASPECTS OF MEDICAL CARE, EVACUATION, AND SUPPLY WITH ARMY AIR FORCES FIELD UNITS, a. Medical Dispensary Detachment, Aviation: The function of this unit is to provide beds’?or one combat group at air fields where hospital facilities are not available. The personnel consists of two medical officers, one dental officer, and seventeen enlisted men, including non-commissioned officers, and technicians. The unit is able to operate an infirmary of twelve hospital beds. It is highly mobile and can be trans- ported by air wherever needed. It may serve an isolated air field or may be placed near a centrally located field and thus serve a group of several tactical units. Patients will be received from the combat and ground crews of the group served by the unit and in emergen- cies from aid, collecting and clearing stations in the vicinity. Patients requiring evacuation from the dispensary will be evacuated by ground ambulances to Ground Force or Army Ser- vice Forces installations or by air to general or station hospitals in the zone of com- munications. b. The Air Evacuation Squadron, Light: This unit is planned for air evacuation operations irTthe forward combat zones. The personnel consists of eight commissioned officers inclu- ding 1 MAC officer, one service pilot (engineering officer), twenty flight officers and one hundred forty seven enlisted men, including air force technicians, medical department tech- nicians, cooks and clerks. The unit is equipped with twenty liaison type planes capable of carrying a pilot and one to four litter patients. The motorized equipment consists of two 3/4- ton ambulances; one 1-ton trailer, water tank (250 gal.); two 1-ton trailers, cargo; three 2 1/2 ton trucks; one 1/4-ton truck, and one 3/4-ton truck. This unit could evacuate clearing stations and collecting stations. It is particular adapted to evacuate isolated medical instal- lations which are inaccessible to large airplanes and to evacuate casualties from armored units. c. Medical Squadron, Air Evacuation, Transport: This unit is organized for the purpose of providing personnel and equipment for operation with the Army Air Forces in the process of evacuation of sick and wounded aboard large transport planes. The unit is composed of headquarters and four evacuation flights. Each evacuation flight contains six air transport teams. Each air transport team is composed of one nurse and one staff sergeant (surgical technician). Each evacuation flight is composed of one medical officer (flight surgeon), six nurses, and eight enlisted men. The evacuation flight contains, in addition to the six air transport teams , a classification section consisting of one medical officer and two corporals. The squadron is equipped with nine 1/4-ton trucks, one 1-ton trailer, one 1-ton water tank trailer (250 gal.), and seven 1/4-ton trailers. The squadron headquarters is composed of headquarters section and a supply section. The headquarters section may be divided into three units: (1) administrative, (2) mess, and (3) transportation. One air transport team provides medical service during flight aboard one transport plane caring for from 18 to 60 patients. This permits the air evacuation flight to provide medical service aboard six transport planes. The whole squadron, can, therefore, provide service aboard 24 transport planes which will usually be provided by two Carrier Squadrons of 13 planes each. The two additional planes will be used for housekeeping and supplies. (Table XXVI) When not employed in the process of air evacuation, personnel of the evacuation flights may be employed on temporary duty at medical installations of the Air Forces, Ground Forces, or Army Service Forces. They will be available at any time for their primary duty SQUADRON HEADQUARTERS EVACUATION FL*S. TOTAL HQ. SECTION TOTAL \ SQUADRON HQ 1 TOTAL 4 | EVACUATION FLIGHTS 1 . (') CLERK (') . (A-) J (3) lH- _X22 MOTOR TRANSPORTATION NCC (■I M ID SUPPLY CORPORAL c; MIL Ml PRIVATES i e CLERK ADMINISTRATIVE (') JJ1 (3) Jill. COOKS HELPER J 4 ) . (4) (A) ORDERLY T?T (2) TRUCK DRIVER f 6 (9) J 9) . TOTAL ENLISTED 2 61 AGGREGATE 7 10 5 10 32 3 12 eo 92 M a) FLIGHT SURGEON (B) CHIEF NURSE (C) ALSO SPECIAL SERVICES REPRESENTATIVE (D) MEDICAL ADMINISTRATIVE "CORPS HI!. IS! ii S! * g !M II fi i !ii fs f; f iel I III 11 is 18 ii SjM8|li iii I MEDICAL SQUADRON, AIR EVACUATION , TRANSPORT TEAM TABLE XXVI. EVfC™??o FL' tsKg." 6. ENL.MEN TEAM UNIT 5 ENL MEN EVACUATION FLIGHT SUPPLY SECTION I OFFICER 9 ENL MEN TRANSPORT TEAM MED. SQ.. AIR EVAC. , TRANS. 6 OFFICERS 25 NURSES 61 ENL MEN SQUADRON HQ. MESS UNIT 10 ENL MEN AIR TRANSPORT TEAM HQ. SECTION I OFFICER I NURSE 20. ENL MEN EVACUATION FLIGHT UNIT 5 ENL. MEN TRANSPORT TEAM T E AM '•S$^ EVACUATION FLIGHT i SECTION | 1. OFFICER 2 ENL MEN of air evacuation. d. Echelons of air evacuation: Two echelons of evacuation are contemplated in the theater of-operations: (1) From division clearing stations and other installations by light ambu- lance (Air Evacuation Squadron, Light) to evacuation field or convalescent hospitals, (2) From these points by large transport airplanes (Medical Squadron, Air Evacuation, Trans- port) to general hospitals in the communications zone. The decision for the utilization of the Medical Squadron, Air Evacuation, Transport within a theater, base or defense command will be that of the Air Force commander. The Medical Squadron, Air Evacuation, Transport will also function in the evacuation of patients from the zone of communications to the zone of the interior. Air evacuation from the theater, base or defense command to the zone of the interior and air evacuation within the zone of the interior is the responsibility of the Air Transport Command. e. The Medical Supply Platoon, Aviation: This unit is composed of two officers, and nine- teen enlisted men. Its function is to procure, store, and issue medical supplies to the unit medical sections of the Air Force. The assignment and location of this unit is flexible, de- pending upon the situation. It may be attached to an Air Service Group, augmenting the me- dical supply section of this group. In this location it will serve two tactical units. The me- dical supply platoon, aviation may be split in half and used to establish sub-depots, if re- quired. Normally two Air Service Groups are supplied by an Air Depot Group. When the Medical Supply Platon, Aviation is attached to the Air Depot Group it will furnish supplies to airdromes directly or through the Air Service Groups. Normally the medical supply platoon, aviation will maintain a level of supplies for ten days which will be replenished from Army, communications zone or base supply depots. The number of Supply Platoons will vary with the dispersion of the Air Force. The requirement will vary from one Medical Supply Platoon per two Air Depot Groups to one Medical Supply Platoon per Air Service Group (Figure 38). MEDICAL SUPPLY CHAIN (AAF TACTICAL UNITS) SUPPLY DEPOT OF : ARMY COMMUNICATIONS ZONE THEATRE BASE air depot GROUP MEDICAL SUP PLY PLATOON AVIATION —m r— AIR BASE GROUP AID STATION AIR SERVICE GROUP MEDICAL SUPPLY SECTION AIR BASE GROUP AID STATION AIR SERVICE GROU P M EDICAL SU PPLY SECTION COMBAT GROUP GROU P SURGEON COMBAT GROU P GROUP SURGEON COM BAT SQUADRON' SQUADRON AID STATION COMBAT SQUADRON- SQUADRON AID STATION COMBAT SQUADRON SQUADRON A I D STATION COMBAT SQUADRON SQUADRON A I D STATION ROUTING OF REQUISITIONS ROUTING OF SUPPLY REPLENISHMENTS FIGURE 38. 280. TABLES OF ORGANIZATION. a. Typical Squadron Medical Detachment. The Medical Detachment of a typical combat squadron consists of one medical officer and eight enlisted men. The Medical Officer, who is the squadron surgeon, is either'a Flight Surgeon or Avia- tion Medical Examiner, and is normally assigned to the Air Echelon of the Squadron. The eight enlisted men comprise: 1 Sergeant - Section Leader 2 Technicians, Grade V - 1 Medical Technician 1 Surgical Technician 5 Privates, First Class or Privates - 2 Ambulance Drivers 1 General Clerk 1 Medical Technician 1 Surgical Technician b. Tabulation of Medical Personnel in Units of the Army Air Forces. (See Table XXVII). 281. TABLES OF BASIC ALLOWANCES. The following tables are extracted from T/BA No. 1, dated July 1, 1942, as corrected by Change 1, dated September 25, 1942 and Change 2, dated January 8, 1943. Only items of interest to Medical personnel are included. SECTION II ARMY AIR FORCES EQUIPMENT Item For mobil- ization Remarks and Basis of Issue Equipment: Emergency field ambulance set (T.O. 00-30-3) Kit: ea 1 Per Fid Amb Clothing and equipment, Flier (T.O. 00-30-41) ea 1 Per Flier Crash tools and equipment (T.O. 00-30-44) ea 1 Per Ap Sq; Adrm Sq; Serv Gp Hq Sq; Dep Gp Hq Sq Emergency Parachute (Alas- kan Parachute Back Pad) ea 1 Per Fir in Alaska or other cold climates Flier, emergency (T.O. 00-30-49) ea 1 Per Fir in nontropical T of Opns Jungle, emergency (T.O. 00-30-51 ea 1 Per Fir in tropical T of Opns Parachute, complete service type ea 1 Per passenger seat in T Ap F*r' 2 ■° ■ -: »w. nctn*n ofioup, 5INGL& 0& wm - £ =B “ x x w £ t sg F10HTM SwUxCrtON, SINGLE ENGINE : 4 g - 55 ~ X X £ ;§■ FIGHHK SQUaDBON,, T*IN jiNGDOi - ft 1 B s £ p M £ :S Bj. AND B,. BOMB. SING, HEAVY OS MEDIUM s i - B R T Hu,. BOMB. GUL'Jf HEAVY, MEDIUM,’ LIGHT OB DIVE I s £S " X X £ ► sS BOMBARDMENT SQUADRON, ,nn 1 ; (B) 1 1 1 5 =s” n £ a hS BCAtBABDMENT SQUADRON, MEDIUM I I Sli I £ £ 5S " X X B E £ts BOMBARDMENT , LIGHT t 5 ||| £ a E5 ~ I I gCMfiABDNCbMT SQUADRON, DIVE I g r=“ 3 f1 8“ ft - —pr p" P ! IK., OBSSKV.TlOil GROUP t I I « 55 “ x x P P OBSERVATION SQUADRON t F|E f* H “£ £ " b b ' w 5 2 Ip AIR OBSERVATION SQ., SPECIAL v n i 3 b £ 5 1 § S ¥S Bi. AID m- SQUADBC*, TROOP CARRIER CO»«A!T I j B |§£ E BS “I I i I r* 3Pj IS HQ. AMD Bl. SQUADRON, TROOP CARRIER WING b } £ I “ D r* HEADQUARTERS, TROOP CARRIER GROUP L | h T 3 £ { P ? 1 | s § s s lp||ll||| f ** issesses r??e2P2P^|l???? ls£)f?IFIif£ ses'a Wnm ttl}P sE 3F.gpg s 'B.rs m ;BR Ef •o m 3 3 6 IF ? , 1 | s s’11! ears Eg a s ?“ t- ? r~rs 8 -nprsrs | §S?,p“|“ s S - a lip ser.E, I ll|if i “ 1 1 11 ” el e . - t'scp es _„Scs tS B| 1Y g 5 §{s 2 — S | || t 8 5 B O Z z i £ f: I I I P | i 1 i s BS 9 V V r PI ■ -c TROOP CARRIER SQUADRON b E S B “ j gg 52 B5B “ B ’ i _ 5S HQ. AND HQ. SQUADRON, SERVICE GROUP r G b | ® £ S *~ £ £ 1 sb SERVICE SQUADRON r E t ” 2 I Pm P P M B M M 5§ AIRDROME SwUADRON, (S P a C 1 A L) T I \ | O £ 5 5 WBH J- EH O H AIK TRANS1PORT WIHG X I 1 -q 3 ££ 5 E 1 5 ep AIR TRANSPORT GROUP b X g i C £ - SE - XX- Vrf M sfe AIR TRANSPORT SQUADRO* b t £ £ 1C B " K» IT PIS HQ.,PHOTO GROUP, i O “ £ £ M P M H E Is PHOTOGRAPHIC GQUAUfcH. ItSCOSHAISSAIlCS i r - X A £ £ PHOTOGRAPHIC SQUADRON- MAPPIHC b £ - bb SS 5 I M E *” r is HQ. AND HQ. SQUADRON, AIR OBOT GROUP I s 1 » :£ 5 * X vs £ M *■* sg BKPOT REPAIR SQUADRON L n E w 5 R S 5 H 55 DEPOT SUPPLY SQUADRON 1 5 5 ESE *> ..1 ES *■ B SL __ E S ns MEDICAL SUPPLY PLATOON. AVIATION r I TABLE 27. MEDICAL DETACHMENTS IN ARMY AIR FORCES 271 SECTION m CHEMICAL WARFARE EQUIPMENT Item For mobil- ization Remarks and Basis of Issue Impregnate, shoe Oz 8 Per ind when directed by higher auth ♦Mask, gas, service ea 1 Per ind ♦Ointment, protective tube 1 Per ind when directed by higher auth Respirator, dust Ml ea 1 Per ind when atzd by high auth ♦Sack, gas, resistant Ml ea 1 Per ind when atzd by CO ♦Expendable SECTION V MEDICAL EQUIPMENT Part 1. - Individual equipment Item For mobil- ization Remarks and Basis of Issue Brassard, Geneva Convention ea 1 Per chaplain; ind (Med and Dent Serv) asgd to T of Opns Brassard, Green Cross ea 1 Per ind (Vet asgd to T of Opns) Kit: Dental officer’s ea 1 Per Dent 0 Dental private’s ea 1 Per Tech, Pvt lei or Pvt, MD on Dent duties Medical officer’s ea 1 Per Med 0 Medical noncommissioned officer’s ea 1 Per NCO, MD on Med Serv Medical private’s ea 1 Per Tech, Pvt lei or Pvt, MD on Med Serv Packet, first aid, parachute ea 1 Per parachute Part 2. - Organizational equipment Item For mobil- ization Remarks and Basis of Issue Air Base Group Aid Equipment ea 1 Per Dep Gp Hq Sq; Serv Gp Hq Sq Blanket, OD ea 8 Per Field Amb Case, meat and dairy inspection ea 1 Per Vet Off (Asgd to T of Opns) Chest, MD No. 60, Dental ea 1 Per Med Det with Gp Hq (except A Dep Gp and Serv Gp) Kit: First-aid, arctic ea 1 Per Bomb Ap (H), Bomb Ap (M) or T Ap when flying over Arc- tic Regions First-aid, aeronautic ea 1 2 3 4 5 Per single place Ap Per two place Ap Per Bomb Ap (L), T Ap, small Per Bomb Ap (M), Bomb Ap (H) Per T Ap (Large), Bomb Ap (H) (Larger than B-17 and B-24 type) First-aid, motor vehicle, 12 unit ea 1 Per four (4) fuel consuming motor vehicles or fraction thereof First-aid, jungle ea 1 Per Bomb Ap (H), Bomb Ap (M), or T Ap when flying over tropical regions Litter ea (a) 10 18 33 a. Per type Ap as directed by higher auth Per 10 litter capacity Amb Ap Per 18 litter capacity Amb Ap Per 33 litter capacity Amb Ap Litter, steel pole (99376) ea 4 Per field Amb Strap, securing ea (a) 10 18 33 a. Per type Ap as directed by higher auth Per 10 litter capacity Amb Ap Per 18 litter capacity Amb Ap Per S3 litter capacity Amb Ap Machine, imprinting (for use with individual identification ea 1 Per Med Det AF Repl Dep (Overseas) tag) Squadron Aid Station ea 1 Per Med Det w/Sq (except Serv Gp Hq Sq; Dep Gp Hq Sq) SECTION VI ORDNANCE EQUIPMENT Item For mobil- ization Remarks and Basis of Issue Pistol, automatic, cal. 45, M1911A1 ea 1 Per 0, WO SECTION vn QUARTERMASTER EQUIPMENT Part 1. - Organization Equipment - Other Than Clothing Item —For mobil- ization Remarks and Basis of Issue Ax, single bit, 4-pound ea 1 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Bag, canvas, water steri- lizing ea 1 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Container, round, insulated, M1941 ea 1 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Container, water, 5-gallon capacity ea 5 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Cot, canvas, folding ea (a) 1 (a) Per Ind as directed by higher auth Drum, gasoline, 5-gallon capacity ea 2 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Glasses, sun, with case pr 1 Per Ind stationed in Arctic, sub-arctic or desert regions (not issued AF glasses, sun, flying) Headnet, mosquito ea 1 Per Ind when atzd by higher auth; Fliers jungle emerg kit Lantern, gasoline ea 3 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Paulin, canvas, 12 by 17 feet, khaki ea 3 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Pickmattock, intrenching ea 1 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Range, field, M1937, 1 unit cabinet ea 1 Per Med Sec Dep Gp Hq Sq;, Med Sec Serv Gp Hq Sq Screen, latrine, complete with pins and poles ea 2 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Shovel, D-handled, round point No, 2 ea 1 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Sledge, blacksmiths’ double- faced, 8-pound ea 1 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Stove, tent, M1924 ea 3 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Tent, hospital ward, complete ea with pins and poles 1 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Tent, wall, large, complete ea with fly, pins, and poles 1 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Tent, wall, small, complete ea with fly, pins, and poles 3 Per Med Sec Dep Gp Hq Sq; Med Sec Serv Gp Hq Sq Part 2. - Motor Transport Equipment Item For mobil- ization Remarks and Basis of Issue Ambulance, 3/4 ton, 4x4 ea 1 Per AAF Hq Sq; AF Hq Sq; Comd Hq Sq; Wing Hq Sq; Serv Gp Hq Sq; Dep Gp Hq Sq; Dep Rep Sq; Dep Sup Sq; Serv Sq; Fi Con- trol Sq; Avn Sq; Tow Target Sq ea 2 Per Bomb Sq; Fi Sq; Obsv Sq; Transport Sq; Adrm Sq; Photo Sq; Map Sq; Ferrying Sq SECTION vm SIGNAL EQUIPMENT Item. For mobil- ization Remarks and Basis of Issue Flashlight, TL-122-A ea 1 Per 0; WO Headset, HS-38 ea 1 Per Fir Headset, HS-33 ea 1 Per Fir SECTION X OFFICER’S AND WARRANT OFFICER’S CLOTHING AND EQUIPMENT The itemslistedin this section are for the most part a repetition of items given in other sections of the table; such items are repeated here for convenience and are not to be duplicated. Items under “Purchase” column may be purchased commercially. Part 1. - Army Air Forces Equipment 1 ~T RE” 5 Purchase Item Issue Required Optional Remarks and Basis of Issue Bag, clothing ea 1 Per 0 Fir Equipment, field, shelter ea 1 — Per 0 as directed by higher auth Kit, clothing and equipment officer and enlisted pilot ea 1 Per 0 Fir Part 2. - Chemical equipment 1 IT r_? 5 Purchase Item T3 cu Jh 73 a Remarks and Basis of Issue CD 1 o o* 4-J CO 'rH 0) PS 8* Mask, gas, service ea 1 — Issued only for Fid Serv or as ordered by WD ~~T~ ■nr- 5 Item Issue purchase Remarks and Basis of Issue Required Optional Packet, first-aid 1 —- --- Per 0 Per WO Part 3. - Medical equipment Part 4. - Ordnance equipment I 3 3 Insignia, cap, WO’s ea 1 .... Per WO when cap is auth Insignia, collar, 0Js pr 2 — Per 0 (state arm, service) Insignia, collar, O’s “U.S” pr 2 — Per 0, WO Insignia, collar, WO’s pr 2 — Per WO Insignia, grade ea 2 — Per 0, according to grade Insignia, shoulder, sleeve ea 1 — Per 0, WO (AR 600-40 and later directives) Jacket, field ea — 1 Per 0, WO Kit, sewing ea — 1 Do Laces, shoe, extra pr 1 1 Do Add per 0, WO Leggings, canvas, dismounted pr 1 — Per 0, WO (only when auth by CO) Locker, trunk ea — 1 Per 0, WO Mattress ea — 1 Do Mirror, trench ea — 1 Do Necktie, cotton, mohair. olive drab ea 1 T Do Add per 0, WO Overcoat, olive drab, O’s ea 1 Per 0, WO or Overcoat, short, 0*s ea — i Do Pajamas pr — 2 Do Pen, fountain ea — 1 Do Pillow, feather and cotton ea — 1 Do Pillowcase ea — 2 Do Raincoat ea 1 — Do Razor ea 1 — Do Shirt, cotton, khaki ea 1 2 Do Add per 0, WO Shirt, wool, olive drab ea 2 1 Per 0, WO Add per 0, WO Shoes, Army, russet pr 1 1 Per 0, WO Add per 0, WO Slippers or gymnasium pr — 1 Per 0, WO shoes Soap, hand ea 1 — Do Soap, shaving ea 1 — Do Socks, cotton pr 6 — Per 0, WO ( at least one pair to be plain tan or brown) Socks, wool pr — 6 Per 0, WO Towel, face ea 2 2 Do Add per 0, WO Trousers, cotton pr 2 — Per 0, WO Trousers, wool pr 2 — Do Undershirts, cotton ea 3 — Do Undershirts, wool ea 3 — Do Watch, 7 jewel or better ea 1 Do I lH 5 Item Issue Purchase Remarks and Basis of Issue Required Optional Cartridge, ball, pistol, cal. ea 21 ... ... Per pistol .45 (round) Holster ea 1 — — Do Magazine, extra ea 2 — — Do Pistol, automatic, cal, 45 ea 1 — ... Per 0 1 Per WO Part 5. - Quartermaster clothing and equipment The clothing and equipment shown in this section are not issued, these articles are obtained by purchase. Articles issued are provided for under proper sections of appropriate Tables of Basic Allowances. Authorization: AR 600-35, AR 600-40, AR 600-38, AR 600-95. 1 3“ ? Item Re- quired Op- tional Remarks and Basis of Issue Belt, cloth ea 1 Per 0, WO Belt, web, waist ea 1 — Do Book, memorandum, ea 1 — Do pocket, with pencil Brush, clothes ea — 1 Do Brush, hair ea — 1 Do Brush, shaving ea — 1 Do Brush, shoe ea — 1 Do Brush, tooth ea 1 — Do Bucket, canvas, folding ea — 1 Do Cap, garrison, O’s ea 1 Do Cap, service, O’s ea — 1 Do Coat, wool, service ea 1 -—- Do Comb ea 1 1 Added per 0, W0 Per 0, WO Drawers, cotton pr 3 — Do Drawers, wool pr 3 — Do Gloves, dress, chamois pr 1 Do leather or chamois - colored material Gloves, dress, white pr — 1 Per 0, WO (for formal occa- Gloves, wool, Olive drab pr 1 sions) Per 0, WO (for Field Serv as Handkerchief, cotton. ea 6 directed by CO) Per 0, WO white Insignia, cap, O’s ea 1 — Per 0 when cap is auth Part 6. - Signal Equipment I 5 Purchase Item Issue T3 (D £ 2 cr CD K Optional Remarks and Basis of Issue Knife, pocket ea Message, book, M-105-A ea 1 — 1 Per 0, WO Do Current T/BA No. 21, Quartermaster Clothing and Individual Equipment, will be used as a basis of requisitioning clothing and individual equipment. Abbreviations: Adrm - Airdrome Amb - Ambulance Ap - Airplane Asgd - Assigned Atzd - Authorized Bomb - Bombardment Comd - Command Dep - Depot Det - Detachment Fi - Fighter Fid - Field Fir - Flier Gp - Group H - Heavy Hq - Headquarters L - Light M - Medium O - Officer Obsn - Observation Serv - Service Sq - Squadron T Ap - Transport Airplane T of Opns - Theater of Operations Tech - Technician WO - Warrant Officer 282. AIR BASE GROUP AID STATION EQUIPMENT (97195). The items of equipment enumerated below are components of the Air Base Group Aid Station Equipment, issued to Medical Detachments of Headquarters Squadrons of both Air Depot Groups and Air Service Groups: Refer to Paragraph Item No. Item Quantity a. 77510 Chest, Tool, Small . . 1 b. 95025 Chest, MD, No. 60, Dental " (1) 97905 Tray Set, Type 5 (2) 95093 Syringe, Hypodermic, Cartridge Type c. 97450 Box of Bedpans d. 97465 Blanket Set, Small e. 97565 Chest, MD, No. 1 . . 1 ~ (1) 97540 Chest, Field, Modified f. 97570 Chest MD, No. 2 . . 1 ~ (1) 93085 Case, Operating, Small, Improved (2) 97890 Tray Set, Type 1 g. 97575 Chest, MD, No. 4 . . 1 ~ (1) 97895 Tray Set, Type 3 h. 97757 Gas Casualty Set, Complete . . 1 (1) 97758 Gas Casualty Case, Aprons and Gloves (2) 97759 Gas Casualty Chest i. 97775 Lantern Set . . 1 J. 97793 Pajama Set, Coat, Winter . . 1 k. 97794 Pajama Set, Trouser, Coat . . 1 X 97795 Physical Examination Set, Flight Surgeons i. . 1 “ (1) 30770 Case, Diagnostic, Eye, Ear, Nose, and (2) 38800 Throat Vision Test Set (3) 93098 Case, Trial Lens, Pocket Set. . , m. 97812 Pillow Case Set . . 1 n. 97814 Sheet Set . . 1 0. 97815 Splint Set . . 2 P- 97825 Surgical Dressings. . . . 1 q. 97847 Towel Set, Bath . . 1 r. 97848 Towel Set, Hand . . 1 s. Items not included in Chests, Cases, etc. The detailed contents of each of the items is as follows: a. 77510 Chest, Tool, Small 77511 Chest, Tool, Small, Empty each 1 76570 Stencil Set set 1 76590 Tag, Shipping, Linen bndl 5 77182 Bit, Auger, 5/16-inch each 1 77183 Bit, Auger, 1/2-inch each 1 77184 Bit, Auger, 3/4-inch each 1 77185 Bit, Auger, 1-incty each 1 77190 Bit, Screwdriver, 3/8-inch each 1 77245 Box Opener each 1 77290 Brace each 1 77485 Chalk Line with Reel and Awl, Complete each 1 77520 Chisel, Cold, 1/2-inch each 1 77526 Chisel, Socket Firmer 1/2-inch each 1 77540 Chisel, Socket Firmer, 1-1/2 inch each 1 77990 File, 5-inch each 1 77993 File, Mill Bastard each 1 78170 Hammer each 1 78180 Hatchet each 1 78192 Hone, Oil, 8 by 2 inches, Carborundum each 1 78810 Plane, Smoothing each 1 78820 Pliers, Combination each 1 78850 Rule each 1 78860 Saw, Crosscut, 20-inch each 1 78880 Saw, Rip each 1 78922 Screws, Assorted box 1 78930 Screw Driver, 3-inch each 1 79050 Spokeshave each 1 79267 Tacks and Brads, Assorted tin 1 79300 Tape Measure, 50 feet each 1 79420 Try Square each 1 b. 95025 Chest, MD, No. 60, Dental. 97535 Chest, Field, Plain, Equipped with each 1 97906 Tray Set, Type 5 (See Par. 282b(l)) each 1 10510 Alcohol, Denatured . . quart 1 11570 Creosote, USP ounce i 11840 Eugenol, USP ounce 1 12830 Mercury, USP , . . . 1/4 lb 1 13205 Oil, Theobroma, Modified tube 1 13835 Procaine Hydrochloride, Cartridge, 2%, 2.4 cc boxes 2 13850 Pumice, Fine, Powder pound 1 14070 Silver Nitrate and Formaldehyde, USP box 1 20130 Cotton, Absorbent, Compressed ounce 2 50020 Alloy, 1 oz bottle 2 50180 Blower, Chip each 1 50350 Bur, No. 2, Angle Handpiece pkg 1 50360 Bur, No. 4, Angle Handpiece pkg 1 50370 Bur, No. 6, Angle Handpiece pkg 1 50390 Bur, No. 9, Angle Handpiece pkg 1 50430 Bur, No, 35, Angle Handpiece pkg 1 50440 Bur, No. 37, Angle Handpiece pkg 1 50450 Bur, No. 39, Angle Handpiece pkg 1 50520 Bur, No. 557, Angle Handpiece pkg 1 50550 Bur, No. 560, Angle Handpiece pkg 1 50610 Bur, No. 1/2, Straight Handpiece pkg 1 50630 Bur, No. 2, Straight Handpiece pkg 1 50640 Bur, No. 4, Straight Handpiece pkg 1 50650 Bur, No. 6, Straight Handpiece pkg 1 50710 Bur, No. 35, Straight Handpiece pkg 1 50720 Bur, No. 37, Straight Handpiece pkg 1 50820 Bur, No. 557, Straight Handpiece pkg 1 50830 Bur, No. 558, Straight Handpiece pkg 1 51035 Burnisher, Stellite, “H” each 1 51045 Burnisher, Stellite, . each 1 51055 Burnisher, Stellite, “5-7 ’ each 1 51070 Burnisher, Stellite, “l-2” each 1 51220 Cement, Permanent, Pearl Gray box 1 51240 Cement, Silicate, Case each 1 51250 Cement, Silicate, Liquid, Caulk bottles 2 51265 Cement, Silicate, Shade 20 bottle 1 51275 Cement, Silicate,, Shade 21 bottle 1 51285 Cement, Silicate, Shade 22 bottle 1 51295 Cement, Silicate, Shade 23 bottle 1 51305 Cement, Silicate, Shade 24 bottle 1 51315 Cement, Silicate, Shade 25 bottle 1 51325 Cement, Silicate, Shade 26 bottle 1 51335 Cement, Silicate, Shade 27 bottle 1 51345 Cement, Silicate, Shade 28 bottle 1 51355 Cement, Silicate, Shade 29 bottle 1 51385 Cement, Silicate, Measuring Device each 1 51390 Cement, Silicate, Shade Guide, Caulk each 1 51410 Cement, Silicate, Varnish, 1 oz bottle 1 51422 Cement, Temporary, Anodyne pkg 1 51550 Chisel, No. 5 each 1 51580 Chisel, No. 48 each 1 51585 Chisel, Wedelstaedt, No. 41 each 1 51587 Chisel, Wedelstaedt, No. 42 each 1 51660 Cleaners, No. 0 pkg 1 51680 Cleaners, No. 2 pkg 1 52300 Disk, Paper box 1 52500 Elevator, Winter, No. 122 each 1 52510 Elevator, Winter, No. 123 each 1 52520 Elevator, Winter, No. 135 each 1 52560 Engine, Oil, 1 oz bottle 1 52570 Engine, Foot each 1 52610 Engine, Handpiece, Angle (Doriot) each 1 52630 Engine, Handpiece, Straight (Doriot) each 1 52650 Excavator, No. 8 each 1 52660 Excavator, No. 17 each 1 52670 Excavator, No. 23 each 1 52680 Excavator, No. 34 each 1 52695 Excavator, No. 49 each 1 52697 Excavator, No. 50 each 1 52720 Excavator, No. 63 each 1 52730 Excavator, No. 64 each 1 52772 Excavator, No. 77 each 1 52773 Excavator, No. 78 each 1 52780 Excavator, No. 81 each 1 52790 Explorer, No. 5 each 1 52800 Explorer, No. 6 each 1 52810 Explorer, No. 23 each 1 53110 Floss, 100 Yards spool 1 53190 Forceps, No. 18R each 1 53200 Forceps, No. 18L each 1 53220 Forceps, No. 65 each 1 53240 Forceps, No. 150A each 1 53250 Forceps, No. 151A each 1 53260 Forceps, No. 210 each 1 53262 Forceps, No. 215 each 1 53490 Gutta-Percha, Temporary, 1 oz box 1 53580 Holder, Cotton each 1 53590 Holder, Mercury each 1 53600 Holder, Napkin each 1 53610 Holder, Nerve Broach each 1 53800 Lamp, Alcohol, SSW-1 each 1 53810 Lamp, Alcohol, SSW-1, Wick each 2 53910 Lancet, VoHand, No. 2 each 1 54010 MaHet, Plugging each 1 54030 Mandrel, No. 303, for Angle Handpiece each 6 54050 Mandrel, No. 303, for Straight Handpiece each 6 54070 Mandrel, Morgan-Maxfield, for Angle Handpiece each 2 54080 Mandrel, Morgan-Maxfield, for Straight Hand- piece each 2 54120 Mechanical Dam each 1 54170 Mirror, Mouth each 1 54180 Mirror, Mouth, Plane Glass each 2 54205 Mortar and Pestle, 3 cm each 1 54260 Pliers, No. 2, Dressing each 1 54275 Pliers, No. 104 each 1 54360 Plugger, Black, No. 1 each 1 54370 Plugger, Black, No. 3 each 1 54400 Plugger, Ladmore, No. 3 each 1 54500 Plugger, Woodson, No. 1 each 1 54510 Plugger, Woodson, No. 2 each 1 54520 Plugger, Woodson, No. 3 each 1 54740 Point, No. 183, Straight Handpiece each 6 54741 Point, No. 184, Straight Handpiece each 6 54800 Point, No. 226, Straight Handpiece each 6 54830 Point, No. 241, Straight Handpiece each 6 55000 Polisher, Rubber Cup boxes 3 55020 Pot, White each 2 55040 Probe each 1 55190 Retainer, Matrix, No. 1 each 1 55200 Retainer, Matrix, Bicuspid Band, Medium pkg 1 55220 Retainer, Matrix, Molar Band, Medium pkg 1 55400 Saw, Ribbon each 3 55440 Scaler, No. 33 each 1 55450 Scaler, No. 34 each 1 55495 Scaler, Pyorrhea, Towner, No. 01-5 each 1 55497 Scaler, Pyorrhea, Towner, No. 02-6 each 1 55499 Scaler, Pyorrhea, Towner, No. 04-8 each 1 55593 Shears, Crown, Universal. each 1 55620 Slab, Caulk-6 each 1 55680 Spatula, Cement each 1 55700 Spatula, SteHite each 1 55760 Stick bundle 1 55780 Strip, CeHuloid box 1 55800 Strip, Polishing, Coarse box 1 55810 Strip, Polishing, Fine box 1 55820 Strip, Polishing, Medium box 1 55970 Syringe, Water each 1 56830 Wheel, No. 301 each 1 56840 Wheel, No. 302 each 1 56850 Wheel, No. 304 each 1 56860 Wheel, No. 305 each 1 56960 Wire, Brass, Ligature box 1 71780 Towel, Hand each 24 74560 Brush, Hand each 1 74930 Soap, White, Floating bar 1 75150 Book, Blank, 8 Vo each 1 75400 Envelope, No. 189 . pkg 1 76100 Paper, Typewriter, Bond, 8 by 10 1/2 inches . . sheets 50 76240 Pencil each 1 79320 Thermometer, Clinical each 1 93770 Sutures, Silk, Braided, Non-Capillary, 3 sizes . pkg 1 95021 Chair, Dental, Field each 1 95093 Syringe, Hypodermic, Cartridge Type, complete (see par. 282b(2)) set 1 97675 Container, Metal, No. 1 '(for 99610). each 2 99070 Basin, Canvas each 1 99215 Cup, Enamelware each 2 99285 Hone, Oil, 3 1/2 inch each 1 99515 Sterilizer, Hypodermic Needle each 1 99540 Sterilizer, Instrument, 9-3/4 inch each 1 99610 Vial, Glass-Stoppered each 6 Form 57 Report of Dental Service each 25 Form 79 Register of Dental Patients (card! each 250 (1) 97905 Tray Set, Type 5. 97840 Table Top each 1 97875 Tray, No. 8 each 1 97880 Tray, No. 9 each 1 97920 Tray, tool each 1 (2) 95093 Syringe, Hypodermic, Cartridge Type, Complete, 55930 Syringe, Hypodermic, Cartridge Type, Complete each 1 55938 Needle, 25 gage, 1-Inch Canula each 10 55940 Needle, 23 gage, 1-7/8 inch Canula each 10 c. 97450 Box of Bedpans. 77170 Bedpans each 9 78837 Pot, Chamber each 3 79440 Urinal, Enamelware each 9 d. 97465 Blanket, Set, Small. 97470 Blanket Set, Small, Case, Empty each 1 99090 Blanket, O.D each 12 e. 97565 Chest, MD, No. 1. 97540 Chest, Field, Modified (see par. 282e(l)) each 1 Packed in Top Drawer 34680 Scissors, Bandage each 2 75150 Book, Blank, 8 Vo each 1 76240 Pencil each 1 77010 Apron, Rubberized each 2 78770 Pin, Safety, Large cards 4 78780 Pin, Safety, Medium cards 4 92050 Dressing, First-aid, Large pkgs 50 99070 Basin, Canvas each 2 99110 Book, Note, Manifolding, Binder each 1 99115 Book, Note, Manifolding, Filler each 1 Packed in Bottom Drawer 20090 Bandage, Muslin, 5-inch . dozen 1 20130 Cotton, Absorbent, Compressed ounces 25 20240 Gauze, Plain, Sterilized pkgs 25 20340 Plaster, Adhesive, 1-inch spools 6 20350 Plaster, Adhesive, 3-inch spools 6 91120 Iodine Swab, 1 1/2 cc boxes 12 92010 Bandage, Gauze, Compressed, 3-inch box l 92040 Bandage, Triangular, Compressed. each 20 92060 Dressing, First-Aid, Small pkgs 60 (1) 97540 Chest, Field, Modified. 97535 Chest, Field, Plain (less one handle), equipped with bracket table board and containing: .... each 1 97530 Chest, Field, Drawer each 2 97790 Litter Support Bracket each 2 f. 97570 Chest, MD, No. 2. 97535 Chest, Field, Plain: equipped with tray set, type 1 (97890) (see par. 282f(2)) . each 1 Packed in Top Tray 11790 Ether (for anesthesia) 1/4 lb 4 11800 Ethyl Chloride, USP 3 oz. 1 11840 Eugenol, USP ounce 1 12750 Mercuric Oxide, Yellow, Ointment, USP 1/4 oz 4 12854 Mercury Bichloride, Large Poison Tab, USP . . 250 1 13340 Petrolatum, USP pound 1 14636 Sulfanilamide, Crystalline, 5 grams in Sterile. . Individual Double-Wrapped Envelope pkgs 4 20130 Cotton, Absorbent, Compressed ounces 2 20350 Plaster, Adhesive, 3-inch spool 1 34680 Scissors, Bandage each 1 36110 Applicator, Wood carton 1 75150 Book, Blank, 8 Vo each 1 76240 Pencil each 4 77280 Box, Tablet, Folding each 72 78770 Pin, Safety, Large cards 2 78780 Pin, Safety, Medium cards 2 91010 Acid, Boric, Ointment, 1 oz, USP tubes 6 91025 Ammonia, Aromatic, 1/3 cc pkgs 2 91110 Iodine, 15 Gr,and Potassium Iodide,22.5 Gr,USP box 1 91140 Mercurial ointment, Mild, 1/2 Oz, USP tubes 6 91155 Morphine Tartrate, USP, 1/2 Gr Solution boxes 10 91230 Zinc Oxide Ointment, 1 oz. USP tubes 6 92010 Bandage, Gauze, Compressed, 3-inch each 12 97700 Container, Metal, No. 7 (12 oz) 1 each for the following; each 7 10100 Acid, Acetylsalicylic, USP, 5 Gr Tab 500 10660 Ammonium Chloride Troches, USP X , . . 250 91030 Bismuth Subcarbonate USP, 5 Gr Tab. . . 1000 14180 Sodium Bicarbonate and Peppermint Tab, 1000 14637 Sulfanilamide, USP, 5 Gr Tab 500 14641 Sulfathiazole, USP, 7.7 Gr Tab 350 1K75825 Sodium Amytal, NNR, 0.2 Gm.(3 Gr)Tab . 500 97710 Container, Metal, No. 9 (3 oz) 1 each for the following: each 6 10570 Aloin Compound, Pill or tablet 250 10845 Atabrine Tablets, 100 Mgm 200 11490 Codeine Sulfate, USP, 1/2 Gr Tab 500 13396 Phenobarbital, USP, 1/2 Gr Tab 500 13730 Potassium Permanganate, USP, 5 Gr . . . Tab 300 14622 Sulfadiazine, 0.5 Gm (7.7 Gr) Tab 100 99270 Graduate, 60 cc each 2 Form 52b Emergency Medical Tab (20 in book in duplicate) book 1 Packed in Middle Tray 37200 Razor, Safety each 1 37210 Razor, Safety, Blades pkg 1 40580 Bottle, Wide Mouth, 50 cc, Cork Finish: with Cork No. 14 (77682) each 2 77950 Dropper, Medicine dozen 1 91015 Acid, Salicylic, Ointment, 1 oz tubes 6 91145 Mercuric Ointment, Ammoniated, 1 oz, USP . . . tubes 12 91215 Sulfur Ointment, 1 oz, USP. tubes 6 93780 Tourniquet, Field each 4 99285 Hone, Oil, 3-1/2 inch each 1 99585 Tray, Instrument, Approximately 10 inch each 1 For Prophylaxis 38610 Syringe, Urethral, Prophylaxis each 6 74930 Soap, White, Floating bars 2 77205 Box, Cash, containing the following: each 1 10730 Apomorphine Hydrochloride, 1/10 gr. . . Hypo Tab, USP 20 1 10860 Atropine Sulfate, USP, 1/150 Gr Hypo Tab 20 1 11105 Caffeine with Sodium Benzoate, 7.5 Gr Amp . . . dozen 1 11760 Epinephrine, Soluble Salt, 3/200 Gr Hypo Tab. . 20 3 12955 Morphine Sulfate, USP, 1/4 Gr Hypo Tab 20 20 13840 Procaine Hydrochloride and Epinephrine Hypo . Tab 20 5 37800 Suture, Catgut, Chromic, Size 2 tubes 12 37860 Suture, Catgut, Plain, Size 1 tubes 12 37870 Suture, Catgut, Plain, Size 2 tubes 12 38440 Syringe, Luer, 2 cc each 3 38450 Syringe, Luer, 10 cc each 1 38470 Syringe, Luer, Needle, 25 gage, 1/4 inch Canula each 4 38490 Syringe, Luer, Needle, 23 gage, 3/4 inch Canula each 4 38510 Syringe, Luer, Needle, 19 gage, 1-3/4 Inch Canula each 2 38520 Syringe, Luer, Needle, 17 gage, 3-inch Canula,. each 2 38530 Syringe, Luer, Needle, 15 gage, 3-lnch Canula., each 2 74040 Spoon, Tea each 2 79320 Thermometer, Clinical each 6 99200 Corkscrew, Folding each 1 99515 Sterilizer, Hypodermic Needle each 1 78680 Paper, Toilet roll 1 91150 Mercurous Chloride Ointment, 1 oz tubes 12 91190 Protein Silver, Mild, USP, 4-6/10 Gr Tab . . . . bottle 1 91200 Protein Silver, Strong, USP, 4-6/10 Gr Tab. . . bottle 1 99225 Cup, Paper, Noncollapsible each 40 Packed in Bottom Tray 12040 Foot Powder 1/4 lb 4 12640 Magnesium Sulfate, USP 4 lbs 1 14619 Sulfadiazine Ointment, 5% 4 oz 18 14636 Sulfanilamide, Crystalline, 5 Grams in Sterile. . Individual Double-Wrapped Envelope pkgs 8 32760 Forceps, Towel 5-1/4 inch each 2 35510 Tube, Breathing, Large. each 2 35570 Tube, Trachea, Size 4. - each 1 36830 Gloves, Medium, Size 7-1/2 pair 2 36850 Gloves, Medium, Size 8-1/2 pair 2 36960 Inhaler, Yankauer each 1 40580 Bottle, Wide Mouth, 50 cc., Cork-Finish, with Cork No. 14 (77682) each 2 71780 Towel, Hand each 6 74560 Brush, Hand each 2 77010 Apron, Rubberized each 1 77060 Bag, Hot Water and Syringe each 1 77130 Basin, Pus each 1 77160 Battery, Dry CeH each 2 78010 Flashlight: with Lamp each 1 78020 Flashlight Lamp . each 2 93085 Case, Operating, Small, Improved, Complete (see par. 282f. (1) each 1 94295 Chlorine Test Set set 1 97690 Container, Metal, No. 5: containing the follow- ing each 1 31070 Catheter, Urethral, Rubber, 14F . each 2 31080 Catheter, Urethral, Rubber, 16F . each 2 31090 Catheter, Urethral, Rubber, 18F • each 2 31100 Catheter, Urethral, Rubber, 22F . each 2 97730 Container, Metal, No. 14: containing the follow- ing each 2 10480 Alcohol, USP qts 2 99070 Basin, Canvas each 2 99215 Cup, Enamelware each 3 99265 Gloves, Rubber, Pouch each 1 99540 Sterilizer, Instrument, 9-3/4 inch: containing the f oHowing each 1 37730 Stethoscope each 1 38750 Tube, Stomach each 1 (1) 93085 Case, Operating, Small, Improved. 93086 Case, Operating, Small, Improved, Empty .... each 1 31590 Depressor, Tongue, Bosworth each 1 31730 Director, Grooved each 1 32230 Forceps, Dressing, Bozeman, Straight each 1 32240 Forceps, Ear, Angular each 1 32300 Forceps, Hemostatic, Rankin-Kelly, Straight . . each 4 32310 Forceps, Hemostatic, Rochester, Pean, Curved each 2 32500 Forceps, Mastoid, Rongeur, Bane each 1 32695 Forceps, Tissue, Spring, 4-1/2 inch each 1 32700 Forceps, Tissue, Spring, 5-1/2 inch each 1 32967 Holder, Needle, Hegar-Mayo each 1 33250 Knife, Ear, Myringotome each 1 33365 Knife, Operating, Handle, No. 3 each 1 33369 Knife, Operating, Detachable Blade, No. 10 . . . pkg 1 33370 Knife, Operating, Detachaleb Blade, No. 11 . . . pkg 1 33371 Knife, Operating, Detachable Blade, No. 12 . . . pkg 1 33373 Knife, Operating, Detachable Blade, No. 15 . . . pig 1 33560 Needle, Aneurism, Cooper each 1 33631 Needle, Catgut, Size 2, Half-Circle. ........ pkg 1 33641 Needle, Catgut, Size 4, Half-Circle . pkg 1 33670 Needle, Catgut, Size 3, 3/8 Circle. pkg 1 33791 Needle, Intestinal, Size 2, Half-Circle pkg 1 33802 Needle, Intestinal, Size 4, Half-Circle pkg 1 33821 Needle, Intestinal, Size 1-3/4 inches, straight. . pkg 1 33925 Needle, Surgeon’s Regular, Size 2, 3/8 Circle. . pkg 1 33935 Needle, Surgeon’s Regular, Size 6, 3/8 Circle . pkg 1 33945 Needle, Surgeon’s Regular, Size 10, 3/8 Circle, pkg 1 33950 Needle, Surgeon’s Regular, Size 12, 3/8 Circle, pkg 1 33961 Needle, Surgeon's Regular, Size 16, 3/8 Circle, pkg 1 33971 Needle, Surgeon’s Regular, Size 20, 3/8 Circle, pkg 1 33991 Needle, Uterine, Size 1, Half-Circle pkg 1 34011 Needle, Uterine, Size 5, Half-Circle pkg 1 34021 Needle, Uterine, Size 7, Half-Circle pkg 1 34240 Probe, 8-inch......... each 1 34690 Scissors, Dissecting, Curved, 5 1/2 inch each 1 34750 Scissors, 1 Point Sharp, 5 1/2 inch each 1 35150 Speculum, Ear. Set 1 35210 Speculum, Nasal each 1 35360 Spud, Eye each 1 36890 Headband, Leather Strap each 1 36910 Headband, Mirror each 1 37996 Suture, Silk, Dermal, Medium pkg 1 38050 Suture, Silkworm Gut, Coarse coll 1 38130 Syringe, Ear, 2 ounces each 1 93705 Shield, Mirror, Metal. - each 1 (2) 97890 Tray Set, Type 1. 97840 Table Top . each 1 97850 Tray, No. 1 each 1 97855 Tray, No. 2 each 1 97860 Tray, No. 3 each 1 g. 97575 Chest, MD, No. 4. 97535 Chest, Field, Plain, equipped with Tray Set Type 3 (97895) (see par. 282g.(l)) each 1 75150 Book, Blank, 8 Vo each 1 75360 Clip, Paper, Gem, No. 1 box 1 75400 Envelope, No. 189 pkgs 6 75420 Envelope, No. 36 pkg 1 75430 Envelope, No. 84 pkg 1 75870 Mucilage, 4 oz. bottle bottle 1 75940 Pad, Prescription each 1 75960 Pad, Memorandum, 6 by 9 incheseach 4 75970 Pad, Memorandum, 8 by 10-1/2 inches each 2 76020 Paper, Blotting, 3 by 9-1/2 Inches . . . pieces 4 76040 Paper, Carbon, Black, 8 by 10-1/2 inches box 1 76100 Paper, Typewriter, Bond, 8 by 10-1/2 inches ream 1 76110 Paper, Typewriter, Manifold, 8 by 10- 1/2 inches reams 2 76240 Pencil dozen 2 76250 Pencil, Blue each 1 76270 Pencil, Indelible each 2 76280 Pencil, Red each 1 76310 Penholder. each 4 76370 Ribbon, Typewriter each 1 76390 Ruler, 12-inch each 1 76580 Tack, Thumb each 24 76590 Tab, Shipping, Linen bundle 1 78760 Pin, Common paper 1 99110 Book, Note, Manifolding, Binder each 2 99115 Book, Note, Manifolding, Filler each 4 99290 Ink Bottle, Hard Rubber each 1 99295 Ink Powder, Black tube 1 99435 Pens, Steel, Assorted dozen 1 99595 Typewriter, Portable each 1 (1) 97895 Tray Set, Type 3. 97510 Cabinet, Stationery (one drawer & 4 document files) each 1 97835 Table and Stool Set each 1 97845 Table, Typewriting each 1 h. 97757 Gas Casualty Set, Complete. 97758 Gas Casualty Case, Aprons and Gloves (see par. 282h.(l) each 2 97759 Gas Casualty Chest (see par. 282h.(2) each 1 (1) 97758 Gas Casualty Case, Aprons and Gloves 97470 Blanket Set, Small, Case, Empty each 1 99030 Apron, Impermeable each 20 99263 Gloves, Impermeable pair 29 (2) 97759 Gas Casualty Chest. 97535 Chest, Field, Plain: equipped with tray set, type 8 (97917) each 1 10100 Acid, Acetylsalicylic, USP, 5 Gr Tab 1000 1 10690 Amyl Nitrite, USP, 5 Minim, Amp pkgs 15 11380 Chloroform (for anesthesia) 1/4 lb 4 11615 Cupric Sulfate, USP pound 1 12291 Hydrogen Peroxide Solution, 8% pounds 12 14150 Sodium Bicarbonate, USP. pound 1 14619 Sulfadiazine Ointment, 5% 4 oz 2 1K24810 Eye Solution M-l, 1/2 oz pkgs 10 1K61100 Pontocaine Compound Ointment, 1 oz tubes 10 1K76525 Sodium Sulamyd, 1 Gram, 25 pkg 1 74930 Soap, White, Floating bars 2 77950 Dropper, Medicine dozen 1 91026 Amyl Salicylate pint 1 91053 Calcium Hypochlorite 3 3/4 lb 4 91085 Dichloramine-T, 20% in Triacetin pint 11 91090 Eye and Nose Drops, 1 oz bottles 2 91187 Protective Ointment, CWS tubes 60 i. 97775 Lantern Set, 97780 Lantern Set, Crate, Empty each 1 97717 Container, Metal, No. 11 each 1 99320 Lantern each 2 99325 Lantern, Globe, White each 1 99330 Lantern, Globe, Green each 2 99335 Lantern, Wick each 6 99620 Waste pound 1 j. 97793 Pajama Set, Coat, Winter. 71640 Pajama Coat, winter each 60 (30 medium, 20 large, 10 small) 97470 Blanket Set, Small, Case, Empty each 1 k. 97794 Pajama Set, Trousers, Winter. 71660 Pajama trousers, Winter each 60 (30 medium, 20 large, 10 small) 97470 Blanket Set, Small, Case, Empty each 1 I. 97795 Physical Examination Set, Flight Surgeon’s. 97800 Physical Examination Set, Flight Surgeon’s Chest, Empty each 1 12280 Homatropine Hydrobromide, USP vial 1 20130 Cotton, Absorbent, Compressed ounces 16 30770 Case, Diagnostic, Eye, Ear, Nose & Throat (see Par. 2821_(1)) each 1 32240 Forceps, Ear, Angular each 1 36110 Applicator, Wood carton 1 36160 Bag, Politzer each 1 36525 Color Test Book, Ishihara type each 1 36680 Depressor, Tongue carton 1 36685 Depth Perception Apparatus each 1 36870 Hammer, Percussion each 1 37080 Lantern, Muscle Test each 1 37145 Perimeter, Hand each 1 37147 Perimeter Charts, Schweigger, Left each 2 37148 Perimeter Charts, Schweigger, Right each 2 37152 Phorometer, with Chair Attachment each 1 37160 Pin, White Head each 24 37340 Rule, Ivory each 1 37350 Rule, Prince each 1 37370 Sphygmomanometer, Aneroid each 1 37730 Stethoscope each 1 38626 Tangent Curtain, Folded each 1 38690 Tube, Diagnostic, Ear each 1 38800 Vision Test Set (see par. 282 1(2) . each 1 38860 Watch, Stop each 1 71780 Towel, Hand each 3 77950 Dropper, Medicine . . . dozen 1 79290 Tape Measure, 60 inches each 1 79320 Thermometer, Clinical each 2 93098 Case, Trial Lenses, Pocket Set. (see par. 282 1(3) each 1 Switch Box and Bracket each 1 (1) 30770 Case, Diagnostic, Eye, Ear, Nose, and Throat. Container, Leather each 1 AOC-1077 Cords: with male fittings at transformer end & plug at handle end each 1 AOC-1096 Cord Adapter: to permit use of battery handle thru cords each 1 AOC-1074 Cord Handle: Detachable plug type each 1 31595 Depressor, Tongue, Electric each 1 Handle: for 2 cell Eveready-950 each. 1 34029 Ophthalmoscope, Electric each 1 34040 Otoscope, Electric each 1 34405 Retinscope, Electric i . each 1 Lamp: Mazda Flashlight Screw Base 2-1/2 volts each 6 (2) 38800 Vision Test Set 38810 Dial: Triple Line, Astigmatic each 1 38820 Pamphlet of Instructions each 1 38830 Test Type Card: Jaeger, Indestructible .... each 1 38840 Test Type Card: Snellen each 1 38850 Test Wools, Holmgren set 1 (3) 93098 Case, Trial Lens, Pocket Set. Container, Leather each 1 Lens, Cylindrical, Concave: .25: .50; .75; 1.00; 2.00;-3.00 pair 1 Lens, Cylindrical, Convex: .25; .50; .75; 1,00; 2.00; 3.00 pair 1 Lens, Spherical, Concave: .25; .50; ,75; 1.00: 2.00; 3.00; 4.00 pair 1 Lens, Spherical Convex: .25; .50; .75; 1.00; 2.00; 3.00; 4.00 pair 1 Disc, Red: Glass each 1 Disc, Opaque; Fiber each 1 m. 97812 Pillow Case Set. 71690 Pillow Case each 100 97470 Blanket Set, Small, Case, Empty each 1 n. 97814 Sheet Set. 71720 Sheet each 60 97470 Blanket Set, Small, Case, Empty each. 1 o. 97815 Splint Set. 97820 Splint Set, Case, Empty each 1 37386 Splint, Basswood set 1 37455 Splint Strap each 6 37480 Splint, Thomas, Arm, Hinged each 6 37500 Splint, Army, Leg, Half-Ring each 6 37515 Splint Support and Foot Rest * . . each 12 37540 Splint, Wire Ladder each 6 79230 Strap and Buckle, 3-feet each 6 p. 97825 Surgical Dressings. 14120 Soap, Soft pound 1 14619 Sulfadiazine Ointment, 5% 4 oz 8 14636 Sulfanilamide, Crystalline, 5 Grams in Sterile Individual Double-Wrapped Envelopes .... pkgs 4 14641 Sulfathiazole, USP, 7.7 Gr. Tab 1000 2 20130 Cotton, Absorbent, Compressed ounces 44 20240 Gauze, Plain, Sterilized pkgs 140 20340 Plaster, Adhesive, 1-inch spools 12 37386 Splint, Basswood set 1 78770 Pin, Safety, Large cards 2 78780 Pin, Safety, Medium cards 2 78790 Pin, Safety, Small cards 2 91010 Acid, Boric, Ointment, 1 oz. USP tubes 12 91015 Acid, Salicylic, Ointment, 1 oz tubes 12 91110 Iodine, 15 Gr. and Potassium Iodide, 22.5 Gr. USP boxes 6 92010 Bandage, Gauze, Compressed, 3-inch box 1 92060 Dressing, First-Aid, Small pkgs 48 93750 Splint, Wire Gauze rolls 6 Form 52b Emergency Medical Tag books 16 q. 97847 Towel Set, Bath. 71770 Towel, Bath each 50 97470 Blanket Set, Small, Case, Empty each 1 r. 97848 Towel Set, Hand. 71780 Towel, Hand each 150 97470 Blanket Set, Small, Case, Empty each 1 s. Items not included in Chest, Cases, Etc. 1K00700 Epinephrine (Adrenalin) in peanut oil doz 2 1K02800 Amytal, 1 1/2 gr Tab 500 1 1K07502 Atabrine, 0.2 Gm Amp 5 5 1K17800 Chinofon, NNR (Yatren) 0.25 Gm, 4 Gr Tab . 50 100 1K20615 Nikethamide, (Coramine) 100 1 1K34710 Mapharsen, NNR, 0.06 Gm Amp 10 10 1K60100 Plasmochin, 0.01 Gm (1/6 Gr) Tab 500 1 10405 Acid, Tannic, Ointment, 10% with Sulfadiazine, 5% 4 oz 136 10610 Ammonia, Water, Stronger, USP lb 2 10845 Atabrine, Tablets, 100 Mgm 100 250 11110 Calamine, Prepared, NF VI lb 25 13530 Pituitary Solution, Posterior Lobe, USP .... 6 4 13890 Quinine Dihydrochloride, USP, 5 Gr Amp . . . doz 8 13910 Quinine Sulfate, USP, 5 gr Tab 1000 48 14160 Sodium Bicarbonate, USP 10 lb 1 14530 Starch, Corn, Commercial lb 25 14619 Sulfadiazine Ointment, 5% 4 oz 36 14620 Sulfadiazine Ointment, 5% lb 4 14622 Sulfadiazine, 0.5 Gm (7.7 Gr) Tab 1000 3 14623 Sulfadiazine, Sodium, 5 Gm Vial 6 12 14635 Sulfanilamide, USP, Powder lb 10 14637 Sulfanilamide, NNR, 5 Gr Tab 1000 12 14639 Sulfapyradine, 7.7 Gr Tab 1000 5 14641 Sulfathiazole, 7.7 Gr Tab 1000 10 14670 Sulfur, Precipitated, USP lb 25 14700 Talc, Purified, USP lb 25 14850 Tincture, Opium, USP 1/4 pt 2 14860 Tincture, Opium, Camphorated, USP pt 10 15010 Zinc Oxide, USP lb 25 71296 Lamp, Therapeutic, Ultra-Violet, Small .... each 1 71530 Bar, Mosquito each 12 71670 Pillow, Feather each 12 72170 Bowl, Soup, Enamelware each 29 72890 Fork, Table each 25 73090 Knife, Butcher, 12 inch each 1 73160 Knife, Table each 25 73180 Ladle, Small each 1 73320 Opener, Can, Small . each 1 73510 Pitcher, 1 pt each 1 73890 Shaker, Pepper each 2 73910 Shaker, Salt each 2 74035 Spoon, Table, Medium (Dessert) each 25 74270 Tray, Serving each 4 77360 Can, 33-Gallon each 2 77550 Clothesline feet 50 78800 Pitcher, 4 Quart each 1 78820 Pliers, Combination each 1 91010 Acid, Boric, Ointment, 1 oz, USP tube 210 91015 Acid, Salicylic, Ointment, 1 oz tube 144 91030 Bismuth Subcarbonate, USP, 5 Gr Tab btl 50 91140 Mercurial Ointment, Mild, 1/2 oz, USP tube 10 91145 Mercurial Ointment, Ammoniated, 1 oz., USP . tube 360 91150 Mercurous Chloride Ointment, 1 oz tube 210 91155 Morphine Tartrate, USP, 1/2 Gr Solution . . . box 100 91190 Protein, Silver, Mild, USP, 4-6/10 Gr Tab . . btl 5 91200 Protein, Silver, Strong, USP, 4-6/10 Gr Tab. . btl 5 91215 Sulfur Ointment, 1 oz, USP tube 360 91230 Zinc Oxide Ointment, 1 oz., USP tube 360 96060 X-Ray Field Unit, Generator, Gasoline, Elec. each 1 96175 X-Ray Field Unit, Tent, Darkroom each 1 96206 X-Ray Field Unit, Fluoroscopic, Foreign Body Localization, Complete each 1 96215 X-Ray Field, Unit, Fluor> scopic each 1 99145 Buckets, 3 in nest .* nest 3 99185 Chair, Common, Folding each 5 99205 Cot, Folding, Canvas each 12 99215 Cup, Enamelware each 25 99380 Litter, Folding each 12 99395 Mattress Pad each 12 99465 Plate, Dinner, Enamelware each 25 99540 Sterilizer, Instrument, 9-3/4 inch each 1 99570 Table, Dining, Folding each 2 99575 Table, Instrument,., Folding each 1 99580 Table, Operating, Folding each 1 99387 Machine, Imprinting each 1 99600 Unit, Power, Electric each 1 TBA, QM Ax, single Bit, 4-pound each 1 TBA, QM Bag, Canvas, Water, Sterilizing each 1 TBA, QM Container, Round, Insulated, M1941 each 1 TBA, QM Container, Water, 5-gallon capacity each 5 TBA, QM Drum, Gasoline, 5-gallon capacity each 2 TBA, QM Lantern, Gasoline each 3 TBA, QM Paulin, Canvas, 12 by 17 feet, Khaki each 3 TBA, QM Pickmattock, Intrenching each 1 TBA, QM Range, Field, M1937, 1 unit cabinet each 1 TBA, QM Screen, Latrine, complete with pins and poles, . each 2 TBA, QM Shovel, D-handled, round point No. 2 each 1 TBA, QM Sledge, Blacksmiths’, double-faced, 8-pound. . . each 1 TBA, QM Stove, Tent, M1924 each 3 TBA, QM Tent, Hospital Ward, complete with pins and poles each 1 TBA, QM Tent, Wall, large, complete with fly, pins, and poles each 1 TBA, QM Tent, Wall, small, complete with fly, pins and poles each 3 283. SQUADRON AID STATION EQUIPMENT (97305). The items of equipment enumerat ed below are components of the Squadron Aid Station Equipment, issued to Medical De- tachments with Squadrons, except Detachments with Headquarters Squadrons of Service Groups and Depot Groups: No. Item Quantity- 97465 Blanket Set, Small (see par. 282d.) 1 a. 97545 Chest, Flight Service 1 97575 Chest, MD, No. 4 (see par. 282g ) 1 b. 97740 Crash Splint Unit. ” 2 97757 Gas Casualty Set (see par. 282h.) 1 97825 Surgical Dressings (see 282p.) 1 99380 Litter, Folding 8 99387 Machine, Imprinting 1 TBA-AAF Lamp, Gasoline, Coleman Type 1 TBA-QM Tent, Wall, Large, complete with ropes and pins 1 TBA-QM Guidon, Red Cross 1 a, 97545 Chest, Flight Service. 97550 Chest, Flight Service, Empty each 1 Packed in Top Tray 11675 Digitalis Hypo Solution, 1 Ampule Equals 1 USP XH Unit doz 1 12040 Foot Powder 1/4 lb 1 12750 Mercuric Oxide, Yellow Ointment, USP 1/4 oz 2 20130 Cotton, Absorbent, Compressed ounces 4 33590 Needle, Paracentesis each 1 34680 Scissors, Bandage each 1 37850 Suture, Catgut, Plain, Size 0 tubes 3 37860 Suture, Catgut, Plain, Size 1 tubes 4 37870 Suture, Catgut, Plain, Size 2 tubes 4 37880 Suture, Catgut, Plain, Size 3 tube 1 38410 Syringe, Luer, 2 CC each 2 38490 Syringe, Luer, Needle, 23 Gage, 3/4 inch Canula dozen 1 38550 Syringe, Luer, Needle, Wire bndls 2 38610 Syringe, Urethral Prophylaxis each 3 74040 Spoon, Tea each 1 74560 Brush, Hand each 1 74930 Soap, White, Floating bars 2 76240 Pencil dozen 1 77280 Box, Tablet, Folding each 24 77950 Dropper, Medicine dozen 1 78770 Pin, Safety, Large card 1 78780 Pin, Safety, Medium card 1 79320 Thermometer, Clinical each 4 99105 Book, Note, Approximately 2-1/2 inch each 1 99200 Corkscrew, Folding each 1 Packed in Middle Tray 97700 Container, Metal, No. 7: (12 oz.) 1 each for the following: each 2 10100 Acid, Acetylsalicylic, USP, 5 Gr Tab 500 12640 Magnesium Sulfate, USP 12 oz. 97710 Container, Metal, No. 9: (3 oz.) 1 each for the following: each 5 10570 Aloin Compound Pill 250 10660 Ammonium Chloride Troches, USP X , . . . 100 11290 Cascara Sagrada Extract, USP, 2 Gr Tab. . 250 12410 Ipecac and Opium Powder, USP, 5 Gr Tab . 200 14180 Sodium Bicarbonate and Peppermint Tab. . 300 10730 Apomorphine Hydrochloride, 1/10 Gr Hypo Tab, USP 20 1 10860 Atropine Sulfate, USP, 1/150 Gr Hypo Tab .... 20 1 11100 Caffeine with Sodium Benzoate, USP, 1 Gr. Tab. 100 1 11490 Codeine Sulfate, USP, 1/2 Gr Tab 500 1 11760 Epinephrine Soluble Salt, 3/200 Gr Hypo Tab. . . 20 1 11790 Ether (For Anesthesia) 1/4 lb. 2 11840 Eugenol, USP ounce 1 12854 Mercury Bichloride, Large Poison,Tab, USP. , . 250 1 12955 Morphine Sulfate, USP, 1/4 Gr Hypo Tab ... 20 4 13396 Phenobarbital, USP, 1/2 Gr Tab 100 1 13730 Potassium Permanganate, USP, 5 Gr Tab .... 100 1 13840 Procaine Hydrochloride and Epinephrine Hypo . Tab 20 1 14619 Sulfadiazine Ointment, 5%. 4 oz 4 20350 Plaster, Adhesive, 3-inch spools 3 31080 Catheter, Urethral, Rubber, 16F, each 1 31100 Catheter, Urethral, Rubber, 22F. each 1 36840 Gloves, Medium, Size 8 pairs 2 37370 Sphygomomanometer, Aneroid each 1 91010 Acid, Boric, Ointment, 1 oz. USP tubes 2 91015 Acid, Salicylic, Ointment, 1 oz tubes 4 91030 Bismuth Subcarbonate, USP, 5 Gr Tab bottle 1 91070 Cocaine Hydrochloride, USP, 2 Gr Hypo Tab . . tube 1 91110 Iodine, 15 Gr, and Potassium Iodide, 22.5 Gr, USP box 1 91140 Mercurial Ointment, Mild, 1/2 oz, USP tubes 2 91145 Mercuric Ointment, Ammoniated, 1 oz, USP. . . tubes 4 91150 Mercurous Chloride Ointment, 1 oz tubes 10 91155 Morphine Tartrate, USP, 1/2 Gr Solution .... boxes 4 91190 Protein Silver, Mild, USP, 4 6/10 Gr Tab .... bottle 1 91200 Protein Silver, Strong, USP, 4 6/10 Gr Tab . . . bottle 1 91215 Sulfur Ointment, 1 oz, USP tubes 4 91230 Zinc Oxide Ointment, 1 oz, USP tubes 4 99515 Sterilizer, Hypodermic Needle each 1 Packed in Bottom of Chest 36110 Applicator, Wood. carton 1 36680 Depressor, Tongue carton 1 36960 Inhaler, Yankauer each 1 37730 Stethoscope each 1 71780 Towel, Hand each 4 77060 Bag, Hot Water and Syringe each 1 77160 Battery, Dry Cell each 4 77780 Cup, Paper carton 1 78010 Flashlight (with lamp). each 1 78020 Flashlight Lamp each . 4 79460 Vial, 1 oz dozen 1 91020 Alochol, Denatured, 1 pt.. ){■ tins 2 91025 Ammonia, Aromatic, 1/3 cc pkgs 2 91120 Iodine Swab, 1-1/2 cc boxes 6 92000 Bandage, Gauze, Adhesive, 1 by 3 inches pkgs 6 92004 Bandage, Gauze, Compress, 2 by 2 inches .... pkgs 25 92010 Bandage, Gauze, Compressed, 3-inch each 12 92040 Bandage, Triangular, Compressed each 4 92050 Dressing, First-Aid, Large pkgs 4 92060 Dressing, First-Aid, Small pkgs 10 93085 Case, operating, Small, Improved, Complete (see par. 282f(l)) each 1 93780 Tourniquet, Field each 1 99070 Basin, Canvas each 1 99215 Cup, Enamelware each 3 99540 Sterilizer, Instrument, 9 3/4 inch each 1 b. 97740 Crash Splint Unit. 97820 Splint Set, Case, Empty: for the following • • • • each 1 37386 Splint, Basswood set 1 37455 Splint, Strap each 2 37480 Splint, Thomas, Arm, Hinged. . . . each 2 37500 Splint, Army, Leg,Half-Ring. , . . each 2 37515 Splint Support and Foot Rest .... each 4 37540 Splint, Wire Ladder each 2 97515 Case, Tent Pin, for the following each 1 20080 Bandage, Muslin, 3-inch . . doz 1 20130 Cotton, Absorbent, Compressed. . oz 12 20340 Plaster, Adhesive, 1-inch Spools 2 92010 Bandage, Gauze, Compressed, 3-inch each 36 99040 Axe, Hand, Fire each 1 99090 Blanket, O.D each 2 99277 Hacksaw, Frame, Adjustable each 1 99278 Hacksaw, Blade, 10 inch each 1 99380 Litter, Folding each 1 99410 Pad, Heat, Complete each 1 99493 Shovel, Entrenching each 1 284. CONTENTS OF MISCELLANEOUS KITS AND CASES, a. Equipment, Emergency Field Ambulance Set (TO 00-30-3). Blanket, Gray, M.D each 4 78440 Litter, Complete with slings each 4 QM Axe, Fire each 1 QM Extinguisher, Fire, C02, 15 lb each 1 b. Kit, Crash Tools and Equipment, Ground, (TO 00-30-44). Class 03-F Extinguisher, fire, type A-2, Spec. 85-2 .... each 2 Class 13 Suit, asbestos, type A-l, Spec. 3109 ........ each 2 Class 17-B Axe, fire, pick head, 6 lb., handled each 2 Bar, wrecking, gooseneck, 3/4” x 30”. ...... each 1 Bar, wrecking, offset, 3/4” by30”. . .' each 1 Blade, saw, hack, hand, 10”, 32 point, H.S each 12 Chisel, cold, flat, 3/4”, cutting edge each 1 Clipper, bolt, rigid head, shear cut, 5/8” cap . . each 1 Frame, hacksaw, 8” to 12”, adjustable each 1 Hammer, machinist’s, ball peen, 20 oz .each 1 Hatchet, hunter’s 3-5/8” cutting edge, in leather sheath each 1 Knife, hunting, in leather sheath, 5” blade .... each 1 Pliers, lineman’s, side cutting, 8” each 1 Saw, hand, hack, 24’ , 15 point each 2 Sledge, blacksmith’s, cross peen, 6 lb each 1 Snip, tinner’s, hand, straight cut, 4” cut pair 1 Class 19 41K1586 Box Assembly, crash tools each 1 41D7287 Box Assembly, flashlight, crash tools each 1 Extinguisher, fire, C02, 15 lb. cap., Spec. 40222 each 1 32B3686 Hook Assembly, grappling, (Consists of one grappling hook with 60 ft. length of 5/16” extra flexible aircraft cable and tow hook attached) each 1 Signal Corps 3A30 Battery, BA-30, (2 in use and 4 spare) each 6 6Z4002A Flashlight, TL-122-A each 1 Lamps, LM-35, (1 in use, 1 spare) each 2 c. Kit, Jungle, Emergency (TO 00-30-51) Class 05-A — Compass, pocket type, hunting case each 1 Class 13 41A9711 Box, emergency container, fish tackle, 3” x l” x 3/4” each 1 35A5510 Case, waterproof, match each 3 (One containing vial of iodine) (One containing vial of quinine) (One containing matches) 41D4293 Container assembly, emergency rations (L rations) each 2 38J5271 Container assembly, jungle emergency, parachute back pad each 1 Headnet, mosquito each 1 Class 17-B Machete, in leather sheath each 1 Stone, sharpening, India, medium 4” by 3/8” x 3/8” each 1 Class 21 Line, linen, fish, braided, 30 lb. test feet 30 Class 29 Hook, fish (2 each of sizes No. 2, 4, and 6) . . , . each 6 Ordnance Equipment Cartridge, pistol ball, caliber .45 each 20 Note: In addition to the items carried in the kit, one pistol, automatic, .45 caliber, will be carried on the individual during flights over jungles). d. 80210 Case, Meat and Dairy Inspection. 80211 Case, Meat and Dairy Inspection, Empty each 1 71780 Towel, Hand each 2 73145 Knife, Skinning each 2 74090 Steel, Butcher s each 1 74930 Soap, White, Floating bar 1 75980 Pad, Stamp, Dry each 1 77160 Battery, Dry Cell each 1 78010 Flashlight each 1 78020 Fashlight Lamp. each 1 80032 Box and Crate Opener each 1 80528 Container, ink each 1 80800 Hook, Gland each 1 80995 Opener, Can, Special each 1 81115 Stamp, Meat Inspection, Metal each 1 81121 Stone, Carborundum each 1 81270 Thermometer, Clinical each 1 81280 Thermometer, Dairy each 1 81290 Trier, Cheese, Lard and Butter' each 1 81320 Trier, Lard and Butter, 18-inch, each 1 81330 Trier, Meat, 8-inch each 2 94330 Magnifier, Folding each 1 99110 Book, Note, Manifolding,Binder each 1 99115 Book, Note, Manifolding, Filler each 1 99130 Box, Soap each 1 e. 97100 Kit, Dental Officer’s. 97065 Kit Component, Cantle Ring Strap each 1 97070 Kit Component, Insert, Type I each 1 97080 Kit Component, Litter Strap each 1 97085 Kit Component, Pouch each 1 13835 Procaine Hydrochloride, Cartridge, 2%, 2.4 CC box 1 20130 Cotton, Absorbent, Compressed ounce 1 20340 Plaster, Adhesive, 1-inch spools 2 44150 Stopper, Rubber, Solid, No. 2 (for 9960*5) each 1 51550 Chisel, No. 5 each 1 51580 Chisel, No. 48 each 1 52500 Elevator, Winter, No. 122 each 1 52510 Elevator, Winter, No. 123 each 1 52720 Excavator, No. 63 each 1 52730 Excavator, No, 64 each 1 52790 Explorer, No. 5 each 1 53240 Forceps, No. 150A each 1 53250 Forceps, No. 151A each 1 54170 Mirror, Mouth each 1 54260 Pliers, No. 2, Dressing each 1 54500 Plugger, Woodson, No. 1 each 1 76240 Pencil each 1 78770 Pin, Safety, Large card 1 78780 Pin, Safety, Medium card 1 91120 Iodine Swab, 1 1/2 CC boxes 2 95093 Syringe, Hypodermic, Cartridge Type, Complete (see par. 282b(2)) set 1 97040 Case, Cotton, for Dental Instruments each 1 97050 Case, Instrument, Medical Officer’s (see par. 284e(l)) each 1 97675 Container, Metal, No. 1 (for 91120, 99610) each 2 97685 Container, Metal, No. 4 (for 99605) each 1 99515 Sterilizer, Hypodermic Needle each 1 99605 Vial, Glass 60 CC each 1 99610 Vial, Glass- Stoppered each 3 Form 52b Emergency Medical Tab book 1 (1) 97050 Case, Instrument, Medical Officer’s. 97051 Case, Instrument, Medical Officer’s Empty. . . each 1 97052 Case, Instrument, Medical Officer’s, Container Metal, for 2 knives each 1 30085 Bistoury, Sharp-Pointed, Straight, 1-5/16 inch each 1 32288 Forceps, Hemostatic, Abbey each 1 32295 Forceps, Hemostatic, Jones each 1 32695 Forceps, Tissue, Spring, 4 1/2 inch each 1 33356 Knife, Operating, 11/4 inch blade each 1 33935 Needle, Surgeon’s Regular , Size 6, 3/8-Circle pkg 1 33945 Needle, Surgeon’s Regular, Size 10, 3/8 Circle pkg 1 34011 Needle, Uterine, Size 5, Half-Circle pkg 1 34745 Scissors, 1 Point Sharp, 4 1/2-inch each 1 93770 Sutures, Silk, Braided, Non-CapiHary, 3 Sizes pkgs 3 f. 97105 Kit, Dental, Private’s. 97065 Kit Component, Cantle Ring Strap each 2 97085 Kit Component, Pouch, with Lace each 2 97095 Kit Component, Suspender each 1 In Right Hand Pouch 51422 51422 Cement, Temporary, Anodyne pkg 1 54275 Pliers, No. 104 each 1 55593 Shears, Crown, Universal each 1 55680 Spatula, Cement each 1 55970 Syringe, Water each 1 56960 Wire, Brass, Ligature box 1 71780 Towel, Hand each 2 76240 Pencil each 1 92060 Dressing, First-Aid, Small pkgs 2 95090 Slab, Square each 1 97080 Kit Component, Litter Strap each 2 Form 52b Emergency Medical Tag book 1 In Left Hand Pouch 20340 Plaster, Adhesive, 1-inch spool 1 34680 Scissors, Bandage each 1 78780 Pin, Safety, Medium card 1 91025 Ammonia, Aromatic, 1/3 CC pkg 1 91120 Iodine Swab, 1 1/2 CC boxes 2 92010 Bandage, Gauze, Compressed, 3-inch each 12 92040 Bandage, Triangular, Compressed each 3 97070 Kit Component, Insert, Type I, with Lace .... each 1 97675 Container, Metal, No. 1 (For 91120) each 1 g. 97765 Kit, First Aid, Aeronautic. (This item is expendable). 97770 Kit, First Aid, Aeronautic, Container each 1 1K27505 Halazone, NNR, 1/16 Gr Tab, 100 bottle 1 91042 Burn-Injury Set, Sulfadiazine Ointment set 1 91095 Eye-Dressing Set set 1 91157 Morphine Tartrate, USP, 1/2 Gr Solution .... each 2 91204 Sulfadiazine, 0.5 Gm (7.7 Gr) Tab pkg 1 91211 Sulfanilamide, Crystalline, 5 Grams in Sterile Individual Double-Wrapped Envelope pkg 1 92060 Dressing, First-Aid, Small pkgs 3 93692 Scissors, 1 Point Sharp, 5 1/2 inch Straight each 1 93780 Tourniquet, Field each 1 Outside Envelope of Kit to Contain: 91122 Iodine Swab, 10 Min pkg 1 92000 Bandage, Gauze, Adhesive, 1 by 3 inches. . . . pkg 1 h. 97762 Kit, First Aid, Arctic. 97662 Container, for kit, First Aid, Arctic each 1 1K24817 Foille, 3/4-Ounce Tube, 2 Tubes in Package pkgs 3 1K27507 Halazone, NNR, 1/16 Gr Tab, 200 bottle 1 20130 Cotton, Absorbent, Compressed ounce 1 20340 Plaster, Adhesive, 1-inch spool 1 91010 Acid, Boric, Ointment, 1 oz , USP tube 1 91122 Iodine Swab, 10 Min pkgs 2 91145 Mercuric Ointment, Ammoniated, 1 oz. USP tubes 2 99157 Morphine Tartrate, 1/2 Gr Solution each 24 91202 Sodium Chloride, 8 Gr Tablet, 100 bottle 1 91204 Sulfadiazine, 0.5Gm(7.7 Gr) Tab pkgs 12 91211 Sulfanilamide, Crystalline, 5 Grams in Sterile Individual Double-Wrapped Envelope .... pkgs 2 92000 Bandage, Gauze, Adhesive, 1x3” pkgs 2 92002 Bandage, Gauze, Compress, 4 by 4 inches . . each 9 97734 Container, Paper (Cardboard), 1 1/2 x 4? . . . each 5 10100 Acid, Acetylsalicylic, USP, 5 Gr Tab 150 10570 Aloin Compound, Pill or Tblet 200 14180 Sodium Bicarbonate and Peppermint Tab . . . 200 91030 Bismuth Subcarbonate, USP, 5 Gr Tab 200 91190 Protein, Silver, Mild, USP, 4-6/10 Gr Tab . . 100 97734 Container, Paper (Cardboard), 1 1/2 x 4”. . . each 2 1K61500 Vitamins, Multivitamin Capsule 300 97734 Container, Paper (Cardboard) 1 1/2 x 4”. , . . each 2 91205 Sulfaguanidine, 0.5 Gm (7.7 Gr) Tab 150 i. 97764 Kit, First Aid, Gas Causalty. 97663 Container, for Kit, First Aid, Gas Casualty. . each 1 10690 Amyl Nitrite, USP, 5 Minim, Amp pkg 1 91086 Dichloramine-T, 20%, in Triacetin, 2 1/2 oz bottle 1 91091 Eye and Nose Drops, 1/2 ounce pkg 1 91105 Hydrogen Peroxide, Solution, 8%, 2 1/2 oz bottle 1 91172 Phosphorus Burn Set set 1 91187 Protective Ointment, CWS tube 1 92118 Pad, Cotton, Approximately 1 1/4 by 2 inches pkg 1 1K24810 Eye Solution, Ml, 1/2 oz pkg 1 1K61100 Pontocaine Compound Ointment, 1 oz .... tube 1 j. 97763 Kit, First Aid, Jungle. 97664 Container, Kit, First Aid, Jungle each 1 1K27507 Halazone, NNR, 1/16 Gr Tab, 200 bottles 2 1K31205 Insect Repellent, 2 1/2 oz. bottles 12 37055 Kit, Suction . each 1 91122 Iodine Swab, 10 min pkgs 4 91157 Morphine Tartrate, USP, 1/2 Gr Solution . . . each 24 91202 Sodium Chloride, 8 Gr Tablet, 100. bottle 1 91204 Sulfadiazine, 0.5 Gm( 7.7 Gr) Tab pkgs 12 92000 Bandage, Gauze, Adhesive, 1 by 3 inches .... pkgs 5 97734 Container, Paper (Cardboard), 1 1/2 by 4 inches each 3 10100 Acid, Acetylsalicylic, USP, 5 Gr Tab 150 10570 Aloin Compound, Pill or Tablet 200 10845 Atabrine Tablets, 100 MGM 100 97734 Container, Paper (cardboard), 1 1/2 by 4 inches . each 2 14180 Sodium Bicarbonate and Peppermint Tab 400 97734 Container, Paper (cardboard), 1 1/2 by 4 inches each 10 91205 Sulfaguanidine, 0.5Gm(7.7 Gr) Tab 750 k. 97771 First Aid Kit, Motor Vehicle, 24-Unit. 97772 Kit, First Aid, Motor Vehicle, 24-unit, containereach 1 78780 Pin, Safety, Medium card 1 91025 Ammonia, Aromatic, 1/3 cc pkg 1 91042 Burn-Injury Set, Sulfadiazine Ointment set 4 91095 Eye-Dressing Set set 2 91122 Iodine Swab, 10 Min pkg 1 91211 Sulfanilamide, CrysR# ine, 5-Grams in Sterile Individual Double-Wrapped Envelope pkgs 2 92000 Bandage, Gauze, Adhesive, 1 by 3 inches .... pkg 1 92002 Bandage, Gauze, Compress, 4 by 4 inches . . . each 3 92004 Bandage, Gauze, Compress, 2 by 2 inches ... pkgs 92015 Bandage, Gauze, 4-inch. pkg 1 92040 Bandage, Triangular, Compressed each 1 92050 Dressing, First-Aid, Large pkgs 2 93797 Tourniquet-Scissors-Forceps Set set 1 1. 97773 First Aid Kit, Motor Vehicle, 12-unit. 97774 Kit, First-Aid, Motor Vehicle, 12-unit, containereach 1 78780 Pin, Safety, Medium card 1 91025 Ammonia, Aromatic, 1/3 cc pkg 1 91042 Burn-Injury Set, Sulfadiazine Ointment set 2 91095 Eye-Dressing Set set 1 91122 Iodine Swab, 10 Min pkg 1 91211 Sulfanilamide, Crystalline, 5 Grams in Sterile Individual Double-Wrapped Envelope pkg 1 92000 Bandage, Gauze, Adhesive, 1 by 3 inches . . . pkg 1 92002 Bandage, Gauze, Compress, 4 by 4 inches . . . each 1 92004 Bandage, Gauze, Compress, 2 by 2 inches . . . pkg 1 92015 Bandage, Gauze, 4-inch pkg 1 92040 Bandage, Triangular, Compressed each 1 93797 Tourniquet-Scissors-Forceps Set set 1 m. 97107 Kit, Jungle, Medical, Individual. 97108 Kit, Jungle, Medical, Individual, Canvas Roll . each 1 10100 Acid, Acetylsalicylic, USP, 5 Gr Tab each 24 10845 Atabrine, Tablets, 100 Mgm each 30 1K27507 Halazone, NNR, 1/16 Gr Tab, 200 bottle 1 1K31200 Insect Repellent, 1 oz bottles 2 20300 Packet, First Aid each 1 20340 Plaster, Adhesive, 1-inch . . spool 1 91096 Foot Powder, 2 oz can 1 91098 Frazer’s Solution, Half-Strength, 1 oz bottle 1 91118 Iodine, 2%, 2 cc vials 2 91202 Sodium Chloride, 8 Gr, Tablet, 100 bottle 1 91204 Sulfadiazine, 0.5 Gm(7.7 Gr) Tab pkg 1 92000 Bandage, Gauze, Adhesive, 1x3.” pkg 1 99615 Vial, Hard Rubber, 1/2 oz (for 10100 and 10845) each 4 n. 97110 Kit, Medical Non-Commissioned Officer’s 97065 Kit Component, Cantle Ring Strap each 2 97085 Kit Component, Pouch, with Lace . . . . k each 2 97095 Kit Component, Suspender each 1 In Right Hand Pouch 99615 Vial, Hard Rubber, 1/2 oz each 6 10060 Acetophenetidin, USP, 5 Gr Tab . . 16 10100 Acid, Acetylsalicylic, USP, 5 Gr Tab . 16 11505 Compound Cathartic, Pill or Tab, NF VI.36 12230 Glycyrrhiza and Opium Compound Mixture USP, Tab 25 12410 Ipecac and Opium Powder, 5 Gr Tab. ,25 20340 Plaster, Adhesive, 1 inch spools 2 38490 Syringe, Luer, Needle, 23 Gage, 3/4-inch Canula . dozen 1 76240 Pencil each 1 77280 Box, Tablet, Folding each 12 78770 Pin, Safety, Large card 1 78780 Pin, Safety, Medium card 1 79320 Thermometer, Clinical each 1 91120 Iodine Swab, 1 1/2 cc boxes 2 93550 Case, Hypodermic, Complete (see Par. 284n(l)) .each 1 93780 Tourniquet, Field each 1 97050 Case, Instrument, Medical Officer's (see par. 284e(l)) each 1 97075 Kit Component. Insert, Type H, with Lace. , . . .each 1 97080 Kit Component, Litter Strap each 2 97675 Container, Metal, No. 1 (For 91120) each 1 99515 Sterilizer, Hypodermic Needle each 1 Form 52b Emergency Medical Tag book 1 In Left Hand Pouch 20130 Cotton, Absorbent, Compressed -.ounces 4 20240 Gauze, Plain, Sterilized pkgs 4 92010 Bandage, Gauze, Compressed, 3-inch each 8 92040 Bandage, Triangular, Compressed each 4 (1) 93550 Case, Hypodermic, Complete. 97680 Container, Metal, No. 2 each 1 10860 Atropine Sulfate, USP, 1/150 Gr Hypo Tab .... 20 1 12955 Morphine Sulfate, USP, 1/4 Gr Hypo Tab 20 2 14580 Strychnine Sulfate, USP, 1/60 Gr Hypo Tab .... 20 1 38440 Syringe, Luer, 2 cc each 1 38490 Syringe, Luer, Needle, 23 Gage, 3/4-Inch Canula each 2 38550 Syringe, Luer, Needle, Wire bndls 2 o. 97115 Kit, Medical Officers. 97065 Kit Component, Cantle Ring Strap each 1 97085 Kit Component, Pouch, with Lace each 1 99615 Vial, Hard Rubber, 1/2 oz each 6 10060 Acetophenetidin, USP 5 Gr Tab ... 16 10100 Acid, Acetylsalicylic, USP, 5 Gr Tab 16 11505 Compound Cathartic Pill or Tab, NF, VI 36 12230 Glycyrrhiza & Opium Compound Mixture USP, Tab .25 12410 Ipecac and Opium Powder, 5 Gr Tab . . 25 20340 Plaster, Adhesive, 1-inch spool 1 38490 Syringe, Luer, Needle, 23 Gage, 3/4-inch Canuladozen 1 76240 Pencil each 1 77280 Box, Tablet, Folding each 24 78780 Pin, Safety, Medium card 1 79320 Thermometer, Clinical each 1 91120 Iodine Swab, 1 1/2 cc boxes 2 92010 Bandage,Gauze, Compressed, 3-inch each 5 93550 Case, Hypodermic, Complete (see par. 284n(l)), each 1 93780 Tourniquet, Field each 1 97050 Case, Instrument, Medical Officer’s (see par. 284e(l)) each 1 97075 Kit Component, Insert, Type H, with Lace .... each 1 97080 Kit Component, Litter Strap each 1 97675 Container, Metal, No. 1 (for 91120) each 1 99515 Sterilizer, Hypodermic Needle each 1 Form 52b Emergency Medical Tag;(20 in book in duplicate)book 1 p. 97120 Kit, Medical Private’s. 97065 Kit Component, Cantle Ring Strap each 2 97085 Kit Component, Pouch, with Lace each 2 97095 Kit Component, Suspender each 1 In Right Hand Pouch 20340 Plaster, Adhesive, 1-inch spool 1 34680 Scissors, Bandage each 1 78780 Pin, Safety, Medium cards 2 91025 Ammonia, Aromatic, 1/3 cc pkg 1 91120 Iodine Swab, 1 1/2 cc boxes 2 92010 Bandage, Gauze, Compressed, 3-inch each 12 92040 Bandage, Triangular, Compressed each 3 93780 Tourniquet, Field each 1 97070 Kit Component, Insert, Type I, with Lace .... each 1 97675 Container, Metal, No. 1 (For 91120) each 1 In Left Hand Pouch 76240 Pencil each 1 92060 Dressing, First-Aid, Small pkgs 8 97080 Kit Component, Litter Strap each 2 Form 52b Emergency Medical Tag book 1 q. 97785 Packet, First Aid, Parachute. 97786 Packet, First Aid, Parachute, Container each 1 91157 Morphine Tartrate, USP 1/2 Gr Solution each 1 92060 Dressing, First Aid, Small pkg 1 93780 Tourniquet, Field each 1 285. FORMULAE OF FREQUENTLY USED PHARMACEUTICALS. 10570 Aloin Compound, Pill or Tablet Aloin gm 0.0130 Ext. belladonna root gm 0.0080 Rosin of podophyllum gm 0.0040 Strychnine sulfate gm 0.0011 11220 Camphor and Opium, Pill or Tablet: Camphor mg 130 Opium mg 65 11555 Coryza Tablet: Camphor gm 0.0130 Quinine sulfate gm 0.0130 Atropine sulfate gm 0.00013 12040 Foot Powder: Salicylic acid gm 3 Starch gm 10 Powdered talcum gm 87 12230 Glycyrrhiza and Opium Compound Mixture Tablet: Acid, Benzoic mg 2.5 Antimony and Potassium tartrate mg 1.0 Extract glycyrrhiza, pure mg 6.0 Camphor mg 2.5 Oil, anise mg 2.5 Opium, pulverized mg 2.5 14180 Sodium Bicarbonate and Peppermint Tablet: Charcoal gm 0.065 Sodium bicarbonate gm 0.260 Oil of peppermint q.s. 286, TRAINING CHANNELS: AVIATION CADETS. (Figure 39) 287. TRAINING CHANNELS: OFFICERS TRAINING IN GRADE. (Figure 40). FIGURE 39. GROUND CREW TRAINING APPLICANTS 1. ARMAMENT 2. ENGINEERING 3. COMMUNICATIONS 4. PHOTOGRAPHY 5. METEOROLOGY COMMISSION 2 ND LIEUT. AC OR FLIGHT OFFICER APPROPRIATE TECH SCHOOL CIVILIAN AND ENLISTED AVIATION CADET APPLICANTS WHITE AGE 18-26 CITIZEN 10 YRS. Q PFC I At 'qualifications 63-EXAM. 63 - EXAM PRE- FLIGHT SCHOOL BOM BAR DIE R-NAVIGATOR 9 WEEKS SPECIAL SCHOOL NAVIGATOR 18 WKS. COM MISSI ON - N AVI GATOR 2ND LIEUT. OR FLIGHT OFFICER 164 EXAM.] SPECIAL SCHOOL BOMBARDIER 12 WKS. COM MISSION-BOMBARDIER 2 ND LIEUT. OR FLIGHT OFFICER GUNNERY 3 CLASSIFICATION CENTERS AIR CREW 64 EXAM. I AIR CREW TRAINING APPLICANTS PILOT - NAVIGATOR BOM BAR DIER SINGLE ENGINE SCHOOL PRE-FLIGHT SCHOOL PILOT 9 WEEKS PRIMARY FLYING SCHOOL 9 WEEKS BASIC FLYING SCHOOL 9 WEEKS COMMISSION - PILOT 2ND LIEUT. OR FLIGHT OFFICER EXAM. i 63 OR 64 EXAM.t I 1 APTITUDE TEST 64 EXAM. TWIN ENGINE SCHOOL 64 EXAM. FIGURE 40. OFFICER TRAINING IN GRADE GROUND CREW 1. ARMAMENT 2. ENGINEERING 3. COMMUNICATIONS 4. PHOTOGRAPHY 5. METEOROLOGY APPROPRIATE TECH. SCHOOL COMMISSION IN GRADE -AC. SPECIAL I QUAD FICATIONSh 63 EXAM. I i OFFICER PERSONNEL OF ARMY 21 — 26 OFFICER TRAINING IN GRADE NAVIGATOR PRE-FLIGHT SCHOOL NAVIGATOR SPECIAL SCHOOL NAVIGATOR COMMISSION IN GRADE NAVIGATOR [mental 1 I EXAM. 1 164 EXAM. *■ I APTITUDE) -_T_E£LJ OFFICER TRAINING IN GRADE BOM BARDIER PRE-FLIGHT SCHOOL BOMBARDIER SPECIAL SCHOOL BOMBARDIER COMMISSION IN GRADE BOM BARDIER OFFICER TRAINING IN GRADE - AIR CREW MENTAL) EXAM. ] 64 EXAM. : APTITUDE TEST OFFICER TRAINING IN GRADE P I LOT PRE-FLIGHT SCHOOL PI LOT PRIMARY FLYING SCHOOL BASIC FLYING SCHOOL ADVANCED FLYING SCHOOL COMMISSION IN GRADE -PILOT r64 EXAM. I 307 INDEX Paragraphs Pages Acceleration: Angular - 147, 149 127, 129 In Aircraft 147-151 127-131 Linear 147-148 127-129 Radial- 147,150 127,129 Accommodation: Abnormal 32 36 Age and 32 36 Average normal (Duane) 32 36 Improvised test of 35 50 Test of 32 36 Acuity: Auditory 41 60 Visual, tests for 32 31 Aerial equilibration 103 96 Aerial orientation 103 96 Aero-otitis media 64-69 79-81 Aerosinusitis 72-75 82-85 Air evacuation 279 266, 267 Airsickness 96-102 93-95 Albumin, human (concentrated), Army-Navy package 214 196-197 Altitude-pressure data 129 108, 109 Alveolar air: Composition of 134 113 Partial pressure of alveolar oxygen in 135 114 Prediction equations for alveolar oxygen tension in 136 114 When breathing air and breathing 100% oxygen 140 118, 121 Alveolar oxygen 135, 136 114, 115 Amebiasis 270 256, 257 Anoxia: Classification 124 106 Definition 123 106 Signs and symptoms 125 106 Therapy 126 107 Anterior chamber: Inspection of 32 35 Anxiety state 119 102 A.O.C. color vision test 32 37 Atmosphere, composition of 128 108 Audiometer test 43 65 Aviation medical examiners: Eligible personnel 4 2 Method of reqi:.esting training for rating 5 2 Requirements 6 2 Blanket, set, small 282 284 Blast injury 274-276 262, 263 Blepharitis 32 35 Blind flight (see Instrument Flight) 103 96 Blood grouping 214 194-196 Blood pressure: Determination 26 17 Service requirements 26 17 Boyle’s law 133 113 Burns: 216-224 199-202 Treatment of 218-222 199-202 Paragraphs Pages Carbon dioxide: Carriage of 137 115, 116 Case; Instrument, medical officer’s 283 299, 300 Meat and dairy inspection 283 298, 299 Operating, small, improved 282 287 Chalazion 32 35 Chancroid 255 229, 230 Charle’s law 133 113 Chemical warfare: Characteristics of chemical agents 229-233 206-211 Reference and training chart 234 211, 212 Chest: Flight service 283 295 MD, No. 1 - 282 284, 285 MD, No. 2 282 285-287 MD, No. 4 282 288 MD, No. 60, dental 282 281-285 Chest, measurements of 21 9,10 Cholera - 268 239, 240 Circulatory failure, peripheral 210-215 193-197 Clearance of flying personnel 193 183-185 Color vision: Tests of 32 37,38 Conjunctiva, inspection of 32 35 Convergence: Near point of (PcB) 32 37 Power of 32 37 Cornea, opacity of 32 35 Craniospinal injuries 225-228 203-205 Crash death: Procedure in 194 185-187 Crash splint unit 283 296, 297 Cycloplegia in refraction 32 39 Dalton’s law - iS3 113 Decompression sickness 88-95 91, 92 Dengue 266 235-237 Dental examination: Classification 52 72 Identification record 54 73 Notations used 51 71 Requirements 53 72 Depth perception: Apparatus for 38 53, 54 Precautions in testing 32 32 Test of 32 31 Diplopia: Crossed 32 33 Homonymous 32 33 Red lens test and 32 34 Disinsectization of aircraft: - Aerosol method 179 156 Pyrethum method 180 156 Divergence, power of 32 33 Drugs, in relation to flying 107-114 98-99 Dysentery, bacillary 268 239 309 Paragraphs Pages Ear: Aero-otitis media 64-69 79-81 Examination of 41 60 Ectropion 32 35 Electrocardiogram 27 18-21 Enophthalmos 32 35 Entropion 32 35 Equilibrium of body 41, 104 61, 96 Equipment: Air base group aid station - - 282 280-293 Emergency field ambulance set 284 297 Improvised, for eye examination 35 42 Squadron aid station 283 294-297 Esophagus: Examination of 41 58 Eustachian tube: Examination of 41 60 Examination for flying: Ear, nose, and throat 41-45 58-66 Eye 32-40 30-57 Dental 51-55 71-73 General physical 18-31 7-29 Psychological and neuropsychiatric 46-50 67-70 Exophthalmos 32 35 Eye: Action of muscles 37 50, 52 Inspection of 32 35 Interpuplllary distance (Pd) 32 37 Intraocular tension of 32 35 Refraction of 32 39 Field, visual, form 32 38 Fllariasis - - - 271 258 Flight surgeon: Eligible personnel 7 2 Method of requesting rating 8 2 Minimum requirements 9 2 Flying fatigue 58-63 75-78 Flying pay 57 74 Flying status, suggestions to Flight Surgeons on 13-17 3-6 Forms: List of forms commonly used 187 166-174 To be completed after disinsectization of aircraft 181 156 WD, AGO Form No. 64 189 175 Gas casualty set, complete 282 289 Gas laws 133 113 Gonorrhea 253 221-224 Granuloma inguinale 237 232 Grounding of flying personnel 193 183-185 Handbook, Flight Surgeon’s: Preparation 3 1 Purpose 2 1 Head injuries 225-228 203-205 Hearing: 'Changes produced by flight 76-82 86-87 Requirements of A.A.F. 42 63-65 Paragraphs Pages Tests for 43 65 Heart: Normal sounds 24 11, 13 Valvular deformities, criteria for diagnosis 25 11, 16 Heat: Effects of on body 263 233, 234 Heat exhaustion 263 233, 234 Heat stroke 263 234 Height, standards of 21 9-10 Helminthic infections 271 258 Henry’s law 133 113 Heterophoria, tests for at 6 meters 32 32 Heterophoria, test, improvised 35 42 History, medical 18 7 Hordeolum 32 35 Hyperphoria 32 33 Hysteria 117 101 Illusions, sensory in flight 105 96-97 Insecticide: Use of in aircraft 177-182 155-158 Instability, vasomotor 23 11 Instructions for completing WD, AGO Form No. 64 189 175 Instrument flight .- - 103-106 96-97 International Sanitary Convention for Aerial Navigation — 170-173 147-154 Jaeger test 32 31 Japanese river fever' 267 235 Kits: Crash tools and equipment, ground 284 297, 298 Dental, officer’s 283 299 Dental, private’s 283 300 First-aid, aeronautic 283 300,301 First-aid, arctic 283 301 First-aid, gas casualty 283 301 First-aid, jungle 283 301, 302 First-aid, motor vehicle, 12-unit 283 302 First-aid, motor vehicle, 24-unit 283 302 Jungle, emergency 283 298 Jungle, medical, individual 283 302, 303 Medical, non-commissioned officer’s 283 303 Medical, officer’s 283 304 Medical, private’s 283 304 Labyrinth: Examination of 41 61 Lantern set 282 290 Larynx: Examination of 41 58 Leishmaniasis 270 257 Library, reference for Flight Surgeons: The permanent library 277 264, 265 The field library 278 265 Lungs: Tuberculosis of 29 26-27 Lymphogranuloma venereum 256 230-232 Paragraphs Pages Malaria: Diagnosis 270 242, 243 Incidence 270 242, 243 Prevention or control of 270 246-256 Treatment 270 244-246 Medical training: Air crews and combat crews 158-162 137-139 Enlisted men 156, 157 137 Medical officers on duty with Army Air Forces 163-165 140-142 Mosquitoes: Elimination from aircraft 178 156 Motion sickness (see Airsickness) 96 93 Nasopharynx, examination of 41 58 Neurasthenia 116 100 Night vision 83-87 88-90 Noxious gases in aircraft 152-155 132-136 Carbon monoxide 152 132 Gasoline fumes 153 136 Hot oil fumes 154 136 Nystagmus: Differential diagnosis of 36 50, 51 Office of the Flight Surgeon 188-195 175-187 Ophthalmoscope, use of 32 40 Orthodiagraphy 28 21 Otitis: External 66, 68 79, 81 Media - - . 66, 68 79, 81 Oxygen: Carriage of 137 115, 116 Requirements at altitude 142 118, 121 Oxygen dissociation of arterial blood 138 115, 117 Oxygen duration chart 145 122, 126 Oxygen equipment: Continuous flow system- 144 122, 123 Demand system 144 122, 124 Portable (walk around) cylinder 144 122, 125 Oxygen saturation of arterial blood at various altitudes - - 141 118 Packet, first-aid, parachute - 283 304 Pajama set, coat, winter 282 290 Pajama set, trousers, winter 282 290 Parachute, use of : 15 5 Pes planus 30 28, 29 Physical examination set, Flight Surgeon’s 282 290, 291 Pillow case set- - 282 291 Plague - - - - 268 239, 241 Plasma: Army-Navy standard package 214 196 Poisonings: Animal (snake, spider, scorpion) 265 234 Plant- 264 234 Prince rule, scales for substitute 35 50 Prisms: Equivalents of obliquely placed 35 49 Property: Miscellaneous procedures 206-209 191, 192 Paragraphs Pages Records of 202-205 190 Protozoal infections 270 242-258 Psychasthenia 118 101 Psychological examination: Scoring 47 70 Suggested inquiries 47 67 Technique of 47 67 Psychoneurosis 115-120 100-103 Psychotherapy 121 103 Quarantine of aircraft 176 155 Records: Transfer of 192 183 Red lens test: Conversion of centimeters to degrees in test 32 34 Improvised 35 49 Procedure 32 34 Refraction of eyes 32 39 Relapsing fever 269 242 Relief of flying personnel 193 183-185 Reports: Care of flier report 190 178-183 Following hospitalization 195 187 Rendered by station hospital or dispensary 183 159-161 Rendered by a tactical unit 184 162-164 Report of sick and wounded 185 165 Respiration: Mechanical factors in 132 108, 112 Restoration of flying personnel 193 183-185 Retinoscopy 32 39 Rickettsial infections 267 235, 237-239 Rinne test 43 65 Rocky mountain spotted fever 267 235 Sandfly fever 266 235 Sanitary code, International Sanitary Convention for Aerial Navigation 170-173 147-154 Sanitation: Aerial sanitation 171-182 155-158 Sanitary devices 169 147 Sanitary order 167, 168 144, 145 Sanitary report- 166 143 Schistosomiasis 271 258 Schneider Index 22 9 Schwabach test 43 65 Sheet set 282 291 “Shock” - 210-215 193-197 Sinusitis: Allergic or vasomotor 72, 74 82, 85 Infectious 72, 74 82, 85 Skeletal system, examination of 30 28, 29 Snellen test: 32 31 Compared with Jaeger test 32 31 Improvised card for 35 42 Notations in percentage of visual acuity 32 30 Technique of 32 30 Spinal injuries- 225-228 203-205 Paragraphs Pages Splint set 282 291 Standards, physical for flying 20-21 8-10 Sulfonamides: 108, 236 98, 213 In bacillary dysentery 246 217 In gas bacillus infection 242 215, 216 In gonorrhea 237, 253 213, 221 In peritonitis 244 216 In pneumonia 241 215 In staphylococcal infections 243 216 In streptococcal infections 238 213, 214 In urinary tract infections 245 216, 217 Laboratory control of therapy 249 218 Local use of 247 217 Regulations on use of in flying personnel 250 218 Toxic manifestations of 248 217, 219 Supply: Procurement 199-201 189 Standard supplies 197 188 Within tactical units of the Army Air Forces 198, 279 188, 189 266-269 Surgical dressings 282 292 Syphilis: Diagnosis of 254 224 Treatment of 254 224-227 Table, dark room 39 53 Tables of basic allowances (items of Interest to medical personnel only:) Army Air Forces equipment 281 270 Chemical warfare equipment 281 272 Medical equipment 281 272, 273 Officers and warrant officers clothing and equipment - - 281 275-279 Ordnance equipment 281 273 Quartermaster equipment 281 274, 275 Signal equipment 281 275 Tables of organization: Medical personnel in units of the A.A.F. 280 270, 271 Squadron medical detachment 280 270 Teeth 51-54 71-73 Teleroentgenography 28 21 Temperature conversion table 130 108,111 Towel set, bath 282 292 Towel set, hand 282 292 Training channels: Aviation cadets 286 306, 307 Officers training in grade 287 306-306 Traumatic neurosis 120 102 Tropical medicine 259-273 233-261 Tropics: Diet in - - 261 233 Disease in 262 233 Health in- 260 233 Military problems in - - 272 258-260 Trypanosomiasis 270 257, 258 Typhus fever - - 267 235-238 Venereal diseases 252-258 221-232 Virus infections 266 235, 236 Paragraphs Pages Visual field for form 32 38 Visual requirements, all branches 33 41 Water vapor tension — — - -- -- — - 133 113 Weber test 43 65 Weights, standards of 21 9, 10 X-Ray: Of heart 28 21-26 Of lungs - -- -- - — - — - - - — - — 29 27, 28 Of sinuses and mastoids 44 65, 66 Yaws - -- -- -- -- -- -- -- -- -- -- -- -- -- -- 269 242 Yellow fever - -- - — — - - — - -- -- -- -- - — - 266 235, 236 315 AMENDMENTS AMENDMENTS 317 AMENDMENTS AMENDMENTS 319 AMENDMENTS