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Chapter VII

Contents

CHAPTER VII

PERSONNEL

TABLES OF ORGANIZATION

The personnel contemplated for a 500-bed hospital in tables of organization prior to the war, was as follows:1 20 medical officers, 1 colonel (commanding), 1 major (operating surgeon), 18 captains and lieutenants (1 adjutant, 1 quartermaster, 1 pathologist, 1 eye, ear, nose, and throat specialist, 2 assistant operating surgeons, 12 ward surgeons); 1 dental surgeon, 8 sergeants first class (1 general supervisor, 1 in charge of office, 1 in charge of quartermaster supplies and records, 1 in charge of kitchen and mess, 1 in charge of detachment and detachment accounts, 1 in charge of patients' clothing and effects, 1 in charge of medical property and records, 1 in charge of dispensary); 16 sergeants (1 in dispensary, 2 in store room, 1 in mess and kitchen, 4 in office, 2 in charge of police, 6 in charge of wards); 14 acting cooks; 115 privates first class and privates (68 ward attendants, 3 in dispensary, 5 in operating room, 1 in laboratory, 14 in kitchen and mess, 6 in store rooms, 4 orderlies, 5 in office, 4 outside police, 1 assistant to dentist); 46 nurses, female (1 chief nurse, 1 assistant to chief nurse, 41 in wards, 2 in operating room, 1 dietist).

Because of the fact that the majority of the larger mobilization camp hospitals had a contemplated initial bed capacity of 1,000,2 the personnel referred to above was necessarily augmented.

The organization of these hospitals was based on the fact that the personnel-officers, nurses, and enlisted men-was almost entirely drawn from civil life, a personnel new to Army life and methods. Efforts were made to assign a competent medical officer of the Regular Army in command of each hospital, with three or four regular noncommissioned officers for the training of the enlisted force, and as a nucleus for an organization.

These hospitals were in reality large general hospitals planned for the definitive care and treatment of every sort of ailment, and experience soon demonstrated that the type of work required necessitated a personnel much in excess of that formerly contemplated.

The following table of organization for a permanent staff for a 1,000-bed hospital was adopted: 1 colonel or lieutenant colonel and 4 majors, M. C.; 1 captain or lieutenant, Q. M. C.; 2 captains or lieutenants, S. C.; 12 captains and 13 lieutenants, M. C.; 2 captains or lieutenants, D. C.; 400 enlisted men; 100 nurses, A. N. C.3

OFFICERS

Original assignments of medical reserve officers to base hospitals were made by the Surgeon General in order that these officers might be detailed to the duty most suitable to their training. Those assigned in the various specialties were carefully selected from among officers known to be especially qualified.4


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The Medical Department had no mobilization camps, except the medical officers' training camps, the total authorized quota of which was only 3,000.5 In consequence of this, many medical officers went directly from civil life to camps,6 and the policy was adopted of sending all who could be accommodated to the hospitals at camps for experience and training.7 This resulted in doubling and, in some instances, trebling the hospital staffs; and in overcrowding; but it was beneficial because of the training received and the provision, at all times, of a staff sufficient for any emergency. A subsequent policy was adopted to assign to base hospitals, in general, only those officers, except a certain number for training in the organization of base hospitals for service abroad, found to be not physically suitable for active field service.8

In the late fall of 1917, it became apparent that a certain proportion of medical officers who had gone directly from civil life into the hospitals were not being qualified for their duties as rapidly as desired by the Surgeon General.6 It was then directed that both officers and enlisted men be given training which would best fit them for base hospital work.8 An outline of instruction was promulgated, specifying that as much of it as possible be utilized in connection with the daily work and duties so as not to interfere with the efficiency of the hospital work.9 This established course of instruction made essential the recognition of the fact that not all of the newly commissioned medical officers were equal professionally. The substandard grouping came into existence and a simpler course of instruction was instituted for medical officers found lacking in the knowledge of basic technique of medical practice.7

Many changes in the professional personnel were required, largely due to the fact that it was next to impossible to correctly grade the many men suddenly brought into the service. Then, too, certain officers whose names had been requested for service in Red Cross and evacuation hospitals intended for service overseas necessitated staff changes when the officers concerned joined their units. This prompted the Surgeon General to direct commanding officers of hospitals to report the names of those suitable for the formation of a permanent staff, both administrative and professional, omitting exempted officers.10 The instructions provided for supplementing the permanent staff by officers assigned for temporary duty, upon the request of the commanding officer of a hospital; and, in addition, the assignment, from time to time, of two classes of officers for temporary duty, officers assigned for observation and training; substandard officers, or those below par professionally, assigned for professional instruction.

NURSES

Nurses were assigned to hospitals in the ratio of 1 to 10 beds,10 the assignments being made from time to time on requisitions by commanding officers of hospitals.10 Certain of these nurses were members of base hospitals organized for duty overseas, and for this reason their service at the fixed hospitals in the United States was modified so as to except them from duty in connection with the care of patients with contagious or infectious diseases.10

The distribution of nurses within the hospitals was as follows: Chief nurse (with one or more assistants);11 head nurses, designated by the chief


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nurse, one to each ward, including venereal and psychopathic wards;10 and ward nurses, for day and night duty.

To supplement the supply of graduate nurses a plan was devised providing a constructive method of utilizing the services of unskilled women.12 To this end, in the summer of 1918, the Army School of Nursing was established, with branch schools in various military hospitals in the United States.13

The 1,800 student nurses placed in training made no appreciable contribution, from the standpoint of numbers, to the nursing service in the war. The experiment demonstrated, however, its potential value in the event of a similar contingency.

ENLISTED PERSONNEL

The enlisted personnel, like the officers and nurses, was almost entirely made up of untrained material at the first, and was acquired largely through original enlistments for the Medical Department, and the instrumentality of the draft.14

The following table, showing the various proportions of noncommissioned officers, cooks, privates first class, and privates, with the total enlisted detachment for hospitals of varied sizes, was used as a working basis in determining the enlisted strength of given hospitals:

TABLE 8.-Number of enlisted men assigned to different-sized hospitals.15

Beds

Master hospital sergeants not to exceed-

Master hospital sergeants or hospital sergeants

Sergeants, first-class

Sergeants

Corporals

Total noncommissioned officers

Cooks

Privates, first-class

Privates

Total

200

1

1

8

15

3-5

(a)

12

127

31

200

500

1

3

10

22

10

45

14

201

40

300

800

1

3

13

27

12

55

17

240

48

360

1,000

2

4

16

28

12

60

19

267

54

400

1,100

2

4

16

30

12

62

20

286

57

425

1,200

2

5

16

30

13

64

21

305

60

450

1,300

2

5

17

31

13

66

22

323

64

475

1,400

2

5

17

32

14

68

23

341

68

500

1,500

2

5

18

33

14

70

24

359

72

525

1,600

2

5

18

34

15

72

25

378

75

550

1,700

2

5

20

34

15

74

26

396

79

575

1,800

3

6

20

35

15

76

27

415

82

600

1,900

3

6

21

35

16

78

28

433

86

625

2,000

3

6

21

36

17

80

29

451

90

650

aLimited to 30.

It was impossible, of course, to supply hospitals with noncommissioned officers in the numbers allowed in the tablel;16 and it was expected that promotions to these grades would be made from the available material in the detachments.*

Authority was given commanding officers to make promotions to all grades, Medical Department, to and including sergeant, first class, within the limits provided by the table.17 Promotions to the grades of master hospital sergeant and hospital sergeant were made by the Surgeon General on recommendations of commanding officers of hospitals.17

The Surgeon General appreciated the fact that no ironclad rules could be established in restricting the personnel, and he instructed commanding officers

*For details of methods used in determining assignments and promotions of enlisted personnel, Medical Department, as practiced in base hospitals, the reader is referred to the history of the United States Army Base Hospital, Camp Grant, Ill3., p. 206 of this volume.


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of hospitals to make application for additional enlisted men in the event of an emergency requiring larger numbers.18

A detachment of the Quartermaster Corps, consisting of 1 officer, captain or lieutenant, 2 quartermaster sergeants, 1 sergeant, first class, 7 sergeants (1 stenographer, 1 clerk, 1 overseer, 1 blacksmith, 1 carpenter, 1 engineer), 3 corporals (1 storekeeper, 2 chauffeurs), 1 cook, 2 privates, first class (firemen), 5 privates (laborers), was furnished by the Quartermaster General's Office, for duty about the hospital.18

CIVILIAN EMPLOYEES

Though the military personnel provided for the hospitals was considerable and ordinarily adequate to operate the various hospital services, not all positions therein were filled by them. The base and general hospitals rapidly acquired a highly specialized character which could not have been foreseen, and to meet the demands of the elevated standards, as well as to conserve personnel, especially officer personnel, civilians possessed of the required training were employed. This was especially true in the laboratories, where women technicians were employed19 in the proportion of 1 to every 250 beds, for work in urinalysis and clinical microscopy, preparation of media, bacteriological sections, Wassermann and serologic reactions, keeping records, stenography, typewriting, etc.

For employment in connection with the reconstruction activities of hospitals, women, trained in occupational therapy and physiotherapy, were secured as aides.20

The dietitian service was an innovation in the war hospitals.21 It consisted of women employees, especially trained in the preparation of food, who were largely utilized for supervising the preparation of the special diets for the sick. At the time of the signing of the armistice there were 272 of these dietitians distributed among 97 base, general, and post hospitals of the United States. Some of the larger hospitals had as many as 10 dietitians.

The students of the Army School of Nursing, branches of which were established in all military hospitals, were on a civilian employee status while in training.

HOSPITAL SERVICES

Military hospitals differed materially from hospitals in civil life, aside from the class of patients treated and the character of diseases and injuries encountered within them, in that there was necessitated provision for quarters for officers and barracks for enlisted men, as well as quarters for the nurses. In addition to buildings used for administering the hospital or for housing or feeding the patients, or for heating, there had to be buildings for other purposes, included not only in the professional division-isolation, special therapy, etc.-but for the special administrative control, such as a guardhouse, post exchange, storehouse, etc.

It will be readily appreciated that the services of a large military hospital, when roughly divided into two divisions, formed groups of almost equal magnitude, the administrative division, in fact, slightly overshadowing the professional; so, from the experience gained in administering the general hospitals


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of peace times, the Medical Department was enabled to plan, fairly accurately, what would be needed in the way of the provision of services for the large war hospitals.

The following tabular statement was formulated to furnish a working plan of administration and to give an approximate idea of the personnel required:22

ADMINISTRATION DIVISION

Commanding officer:
   
1 colonel or lieutenant colonel, M. C. 
Adjutant's office (in charge of administrative records and correspondence, telegraph office, telephone exchange, and post office):
    1 major, M. C.
    2 sergeants, first class, H. C. 
    11 privates, H. C.  
    1 sergeant, Sig. C.                           
    1 first-class private, Sig. C.
    2 civilian employees, M. D. (stenographers).  
In charge of medical and surgical records; commanding officer, detachment of patients; in charge of patients' money and valuables:  
    l major or captain, M. C.  
    2 sergeants, first class, H. C. 
    1 sergeant, H. C.  
    6 privates, H. C.  
Quartermaster's office (in charge of quartermaster, medical, ordnance, and Signal Corps property and funds; construction and repair of buildings; transportation; police and care of grounds; disinfecting, laundry, heating, lighting and ice plants; clothing and baggage room of patients): 
    1 major or captain, M. C.  
    1 captain or lieutenant, M. C. 
    2 sergeants, first class, H. C. 
    5 sergeants, H. C.
    22 privates, H. C.  
    2 quartermaster sergeants, Q. M. C. 
    1 sergeant, first class, Q. M. C.  
    7 sergeants, Q. M. C. (1 stenographer, 1 clerk, 1 overseer, 1 blacksmith, 1 plumber, 1 carpenter, 1 engineer).  
    8 corporals, Q. M. C. (1 foragemaster, 1 storekeeper, 1 baker, 1 printer,  1 painter, 1 farrier,1 saddler, 1 gardener).  
    1 cook, Q. M. C.  
    7 privates, first class, Q. M. C. (5 teamsters, 2 firemen). 
    5 privates, Q. M. C. (laborers, scavengers, etc.).  
    Civilian employees (seamstresses, laundry employees, attendants, scrub women, etc.). 
Hospital mess (in charge of hospital messes, kitchens, bakery, and special diet service; post exchange: hospital fund):
    1 captain or lieutenant, M. C. 
    2 sergeants, first class, H. C. 
    4 sergeants, H. C.  
    10 acting cooks, H. C. 
    30 privates, H. C.  
    4 Army Nurse Corps (dietists).  
    6 civilian employees M. C. (1 chief cook, 2 cooks, 2 assistant cooks, 1 baker). 
Commanding officer, detachment, H. C. (in charge of detachment, H. C., on duty at the hospital; recruiting, identification work, and sick call): 
    1 captain or lieutenant, M. C.  
    1 sergeant, first class, H. C. 
    4 sergeants, H. C.  
    2 corporals, H. C.  
    5 acting cooks, H. C. 
    29 privates, H. C.  


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Officer of the day (detailed from roster of medical officers. In charge of the guard; receiving office, roster of patients and morning report of admissions and losses; ambulance, emergency, and fire-alarm service; information office):  
    3 sergeants, H. C. 
    6 privates, H. C.  
Officer of the guard (detailed from roster of junior medical officers. Commands the guard under the direction of the officer of the day):  
    2 sergeants, H. C. 
    2 corporals, H. C. 
    24 privates, H. C. 
This detail is made in time of war only and when the guard is not furnished by the line. 
Chaplain (in charge of chapel, library, reading room, amusement hall, and post school): 
1 officer, Corps of Chaplains.
1 private, H. C.

PROFESSIONAL DIVISION

Chief of medical service (in charge of medical service, receiving ward, and dispensary): 
    1 major, M. C.  
    2 sergeants, H. C. 
    2 privates, H. C.
Chief of surgical service (in charge of the surgical service, including the operating and dressing rooms):
    1 major, M. C.
    1 captain or lieutenant, M. C. 
    1 sergeant, H. C.
    4 privates, H. C.  
    5 Army Nurse Corps.
Wards (ward officers may be assigned additional duties in eye, ear, nose, and throat, genitourinary and other special services; assistants to operating surgeon, etc.):
    12 captains or lieutenants, M. C. 
    6 sergeants, H. C.  
    70 privates, H. C.  
    53 Army Nurse Corps.
Laboratory (in charge of chemical, bacteriological, and X-ray laboratories, and morgue): 
    1 captain or lieutenant, M. C.  
    1 sergeant, first class, H. C. 
    2 sergeants, H. C.  
    4 privates, H. C.
Dental service (in charge of dental service): 
    1 lieutenant, D. C.  
    1 private, H. C.
Nursing service (in charge of nursing service) 
    1 chief nurse, A. N. C.
    1 assistant chief nurse, A. N. C.  
    1 supervising night nurse, A. N. C.  
    7 civilian employees, M. D. (1 cook, 1 assistant cook, 5 attendants). (See also Wards and Hospital mess.)  
Convalescent camp:
   
1 captain or lieutenant, M. C. 
    1 sergeant, first class, H. C. 
    1 sergeant, H. C.  
    6 privates, H. C.
NOTE.-The term "private, H. C." is used in the above table to denote both privates, first class, and privates, H. C.  
(a) The allowance of the members of the Quartermaster Corps or their civilian substitutes and of the civilian employees of the Medical Department will vary according to the character and special work of the hospital, and will be decided in each case by the proper authority. (For  


127

the duties of the several grades in the Quartermaster Corps see "Quartermaster Corps" in the Appendix.)

(b) In time of war 25 per cent of the officers of the professional division, 25 per cent of the ward attendants, and 75 per cent of the nurses might be furnished by personnel from the American National Red Cross Society. This corresponds approximately to one Red Cross hospital column.

On November 11, 1917, the Surgeon General issued instructions providing for three services; namely, surgical, medical, and laboratory, with a chief of service for each; and provided, further, that the services include the following special sections, to be used in whole or in part as found necessary (500-bed basis):23  

SURGICAL SERVICE

1 chief of service

4 surgeons (head section)-

4 surgeons-

    

Brain

    

General

    

Eye

    

Chest

    

Ear, nose, and throat

    

Abdomen

    

Plastic (face and mouth)

    

Fractures

1 roentgenologist

1 surgeon (orthopedic)

2 dentists

1 surgeon (urology)

MEDICAL SERVICE

1 chief of service

1 or 2 psychiatrists (in hospitals of camps in the United States)

4 physicians (including 1 neurologist)

LABORATORY SERVICE

(Pathology, bacteriology, serology, chemistry, morgue, and public health laboratory work for the command.)

1 chief of service (pathology, bacteriology, and serology)

1 assistant

(All other laboratory workers to be under the chief of this service)


At some hospitals there was a mistaken policy of dividing the organization into 8 or 10 divisions in order to place the specialists on the same footing in importance as the major divisions of general surgery and medicine.24 This impediment to efficient administration was soon corrected, but not until after some confusion had resulted. In some hospitals, the organization was never completely straightened out.

INSTRUCTION

It was early provided that such clinics, lectures, classes, and study as were found to be necessary for the training of commissioned and enlisted personnel be instituted at all hospitals.25

INSTRUCTION OF OFFICERS

An outline of instruction for use in the training of medical officers in their duties at base hospitals was provided by the Surgeon General;26 and it was suggested that officers who had been especially selected for training in the administrative division be detailed as assistants to the commanding officer, adjutant, registrar, mess officer, etc., to afford them opportunities to familiarize themselves with the details of routine duty connected with these offices.27

Officers were placed in two main classes:28 first, those found by observation to be professionally qualified; and, second, those who soon proved themselves  


128

to be substandard through inadequate professional education. No definite period was set for the training of substandard men to remedy their defects. It was provided that the training continue so long as there was apparent profit.

The following outline of instructions was used in the training of professionally qualified temporary officers in the duties of medical officers at base hospitals, in connection with clinics and demonstrations:26

ADMINISTRATION

Lectures by the commanding officer, and such officers of the base hospital staff as have had previous experience and training in administrative subjects. These lectures to deal particularly with base hospital regulations and duties, with specific instruction in the duties of commanding officer, adjutant, registrar, mess officer, supply officer, commanding officer of detachments, and ward administration. Such courses of study and recitation will be prescribed in Army Regulations, Manual for the Medical Department, and other manuals as are necessary and practicable.

MEDICAL SUPPLY OFFICERS

1. The supply tables:  
     (a) Classification of supplies. 
     (b) Nomenclature of supplies.
     (c) Normal allowance of various medical department units. (Pars. 474-476 and 842-959, Manual for the Medical Department, 1916.)
2. Requisitions. (Pars. 474-495.)  
3. Transfer of medical supplies. (Pars. 496-500.) 
4. Accountability. (Pars. 501-503.)  
5. Distribution of field supplies in time of peace. (Pars. 504-506.)  
6. Distribution in zone of advance. (See Field Service Regulations.)  
7. Replenishment in combat. (Pars. 551-554 and 858.)  
8. Returns of medical property. (Pars. 507-508.)  
9. Sales of medical property. (Pars. 509-510.)  
10. Distribution of medical property on abandonment of post. (Par. 511.)  
11. Use and care of medical property. (Pars. 512-526.)  
12. Base medical supply depots. (Pars. 782-786.)  
13. The advance medical supply depot. (Pars. 787-792.)

INTERNAL MEDICINE (BY CHIEFS OF MEDICAL SERVICE.

This course of instruction is intended to familiarize medical officers serving with troops in the field with the more important diseases which they may encounter, their diagnosis, and the means or their prevention and treatment, with a view to securing prompt and suitable action when such cases arise.         It is not the purpose of this instruction to make regimental officers hospital specialists, but to indicate to them their part in the teamwork of the Medical Department which will result in each sick soldier receiving promptly the best treatment, whether that be in the regimental field hospital, at the base hospital, or in special general hospitals, and will make them most efficient in preventing the spread of disease among the troops.

I. Examination of recruits.
     1. Methods of examination of the heart. 
     2. Principles of interpretation.  
     3. Causes for rejection.  
     4. Cardiovascular diseases which are most often overlooked in recruiting. 
     5. Border-line cases and difficult decisions.
II. Examination of the lungs.  
III. Disorders of the heart common in soldiers.
     l. The soldier's heart, symptoms, causes, prevention, treatment, including projected special hospitals, and prognosis, military, and individual. Emphasis on the importance of observations of recruits during training by regimental medical officers and overseas. The importance of a sufficient period for convalescence and re-training after acute infections, in particular influenza, trench fever, and diarrhea.  


129

IV. Tuberculosis in the soldier.
V. Lobar pneumonia. The newer knowledge of the fixed types of pneumococci, the means of determination of the type for specific treatment, treatment of Type I, infections by serum; symptoms and physical signs of pneumonia in the first few days and the importance of early diagnosis; prognosis in the different types.
VI. The acute respiratory infections, sore throats, and diphtheria.  
     1. Importance of acute colds and bronchitis as forerunners of pneumonia; complications of acute respiratory infections, especially infection of the accessory sinuses and middle ear.
     2. Tonsillitis, pharyngitis, etc. Importance of throat cultures in all cases; complications, especially acute nephritis, endocarditis, and other forms of streptococcus sepsis; importance of urine examination after tonsillitis before return to duty.
     3. Diphtheria, diagnosis, antitoxin treatment; carriers of the virulent and avirulent bacilli and modes of dealing with them. Carriers after an attack usually harbor bacilli in the tonsils and are even rendered free by tonsillectomy. The Shick reaction and its value in determining the need for immunization of a group of individuals. 
VII. Epidemic meningitis and poliomyelitis.  
     1. Importance of epidemic meningitis among troops in camps and barracks. 
     2. Early symptoms and diagnosis.  
     3. Lumbar puncture and exact diagnosis.  
     4. Serum treatment including strains of meningococci and bearing on failure of serum treatment as in the epidemic among Canadian and British troops early in the war. 
     5. Carriers and the great importance of their detection and isolation. Improved methods for the treatment of carriers.  
     6. A brief sketch of poliomyelitis with reference to the more acute forms and possibility of confusion with meningitis, either epidemic or tuberculous.
VIII. The exanthemata.  
     1. Measles; early diagnosis, especially Koplik spots; treatment and prevention with special reference to Colonel Munson's observations on sun and air.      
     2. German measles and its differential diagnosis from measles.
     3. Scarlet fever; early diagnosis, prevention; the important complications in the throat, heart, kidneys, and joints; combined scarlet fever and diphtheria.
     4. Typhus fever; modern knowledge of transmission by the louse; frequency in prison camps, etc.; symptoms and diagnosis of mild and severe forms; prevention.
     5. Smallpox; recognition of mild cases of varioloid.
IX. The malarial fevers; mode of treatment and prevention.
     1. Treatment of tertian malaria and of estivoautumnal with special reference to the need for continued used of quinine; treatment of pernicious malaria, intravenous and intramuscular use of quinine dihydrochloride.
     2. The animal parasites, especially hookworm; treatment by oil of chenopodium; prevention.
X. Dysentery and diarrhea.
     1. Bacillary dysentery, its causes, symptoms, treatment, and prevention.
     2. Amebic dysentery; diagnosis and difference in symptoms from those of bacillary dysentery; treatment by emetine; importance of early treatment of acute stage; general treatment; amebic cysts and carriers.
     3. The nonspecific diarrheas; causes, prevention, importance of treatment and safeguarding for a few days subsequently.
XI. Typhoid and paratyphoid fevers and trench fever.
     1. Typhoid and paratyphoid with reference to modes of infection and importance of general prophylaxis. Specific immunization; diagnosis in the immunized; carriers.
     2. Trench fever; its symptoms, diagnosis, wholly favorable prognosis; need for rest and for safeguarding during convalescence; theories as to causation and transmission. 
XII. Nephritis, infectious jaundice, and tetanus.
     l. Acute nephritis as seen at the Western Front. 
     2. Infectious jaundice and spirochetal infections.
     3. Tetanus; its prevention; symptoms of mild tetanus; treatment by intraspinous antitoxin. 
XIII. Gas poisoning; its symptoms, diagnosis, prognosis, and treatment.  


130

SYLLABUS OF INSTRUCTION IN STANDARD METHODS FOR TREATING FRACTURES

The purpose of this course of instruction is to familiarize medical officers with standard methods in the treatment of fractures. It is intended that officers so trained will not only serve in the special fracture hospital, but in field, base, and general hospitals, and as regimental officers as well, so that a continuity in the methods for treating fractures can be maintained. By this means, it is proposed to establish teamwork on the part of medical officers throughout the Army, in order that the wounded soldier will receive promptly the most efficient treatment whether at the regimental aid station, the dressing station, the field hospital, the evacuation hospital, or the base hospital, as well as along the lines of transportation. The logical result of this cooperation will be to secure early recovery, lessen deformity, and reduce the number of soldiers permanently disabled to a minimum. It is realized that the exigencies of the service in the zone of the advance will frequently be such as to render the standard methods impracticable, but by indicating clearly the desideratum it is hoped that the difficulties in the field will act not so much as an obstacle but as a stimulus to the ingenuity of the medical officers.

Fractures in war are usually compound and will be much more prevalent than the simple, so that any treatment which considers merely the fracture and not the wound and the soldier would be quite ineffective. Consequently, the course of instruction will be initiated with a brief but thorough presentation of wounds, from a military standpoint, their causes, and their treatment.  This will be followed by the course in standard methods for treating fractures proper. The instruction will be intensely practical in nature, consisting in the demonstration of the splints, their adaptability and application, and in clinics.

CAUSES AND VARIETIES OF WOUNDS

1. Bullet wounds. 
     a. Shrapnel. 
     b. Rifle.  
     c. Pistol. 
2. Shell wounds.
     a. Shell fragments. 
     b. Shell fuse.  
     c. Hand grenade.  
3. Bayonet wound; sword wound. 
4. Burns.
5. Gas.
6. Varieties of wounds. 
     a. Abrasion.  
     b. Contusion. 
     c. Laceration. 
     d. Puncture; complete or incomplete.

CONDITION OF WOUNDED MEN

1. Hemorrhage, excessive (shock). 
2. Exposure; wet, cold. Hunger. 
3. Shell-shock.
4. Gas.
5. Visceral injury; abdominal, thoracic and head. 
6. Infection; pyogenic, tetanus, gas bacillus.
7. Suppuration.

TREATMENT OF WOUNDS

General.
     1. Water administered. 
          a. Mouth.
          b. Rectum.
          c. Hypodermoclysis.  
          d. Intravenous. Dangers. 
     2. Food and hot drinks.  
     3. Medication.  


131

Local.
     1. Wound antisepsis.  
          a. Excision, necrotic tissue.  
          b. Wound cleansing, foreign body removal. 
          c. Tincture of iodine.  
          d. Dakin-Carrel method. 
          e. Dichloramine-T.
2. Hemorrhage.
     a. Pressure by bandage. Cautions. 
     b. Packed. Cautions.  
     c. Tourniquet. Cautions.  
     d. Ligation of artery. Cautions. 
     e. Amputation. Indications. 
3. Dressings.
     a. Dry antiseptic.  
     b. Suture. Indications. 
     c. Drainage. Indications. 
4. Infection.
     a. Suppuration. 
     b. Gangrene. 
     c. Drainage. 

FRACTURES

At the dressing station:
     1. General treatment.  
     2. Wound antisepsis. 2 per cent iodine superficial. 
     3. Wound cleansing.
     4. Immobilization and extension methods.
          I. Fractures of the upper extremity. 
               a. Simplest splint arm to chest. 
               b. Screen wire and wood splints.
               c. If practicable, Thomas arm splint; elbow splint. 
          II. Fractures of the lower extremity.
               a. Rifle down the side of leg with coat between legs and the legs lashed together.  
               b. Screen wire and wooden splints.  
               c. C. femur. Thomas knee splint for fracture of femur. In fracture of femur, the soldier once placed on litter is not to be removed therefrom.
          III. Fracture of rib. Immobilization.
          IV. Fracture of pelvis. Fixation. Not removed from litter. 
          V. Joints.
     5. Infections. Special treatment. 
          a. Tetanus-serum.  
          b. Gas bacillus-aeration. Antitoxin. 
          c. Pyogenic.
6. Amputations, contraindications. Indications. 
7. Anesthesia.
8. Diagnosis tags. These must be kept up to date, particularly with fractures.

TRANSPORTATION

1 . Cases sorted into transportable and nontransportable.
2. Maintenance of immobilization and extension, where practicable. Methods. Not more than 12 hours should elapse without the splint being inspected by a surgeon and necessary adjustments made.
3. Femur, special treatment for fractures of, in transit. Not to be removed from litter. Thomas knee splint inspected once every 12 hours.  


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EVACUATION HOSPITAL, SPECIAL FRACTURE HOSPITAL, BASE HOSPITAL

l. Early and adequate surgery. 
2. Wound antisepsis.
3. Wound cleansing.
4. Conservation of fragments.
5. Immobilization and extension. Standard methods. 
     I. Fracture of upper extremity.  
          a. Humerus.
               1. Jones's humerus extension splint. 
               2. Jones's abduction splint.  
          b. Elbow splint.  
          c. Radius and ulna. Jones's forearm and wrist splint. 
     II. Fracture of lower extremity.  
          a. Femur. Thomas knee splint; Hodgen splint, overhead suspension and extension from Balkan frame or on special fracture bed.
          b. Tibia and fibula. Jones's leg splint and Cabot splint.
     III. Fracture of rib. Immobilization.  
     IV. Fracture of pelvis. Fixation. Bradford frame.  
      V. Joints. Operative indications. Foreign body removal. Drainage. 
6. Malunion and nonunion, caution; late tetanus and infection.  
7. Infections; special treatment.  
8. Operative treatment, indications for.  Standard methods. 
9. Amputation. Special.  
10. Anesthesia. Ether drop method, chloroform; nitrous oxide; spinal, tropococaine. 
11. Examinations, special methods.
     a. Roentgen ray. 
     b. Bacteriological. 
12. Massage and baking. 
13. Hydrotherapy.
14. Curative workshop; reconstruction.

THORACIC WOUNDS

I. Causes and varieties of wounds. 
     1. Bullet wounds.
          a. Shrapnel. 
          b. Rifle.  
          c. Pistol. 
     2. Shell wounds.
          a. Shell fragments. 
          b. Shell fuse.  
          c. Hand grenade.
     3. Bayonet wound, sword wound. 
     4. Varieties of wounds.
          a. Laceration. Thoracic wall. Back.  
          b. Perforating (puncture) wounds-complete, incomplete. 
          c. Concussion of spinal cord-brachial plexus.  
          d. Pseudo-perforating wound. 
II. Pathology.  
     l. Shock.  
     2. Hemorrhage. 
     3. Dyspnea. 
     4. Hemoptosis.  
     5. Vomiting and hiccough.  
     6. Death, immediate causes of. 
     7. Infection.  
          a. Pyogenic. 
          b. Tetanus.  
          c. Bacillus-aerogenes. 
     8. Surgical emphysema.  


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III. Clinical aspects.
     1. Pneumothorax. 
     2. Hemothorax.  
     3. Pyothorax (empyema) 
     4. Fracture of ribs.
     5. Pneumonia.
     6. Pleurisy-effusion.  
     7. Abscess and gangrene of lung. 
     8. Subphrenic abscess.  
     9. Pericarditis. Pneumocardium. 
     10. Paralysis-monoplegia, paraplegia. 
     11. Sequelć.
IV. Treatment.
     l. Immediate firing line, regimental aid, or dressing station.
          a. General care. Water. Hot drinks. Blankets.  
          b. Wound antisepsis. 
          c. Hemorrhage.  
          d. Wound cleansing; if practicable.  
          e. Dressing. Dry gauze, graduated pressure.
          f. Posture of patient-recumbent on affected side. If practicable not disturbed. 
             No walking.
          g. Medication. Morphine. Atropine.  
          h. Transportation. Rest one of main factors in treatment.
     2. Intermediate. Regimental aid. Dressing station.  
          a. General care. Food. Water. Hot drinks. Blankets. 
          b. Wound antisepsis.  
          c. Anesthesia. Chloroform; ether; drop method.  
          d. Wound cleansing. Operation. Indication for. Foreign body, removal.  
          e. Dressings. Immobilization of affected side. 
               l. Fresh cases.  
               2. Suppurative cases. 
                    Dichloramine-T. 
                    Carrel-Dakin.  
                    Moist dressing. 
          f. Medication.  
     3. Field hospital, evacuation hospital, base hospital.
          a. Examination, special methods.  
               Bacteriological.  
               Roentgen ray.
          b. Operations. Special methods. Indications. 
          c. Suppuration; treatment of.  
          d. Complications, special treatment for.

ABDOMINAL WOUNDS

I. Variety of wounds. 
     l. Contusions.
          a. Abdominal wall.  
          b. Ruptured viscera, or blood vessels.  
     2. Puncture wound of abdominal wall (nonpenetrating).  
     3. Penetrating wounds (nonperforative of viscera, or blood vessels). 
     4. Perforating wounds.  
II. Pathology. 
     1. Shock.  
     2. Hemorrhage. 
     3. Infection.  
          a. Pyogenic. 
          b. Tetanus.  
          c. Bacillus aerogenes. 
     4. Protrusion of viscera.  
     5. Perforation, visceral. 
     6. Peritonitis.  
     7. Extraperitoneal infection.  


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III. Diagnosis. Early differential. 
IV. Clinical aspects.  
     1. Hemorrhage.  
     2. Perforation of hollow viscus, early symptoms. 
     3. Extravasation, urine.  
     4. Peritonitis.  
     5. Abscess; subphrenic, perirenal; pelvis. 
     6. Septicemia.
V. Treatment.
     1. Immediate, firing line, regimental aid, or dressing station. 
          a. General care. Blankets. No water. No food.  
          b. Wound antisepsis. Iodine.  
          c. Dressings. Dry gauze.  
          d. Posture of patient. On back, thighs flexed, head raised. 
          e. Medication. Morphine.  
          f. Transportation. Patient moved to adequate operating station as expeditiously as possible. Not removed from litter till operating station is reached. 
     2. Mobile operating unit, field hospital, evacuation hospital.
          a. Wound cleansing.  
          b. Operation; methods and indications for.  
          c. Anesthesia; ether, chloroform-drop method. 
          d. Roentgen-ray examination.
     3. Base hospital.  
          a. Infections, special treatment for. 
          b. Complications, treatment of.  
          c. Roentgen-ray examination.  
          d. Operations, methods and indications for.

OPHTHALMOLOGY

Instructions in ophthalmology should include the following-named subjects.
     1. Methods of testing visual acuity.  
     2. Methods of testing pupillary reaction. Significance of pupillary abnormalities.  
     3. The simpler methods of testing the ocular rotations and the associated movements of the eye, including convergence.
     4. External examinations:
          (a) Method of everting the lids.  
          (b) Examination with oblique light. Especial attention to its importance in detecting abrasions of the cornea, corneal ulcers, the presence of small foreign bodies and iritic adhesions. Use of fluorescin. 
     5. Epiphora and its significance.  
     6. Inflammation of the lacrymal apparatus.  
     7. Inflammation of the lids and globe. In general all cases of inflammation should suggest the following possibilities, arranged in the order of their importance:
          Glaucoma. 
          Iritis. 
          Conjunctivitis. 
          Foreign body in the conjunctiva.
     8. Trachoma and other contagious diseases of the conjunctiva.  
     9. Importance and significance of bacteriological examination in conjunctivitis. 
     10. Indications and contraindications for the use of mydriatics and miotics.  
     11. Wounds of the eye and orbital region.  
     12. The importance of a thorough examination in every case of injury of the globe.  
     13. The importance of X-ray examination in all cases when there is the slightest suspicion of the presence of a foreign body in the eye.
     14. The use of magnets in military eye surgery.  
     15. Methods of testing and significance of increased intraocular tension. Glaucoma and its varieties.  


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     16. Simple methods of determining the field of vision.
     17. The significance of a double vision.  
     18. The causes of gradual and sudden loss of vision, with consideration of whether functional organic.  
     19. Ocular malingering. 
     20.  Eye symptoms in cases of increased intraocular pressure.  
     21.  Ocular headaches, vertigo, and reflex gastric and nervous symptoms. 
     22. Ocular symptoms of disease and focal septic areas, as in alveolar abscess or sinusitis. 

EAR

1. Foreign bodies in the canal. 
    Furunculosis of the canal. 
    Acute otitis media.  
    Acute mastoiditis. 
    Sinus thrombosis.

2. Chronic otitis media. Polypi. 
    Brain abscess.  
    Bárány tests for vestibular function. 
    Labyrinthitis.

NOSE AND THROAT

1. Acute and chronic tonsillitis. 
    Discussion of tonsil operations. Results of operations in preventing absorption.
    Peritonsillar abscess.
    Nasal obstruction.
    Deviation of the septum. Submucous resection of the septum.  
2. Acute and chronic sinusitis.  
    Antrum, frontal, ethmoid, sphenoid-polypi. 
3. Epistaxis.  
    Fracture of the nasal bones. 
    Correction of external deformities of the nose. 
    Catarrh.
    Atrophic rhinitis.  
    Syphilis of the nose and throat.  
4. Acute and chronic laryngitis, papilloma of the larynx-cancer.  
5 (Optional). Direct inspection of the larynx and trachea. 
         Foreign bodies in the trachea and bronchi. 
         The direct examination of the esophagus. 
         Diseases of the esophagus: Stricture, pouch, cardiospasm, cancer. 
         Foreign bodies in the esophagus.

NEUROLOGICAL SURGERY

Skull. 
     Fractures. 
          1.  Varieties. 
               (a) According to mechanism-bending, bursting, expansile.  
               (b) Simple or compound.  
               (c) According to form of fragments-fissured, linear, comminuted, diastasis, depressed, perforating, gunshot.  
               (d) According to situation-vault, base. 
               (e) Infection and complications.  
               (f) Associated brain injuries.  
               (g) Associated injuries to cranial nerves. 
               (h) Associated injuries of blood vessels.  
               (i) Associated injuries of nasal accessory sinuses. 
          2.  Symptomatology.
          3.  Prognosis. 
          4.  Diagnosis. 
          5.  Treatment.


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Meninges.  
     1. Physiology of cerebrospinal fluid. 
     2. Meningitis.  
          Traumatic infective. 
          Pathology and bacteriology. 
          Symptomatology. 
          Diagnosis.  
          Prognosis. 
          Treatment. 
Brain.  
     1. Localization of function. 
          (a) Excitomotor cortex. 
          (b) Sensory field.  
          (c) Visual cortex. 
          (d) Auditory cortex. 
          (e) Olfactory cortex.  
          (f) Cortical speech centers 
     2. Craniocerebral topography.  
     3. Symptomatology of organic disease. 
          (a) General symptoms.  
          (b) Local symptoms. 
     4. Brain abscess.  
          (a) Varieties. 
          (b) Pathology. 
          (c) Symptomatology. 
          (d) Treatment.
     5. Technic of intracranial operations.  
     6. Roentgenography and stereoroentgenography in intracranial disease. 
Spine.  
     1. Surgical anatomy of vertebral column.  
     2. Normal and pathological physiology of the cord. 
     3. Localization in the cord.  
     4. Symptomatology of spinal disease. 
          Cell destruction.  
          Tract degeneration. 
          Root symptoms. 
          Sensory disturbances. 
          Motor weakness and paralysis. 
          Reflex disturbances. 
          Bladder and rectum.
     5. Variations in symptoms according to level. 
     6. The operative technique of laminectomy. 
     7. Extraction of foreign bodies.  
Nerves.  
     l. Function.
          (a) Motor.  
          (b) Sensory-epicritic, protopathic, deep. 
     2. Results of section of motor nerve.  
     3. Results of section of sensory nerve. 
     4. Nerve shock.  
     5. Diagnosis of nerve lesion (traumatic). 
     6. Technique of nerve suture.

PLASTIC AND ORAL SURGERY, SECTION OF SURGERY OF THE HEAD

1. Surgical anatomy of the face and jaws, bones, teeth, accessory sinuses, soft parts.
2. Sepsis: Special forms of sepsis related to mouth, face, and neck treatment. Peridental infection. Infection of antrum of Highmore and other nasal accessory sinuses.
3. Wounds and injuries of the face and jaws, with special consideration of injuries by projectiles.


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4. Fractures of the jaw bones, with special reference to gunshot fractures. Displacements. Emergency treatment. Special care of patient, tissues, etc. Diet. Special methods of fixation, splints, etc.
5. Treatment of deformities of bony and soft tissues following gunshot injuries of face and jaws. Orthopedic splints. Plastic operations. Grafting of soft tissues, bone, and cartilage.  
6. Local anesthesia in surgery of face and jaws.  
7. Interpretation of dental and maxillary roentgenograms.

FOOD AND NUTRITION

l. The scientific background of nutrition.
2. The dynamic effect of the different foodstuffs. 
3. The influence of muscular work on metabolism. 
4. Complete and incomplete proteins.  
5. Accessory foodstuffs.  
6. Governmental regulation of food. 
7. Feeding of European armies.  
8. Protection against spoilage of foods. 
9. Gastric digestion in man.  
10. Work of the Food Division, Surgeon General's Office.

ORTHOPEDIC SURGERY

1. a. The human foot; its physiology, examination, and the significance of its symptoms. 
    b. The soldier's foot and the military shoe; prophylaxis.  
    c. The disabilities of the foot arising during military service and their treatment.  
    Synopsis. A review and an elaboration of the work done in these subjects in the course given in training camps.  
2. Injuries to joints and their treatment.  
    Synopsis. Also a review and elaboration of the preceding course. 
3. a. Injuries to joints and their treatment.  
    b. Special joints-the knee-joint, etc.  
Synopsis. The general subject will be continued and elaborated, and the special peculiarities of the knee-joint and other joints fully discussed.
4. Positions of election for ankylosis.  
    Synopsis. The pathological changes leading to ankylosis and the clinical indications pointing to it will be fully explained. The positions of which the various joints are most serviceable will be definitely defined and the reasons for choice of these positions given.
5. The operative procedures available for restoration of function following failure of repair after nerve injuries.  
     Synopsis. The difficulties involved in the repair of nerves will be fully discussed and the necessity for painstaking orthopedic care in order to secure a successful result after nerve suture emphasized. As alternative measures, where regeneration has failed to take place, tendon transplantation, tendon fixation, and certain bone operations are available, and their technic will be explained.
6. Nonunion and malunion.
    Synopsis. The various causes for nonunion and malunion will be reviewed and the operative procedures indicated discussed.
7. Bone grafting.  
    Synopsis. The danger of operation, and particularly of bone operations, until all sinuses have been closed for at least six months will be strongly emphasized. The indications for bone grafting will be defined and the technic of the various procedures-spinal graft, inlay graft, bone peg-carefully explained.
8. Methods of fixation: Plaster of Paris.  
    Synopsis. The general principles of fixation will be discussed, and the use of plaster of Paris in military work will be fully covered.
9. Methods of fixation: Standard splints.
    Synopsis. The standard splints will be demonstrated and their indications and use carefully explained.  


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10. Methods of fixation: Nonstandard splints.
    Synopsis. Other splints and improvised splints will be demonstrated and their indications and use explained.

TUBERCULOSIS IN THE SOLDIER

Signs of active lesion. The acute lesion. The chronic lesion; activity in chronic lesions; distinction between acute and chronic lesions by physical signs. Distinction by X ray; bronchopneumonic focus; diagnosis of large lesions, isolated or few in number; tuberculous pneumonia; development of caseous lesions; physical signs of tuberculous pneumonia in first stage, in stage of consolidation; cavity signs; recent cavitation; old and dry or nearly dry cavities. Disseminated tuberculosis; miliary (vascular) disseminations. Peribronchial tuberculosis; physical signs; varieties and prognosis; X-ray diagnosis.

Physical examination in tuberculosis.-Necessity of objective examination in military practice. Importance of cough as aid to diagnosis. Topical variations in physical signs in the normal lung. Marginal sounds. Diagnosis by auscultation; breath changes and their significance; kinds and significance of râles. Role percussion plays in diagnosis of chest conditions. Voice transmission; transmission of whisper.

Detection of tuberculosis among soldiers.-Repeated weighing of recruits; those losing weight under training to be specially examined. Tuberculosis usually discovered during an exacerbation; distinction between exacerbation of chronic tuberculosis and incipient active tuberculosis. Role of X ray in the diagnosis of tuberculosis. Question of line of duty (Circular 24, S. G. O., and its interpretation). Infection between adults. What is the danger, if any, of spread of tuberculosis among soldiers from contact with tuberculosis individuals? The hygiene of the tuberculous patient; feeding; indications for rest and exercise; hardening methods.

Examination of the lungs.-Stethoscope; necessary to have a stethoscope which fits the ears; Ford stethoscope; phonendoscope not to be used for routine work. Position of patient during examination. Steps in examination. Inspection; general appearance of patient; general shape of chest; retractions; lagging; diminished expansion; apex beat of heart; pericardial pulsation. Palpation; vocal fremitus; normal variations. Percussion; method; light percussion best; normal variations; outlining of apices by Kronig's method; best to percuss from below upward, comparing sides. Auscultation; best to auscultate from below upward, comparing sides; vocal resonance; normal variations; even pressure of stethoscope necessary; whispered voice transmission; normal variations; breath sounds; instructing patient how to breathe; absence of breath sounds; feeble breathing; rough breathing; harsh breathing; prolonged expiration bronchovesicular breathing; bronchial breathing; cavernous breathing; amphoric breathing; normal variations; auscultation of breath sounds at apices; bronchovesicular breathing at right apex; transmission of breath sounds from trachea; normal disparity between right and left apex; pulmonary râles; extrapulmonary sounds simulating râles; classification, crepitant, crackling, bubbling (so-called moist or subcrepitant râles), sibilant and sonorous râles; gurgling râles; consonating râles; cavity râles; pleural râles. Value of "expiration and cough" in eliciting râles. Check up one phase of the examination with the other. Value of the localization and locality of physical signs.  

INSTRUCTION OF SUBSTANDARD OFFICERS

A less advanced course of instruction was promulgated for officers of the substandard class, with the idea of saving for the Service every man capable of developing into a useful officer.

This simpler curriculum was as follows:28

(a) Clinical training will be given each day as follows, unless circumstances render a change advisable. Attendance is compulsory.
Monday: Chest clinic, one hour. Discussion of cases and of manner of their investigation and presentation.  
Tuesday: Surgical clinic, one hour. Discussion as above.  
Wednesday: Diseases of digestive system clinic. Discussion as above.  
Thursday: Fractures and orthopedic clinic. Discussion as above.  
Friday: Psychiatric, neurologic, ductless glands clinic. Discussion as above.
Saturday: Medical or surgical-Bone and joint clinic. Discussion as above.  


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(b) Instruction should be given to individuals or to classes small enough to permit of individual instruction by chiefs of service as follows, attendance being compulsory on the part of all substandard men.
Monday: By chiefs of medical service. On routine and thorough methods of physical examination and history writing.  
Tuesday: By chief of surgical service. Similar instruction in relation to surgical cases.  
Wednesday: By director of laboratory. On laboratory aids to the ward surgeon; what may be expected from the laboratory, how it may be obtained, what it may mean, preparation of patient.
Thursday: By director of X-ray laboratory. On X-ray aids, what may be expected, how obtained, what it may mean, preparation of patient.
Friday: By adjutant or registrar. Preparation and disposal of hospital records. Importance of them and of their completeness.  
Saturday: Repetition of most needed instruction.
(c) Officers of known incapacity or doubtful capacity will, so far and so long as it is possible, be assigned to base hospitals or other units in excess of the quota of real necessity, for the purpose of the above instruction and will there be under constant instruction and will do a full day's work each day under the supervision of an officer of known capacity.
4. No definite period is set for this training of substandard men to remedy their defects and determine their competence. It should be continued so long as they apparently profit thereby. But an officer who at the end of six weeks of intensive instruction does not give promise of reasonable competence at an early date is not worth continuing in the service.

INSTRUCTION OF NURSES

The Army Nurse Corps, made up almost entirely of members to whom the military aspect of nursing was quite unfamiliar, did not pass through training camps, but went at once to the bedsides of the sick and wounded.29

In forming the personnel of the various hospitals an endeavor was made to detail nurses who were especially skilled in operating-room technique, the administration of anesthetics, etc., and the respective commanding officers were informed of their special qualifications.

Their instruction partook of the characteristics of experience. This experience, enhanced in value by intimate guidance on the part of better trained nurses, or of medical officers, permitted selections to be made for newly organized hospitals in the United States, as well as for hospital units for service abroad.30

One use of nurses, new in the Military Establishment, was as anesthetists. This proved most advantageous, for medical officers were thereby released for other work.

Special courses in the administration of anesthetics31 were given in the large general and base hospitals and at St. Mary's Hospital, Rochester, Minn. 

Reference has been made to the branches of the Army School of Nursing which were established in the various military hospitals. The details of the instruction given in these schools may be found in that volume of this history which deals with Medical Department training.

INSTRUCTION OF ENLISTED PERSONNEL

The wide scope of the duties performed by the enlisted personnel of fixed hospitals necessitated a specialization which, in a twofold manner, generally prevented a comprehensive course of instruction for that personnel as a whole. There was close confinement to restricted details as individuals or as groups; and organization-which included instruction-not only had to go hand in hand with successively greater demands made in the care of the sick, but for a while  


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was a considerable degree behind. Many of the base hospitals had very small beginnings, and the personnel was gradually added as the physical growth of the hospital occurred. Frequently in the earliest days of organization patients were considerably disproportionate to personnel, and instruction necessarily was limited to vital requisites. In general the first essentials in training were rudiments in the care of the sick and in the preparation of food for both patients and personnel.

As the hospital grew and its departments increased in number, coincident with the growth of the personnel, it was found that many technically qualified men could be assigned directly to services,32 wherein they functioned very satisfactorily throughout the existence of the hospital.

Instruction in hospitals was largely carried out in separate departments of the hospitals and in the main was based on practical performance of work under the guidance of those responsible for the integrity of given departments. In this way large numbers of men, both privates and noncommissioned officers, were trained in special duties and made available for the formation of additional units for service at other newly organized hospitals.

Discipline and duties of the soldier were subjects early imparted,33 though in the beginning only disappointing results were obtained because of the impracticability of liberating but a small proportion of members of detachments from their exacting duties. Later on, however, with better organization, it was possible to form groups of the detachments at hospitals and by drilling and instructing separate groups on successive days, in the course of a week, each member of the detachment had received instruction.

TRAINING DEPARTMENTS IN HOSPITALS

In the winter and spring, following the beginning of the functioning of the large hospitals, frequent complaints arose over men being returned to duty from hospitals who proved to be physically incapable of performing duty.34 It was noted that patients who had been confined to hospitals for more than two weeks were rendered unfit for immediate resumption of their full duties as the result of such confinement and because of the medical or surgical conditions for which they had been treated. The soldiers then frequently broke down on return to duty, and their readmission to hospital for further treatment was necessitated.

The Surgeon General directed that hospitals establish training departments in the convalescent division to which convalescents would be transferred by the chiefs of the medical and surgical services of the hospitals.34

These training departments were intended to be auxiliary to development battalions. The men with whom they dealt were those who, for various reasons, had to be kept in hospitals and whose discharge to the development battalions or to duty could be hastened rather than retarded by the training.

While undergoing training these patients were referred, for all purposes of medical or surgical treatment, to the medical officers by whom they were transferred.

A medical officer was designated by the commanding officer of each hospital to have charge of the training. This officer admitted and classified the men according to the strength and condition of each-largely on the recom-


141

mendation of the transferring officer-and supervised their instruction in work, exercise, and drill. He maintained discipline; kept suitable records of all members of the department; and finally determined what disposition the condition of the patients warranted; that is, their discharge to the development battalion or to their former commands.

Under the officer in charge of the training department there were subordinate medical officers in sufficient number to supervise the convalescent wards and the patients therein. The duties of these officers were to have immediate supervision and control of the patients in their charge; to treat all minor ailments, referring major illnesses to the proper service of the hospital; to assist in determining the physical capabilities of the patients, when to advance or retard them.

The classes varied from the lowest, wherein men could not exercise but could attend lectures, to the highest, in which it was found men did more work frequently than those on full duty status. It was found that men went either up or down. If they suffered a retrogression, they were examined by the physical disability board of the hospital with a view to their elimination from the service.

REHABILITATION

The Surgeon General, at the request of the Secretary of War, in January, 1918, called a conference of a number of governmental and civilian organizations interested in the problem of reconstruction of disabled soldiers with the idea of arriving at the best means of administering this work in all its ramifications.35 As a result of the work of the committee in the conference, a report was submitted to the Secretary of War.36 This report outlined the functions of the Medical Department of the Army and the functions of the civilian agencies in carrying on the work of physical reconstruction and rehabilitation. The approved policy for the physical reconstruction of disabled soldiers contemplated that no member of the military establishment disabled in line of duty, even though not expected to return to duty, would be discharged from the service until after he had attained complete recovery or as complete recovery as could be expected considering the nature of the disability.

Physical reconstruction was defined as the most complete form of medical and surgical treatment carried to the point where maximum functional restoration, mental and physical, had been secured.

The completed form of physical reconstruction embraced the equipment of the general and base hospitals, which functioned in physical reconstruction, with curative workshops and educational buildings properly equipped to carry on curative work, physiotherapy buildings, including gymnasia properly equipped to utilize every physical means of cure.

The necessary personnel to administer the work was obtained by commissioning educational officers in the Sanitary Corps.37 Administration officers for physiotherapy were obtained from qualified members of the Medical Corps.38 Enlisted personnel were assigned to both the educational and the physiotherapeutic departments, and civilian women were employed and designated reconstruction aids, to function in two classes: Occupational therapy and physiotherapy.39

On July 31, 1918, the Surgeon General designated the following general hospitals to function in physical reconstruction:40 Walter Reed General  


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Hospital, Takoma Park, D. C.; General Hospital No. 2, Fort McHenry, Md.; General Hospital No. 3, Colonia, N. J.; General Hospital No. 4, Fort Porter, N. Y.; General Hospital No. 6, Fort McPherson, Ga.; General Hospital No. 7, Baltimore, Md. (for the blind); General Hospital No. 8, Otisville, N. Y.; General Hospital No. 9, Lakewood, N. J.; General Hospital No. 11, Cape May, N. J.; General Hospital No. 16, New Haven, Conn.; General Hospital No. 17, Markleton, Pa.; Letterman General Hospital, San Francisco, Calif.; United States Army Hospital, Fort Des Moines, Iowa; Plattsburg Barracks Hospital, Plattsburg Barracks, N. Y.; General Hospital, Fort Bayard, N. Mex.

Special provision was made for the training and education of the blind at General Hospital No. 7, Baltimore, during the year beginning July, 1, 1917.41 This hospital was completed, a corps of teachers, including civilian employees of the Army, augmented by volunteers from civil life, was obtained, and active work was begun on May 30, 1918.

Special arrangements were made for the care of soldiers disabled by deafness and by speech defects at General Hospital No. 11, Cape May, N. J.42 Deaf soldiers were taught lip reading and incidentally were trained in suitable occupations. The soldiers disabled by speech defects were trained in speech articulation and were vocationally trained.

On December 19, 1918, the Chief of Staff approved the Surgeon General's recommendation that the number of centers to function in physical reconstruction to meet the need of rehabilitation of the very large number of disabled men returned from overseas, be amplified.43 The amplification of the centers of physical reconstruction included the alteration of existing buildings, available buildings in the designated centers, the purchase of new or the transfer of the necessary equipment already owned by the Government for workshops, school buildings, farm, motor mechanics, physical education, and the like. To meet the added work indicated the following centers were designated to function in physical reconstruction:44 General Hospital No. 12, Biltmore, N. C.; General Hospital No. 31, Carlisle, Pa.; General Hospital No. 35, Detroit, Mich.; General Hospital No. 36, Detroit, Mich.; General Hospital No. 38, East View, N. Y.; General Hospital No. 41, Fox Hills, Staten Island, N. Y.; General Hospital No. 42, Spartanburg, S. C.; base hospitals at Camps Gordon, Ga.; Jackson, S. C.; Lee, Va.; Meade, Md.; Sherman, Ohio; Taylor, Ky.; Funston (Fort Riley), Kans.; Custer, Mich.; Grant, Ill.; Travis, Tex.; Pike, Ark.; Dodge, Iowa; Lewis, Wash.; Dix, N. J.; Devens, Mass.; Upton, Long Island; and Kearny, Calif.; and on May 1, 1919, General Hospital No. 43, Hampton, Va.

REFERENCES

(1) Manual for the Medical Department, 1916, par. 760. 

(2) Ibid., par. 602.

(3) Letter from the Surgeon General to all commanding officers of hospitals. December 18, 1917. Subject: Enlisted men. On file, Record Room, S. G. O., 320.22-1. Also: Cir. Letter No. 956, Surgeon General's Office, February 2, 1918. Also: Cir. Letter No. (A-169), Surgeon General's Office, March 7, 1918.

(4) Cir. Letter No. 201, Surgeon General's Office, October 15, 1917. 

(5) Annual Report of the Surgeon General, U. S. Army, 1918, 406.

(6) Ibid., 408.


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(7) From a statement on the subject in History of Base Hospital, Camp Grant, Ill., on file, Historical Division, S. G. O. Also: Circular letter from the Surgeon General to commanding officers, base and general hospitals, December 14, 1917. Subject: Practical training substandard officers. Copy on file, Historical Division, S. G. O.

(8) Circular letter from the Surgeon General, October 15, 1917. Subject: Personnel. Copy on file, Historical Division, S. G. O.

(9) Circular memorandum from the Surgeon General, November 15, 1917. Subject: Instruction. Copy on file, Historical Division, S. G. O.

(10) Circular letter from the Surgeon General to commanding officers of hospitals, February 19, 1918. Subject: Administration. Copy on file, Historical Division, S. G. O.

(11) Manual for the Medical Department, 1916, par. 315.

(12) Annual Report of the Surgeon General, U. S. Army, 1918, 312.

(13) Circular letter from the Surgeon General to commanding officers of hospitals, August 9, 1918. Subject: Army School of Nursing. Copy on file, Historical Division, S. G. O.

(14) Bull. No. 32, W. D., May 24, 1917; and Bull. No. 43, W. D., July 22, 1918.

(15) Circular letter from the Surgeon General to commanding officers of hospitals. (Undated.) Subject: Enlisted personnel. Copy on file, Historical Division, S. G. O.

(16) Circular memorandum from the Surgeon General to commanding officers of hospitals, February 23, 1918. Subject: Enlisted personnel. Copy on file, Historical Division, S. G. O. 

(17) Circular letter from the Surgeon General to commanding officers of hospitals, March l, 1918. Subject: Enlisted personnel. Also: Circular letter from the Surgeon General to commanding officers of hospitals, March 27, 1918. Subject: Enlisted personnel. Copies on file, Historical Division, S. G. O.

(18) Circular letter from the Surgeon General to commanding officers of hospitals, March 1, 1918. Subject: Enlisted personnel. Copy on file, Historical Division, S. G. O.

(19) Circular letter from the Surgeon General to commanding officers of hospitals. (Undated.) Subject: Women laboratory technicians. Copy on file, Historical Division, S. G. O. 

(20) Circular letter from the Surgeon General to commanding officers of hospitals, December 20, 1918.  Subject: Status of reconstruction aides. Copy on file, Historical Division, S. G. O. 

(21) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1127.

(22) Manual for the Medical Department, 1916, par. 290.

(23) Circular letter from the Surgeon General to commanding officers of hospitals, November 11, 1917. Subject: Specialists. Copy on file, Historical Division, S. G. O.

(24) Circular memorandum from the Surgeon General to commanding officers of hospitals. (Undated.) Subject: Recognition of sections representing specialists. Copy on file, Historical Division, S. G. O.

(25) Circular letter from the Surgeon General to commanding officers of hospitals, October 15, 1917. Subject: Personnel. Copy on file, Historical Division, S. G. O.

(26) Circular letter from the Surgeon General to commanding officers of hospitals, November 1, 1917. Subject: Professional training of medical officers. Copy on file, Historical Division, S. G. O.

(27) Circular letter from the Surgeon General to commanding officers of hospitals, November 15, 1917. Subject: Detail of especially trained medical officers as assistants. Copy on file, Historical Division, S. G. O.

(28) Circular letter from the Surgeon General to commanding officers of hospitals, December 14, 1917. Subject: Practical training of substandard officers. Copy on file, Historical Division, S. G. O.

(29) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1122. 

(30) Ibid., 1123.

(31) Circular letter from the Surgeon General to commanding officers of hospitals, April 15, 1918. Subject: Comments of inspectors. Copy on file, Historical Division, S. G. O.

(32) G. O. No. 46, W. D., May 9, 1918.

(33) From statements on the subject in Histories of Base Hospitals. On file, Historical Division, S. G. O.

(34) Letter from the Surgeon General to commanding officers of all base hospitals, July 10, 1918. Subject: Training departments in hospitals. On file, Mimeograph Room, S. G. O., B-431.

(35) Memorandum from the Secretary of War to the Surgeon General, January 5, 1918. Conference on physical reconstruction. On file, Record Room, S. G. O., 356 (General).  


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(36) Letter from the Surgeon General to the Secretary of War, January 29, 1918. Subject: Report of conference. On file, Record Room, S. G. O., 356 (General).

(37) Regulations for the operation of curative workshops in military hospitals, March 14, 1918. On file, Record Room, S. G. O., 356 (General).

(38) Letter from the Division of Physical Reconstruction to the Surgeon General, May 28, 1918. Subject: Assignment of medical officers for physical reconstruction. On file, Record Room, S. G. O., 210.3 (Assignments).

(39) Circular of Information concerning the women's auxiliary medical aides, December 31, 1917. On file, Record Room, S. G. O., 231 (Reconstruction Aides).

(40) Release from Committee on Public Information to newspapers, July 31, 1918. Subject: Announcement by the Surgeon General of completion of plans for physical reconstruction of disabled soldiers in general military hospitals. On file, Record Room, S. G. O., 356 (General).

(41) Circular letter, Office of the Surgeon General, June 3, 1918. Subject: Physical reconstruction of invalided and disabled soldiers. On file, Record Room, S. G. O., 356 (General).

(42) Letter from The Adjutant General to the Surgeon General, December 19, 1918. Subject: Modified program for physical reconstruction of disabled soldiers. On file, Record Room, S. G. O., 356 (General).

(43) Memorandum from the Surgeon General to the General Staff, attention of Operating Division, December 10, 1918. Subject: Modified program for physical reconstruction of disabled soldiers. On file, Record Room, S. G. O., 356 (General).

(44) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1176.

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