Contents

CHAPTER IX

COORDINATION OF MEASURES FOR THE IMPROVEMENT OF THE ADMINISTRATION OF HOSPITALS

SANITARY INSPECTORS

A group of specially trained medical officers of long service was constantly engaged in making routine and special inspections of large camps, cantonments, hospitals, and other stations.¹ Their duties primarily pertained to sanitary and administrative matters within camps and cantonments, though they included the inspection of hospitals.

The scope of the inspections which these sanitary inspectors made differed materially from those made by the Inspector General's Department;¹ less stress was laid on details of a purely military nature and more emphasis was placed on matters largely technical, such as nursing and the professional care of the sick, the competency of medical officers, the handling of infectious diseases, the quantity and quality of medical supplies, hospital construction, laboratories, and special diets.

After each inspection a report was made by the sanitary inspectors; and pertinent abstracts were furnished the hospital division of the Surgeon General's Office, for the information of the administrative officers on duty therein. Personal conferences were had with officers on duty in the Surgeon General's Office, when necessary in the correction of deficiencies which had been made of note at one of the inspections.

The following improved form was used in making inspections of hospitals:

REPORT OF SANITARY INSPECTION OF .......... HOSPITAL .........*

At ...................................................on.............................. 1919.

By Colonel ........................................ M. C.

1. Situation :
     (a) Condition of roads.
     (b) Improvement of grounds.
2. Construction:
     (a) Progress on authorized projects.
     (b) Additional required or recommended.
3. Organization and administration:
     (a) Name and efficiency of C. O.
     (b) Adjutant's office, including personnel adjutant.
     (c) Hospital regulations, adequacy of same.
     (d) Officer of the day. Duties.
     (e) What action to eliminate unfit officers?
     (f) What course of instruction given to officers? How many hours?
     (g) Adequacy of officers' quarters.
     (h) Amount and sufficiency of transportation, including ambulances. Is ambulance service satisfactory?

*[Asterisks signify answers to be prepared prior to arrival of inspector].

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4. Nurses:
     (a) Number, sufficiency, efficiency.
     (b) Name and efficiency of chief nurse.
     (c) Adequacy and suitability of quarters.
     (d) Administration of nurses' mess.
5. Detachment enlisted men, M. D.:
     (a) C. O. and organization of office.
     (b) Condition of records.
     (c) Number and efficiency of N. C. O.
     (d) Strength, sufficiency, and efficiency of detachment.
     (e) Sufficiency of clothing and equipment. Are there white suits for all entitled to wear them?
     (f) Instruction and drills. Character and efficiency of guard
     (g) Operation of venereal prophylactic station.
     (h) How often are physical inspections held?
6. Barracks and squad rooms:
     (a) Adequacy.
     (b) Ventilation and heating.
     (c) Equipment.
     (d) Operation of mess and kitchen.
     (e) Character and condition of guardhouse.
7. Registrar's office:
     (a) Organization and administration.
     (b) Status of records and returns.
     (c) Average number of days in hospital per patient during past month.
     (d) Mean daily number of cases in hospital each month since hospital opened (not to cover more than 1 year).
8. Dispensary service:
     (a) Compliance with pars. 240-244, M. M. D.
     (b) Are common drinking cups used to administer medicine?
*9. Dental service.
*10. Medical service.
*11. Surgical service.
*12. Eye, ear, nose, and throat department.
*13. Laboratory, including ward laboratories.
*14. Genitourinary service.
*15. Psychopathic service.
16. Communicable diseases.
     (a) Administration of isolation and other wards. (Memo. S. G. O., Jan. 1, 1918).
17. Wards and care of patients:
     (a) Ward capacity.
     (b) Number of patients present.
     (c) How admitted? Operation receiving ward.
     (d) Care of valuables and other effects (pars. 293 and 303-304, M. M. D.).
     (e) Efficiency of ward service; including nursing, bathing of patients, cleanliness of linen and clothing, and food service to bed patients.
     (f) Do chiefs of service report daily, names of men dangerously ill?
     (g) Are nearest relatives notified direct from hospital regarding seriously ill?
     (h) Are letters from relatives promptly answered?
     (i) Are post cards sent to relatives on arrival, departure, and discharge?
     (j) Care of dead (pars. 87, 162½, 167, 824, A. R.).
     (k) Percentage of dead which are autopsied.
*18. Kitchen and mess management:
     (a) Organization and efficiency personnel.
     (b) Source and quality of supplies.
     (c) System of storage and issue.
     (d) Diets and bill of fare.
     (e) System of feeding in mess hall.

*[Asterisks signify answers to be prepared prior to arrival of inspector].

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*18. Kitchen and mess management-Continued.
     (f) Handling of hospital fund; amount (pars. 248-262, M. M. D.).
     (g) Can any of the fund be spared?
     (h) Have cooks and other food handlers been examined for carriers?
     (i) Adequacy of mess halls, kitchens, and equipment.
     (j) Condition of food served to wards.
     (k) Does nurse supervise serving in wards?
     (l) Food carts, number, efficiency.
     (m) Efficiency of dish washing.
     (n) Condition of bakery, cleanliness of bakers, and character of bread.
     (o) Adequacy of fly prevention (Cir. 133, W. D., 1919, and Cir. Letter No. 148, S. G. O., 1919).
19. Exchange:
     (a) Organization and administration.
     (b) Sanitary condition of food supplies.
     (c) Operating under W. D. Exchange regulations?
     (d) Records and dividends.
20. Laundry:
     (a) Organization and administration.  
     (b) Number and duties of civilian employees. 
     (c) Quality of work, complaints.
     (d) Adequacy of equipment and supplies. 
     (e) Disinfection department.  
     (f) Clean linen and issue department.  
     (g) Arrangements for outside work, prices. 
21. Medical supply department:  
     (a) Are loan cards in use and checked? 
     (b) System of issuing supplies.  
     (c) Sufficiency of supplies.  
     (d) Are hospital requisitions promptly filled?  
     (e) Are medical supplies on hand in accord with balances on stock cards? 
     (f) How often are narcotics and alcoholics checked, and by whom?  
22. Supply and utilities:  
     (a) Number of enlisted men in supply and utilities detachments. Number of civilians 
          Are numbers adequate?
     (b) Status of records and property returns. 
     (c) Sufficiency of supplies.  
     (d) Operation of power plant, heating system, and hot-water system. 
     (e) Water supply.  
     (f) Sewerage system and plumbing.  
     (g) Electric lights, other electrical appliances. 
*23. Fire protection:
     (a) Description of system, adequacy. 
24. Disposal of wastes:  
25. General police of buildings and grounds. 
26. Remarks:  
     (a) Condition of morale, both of officers and enlisted personnel. 
     (b) Efficiency of morale organization.  
     (c) Apparent causes of poor morale if noted. 
27. Résumé.
28. Recommendations made to commanding general. 
29. Recommendations now made to Surgeon General.

MEDICAL INSPECTORS

It was felt that the routine inspections made by the sanitary inspectors of the Surgeon General's Office left much uncovered that pertained to the care of the patient and the quality of the professional services rendered.

*[Asterisks signify answers to be prepared prior to arrival of inspector].  

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In organizing the base hospitals throughout the country, the officers in charge of the various divisions of the Surgeon General's Office selected the principal medical officers to function in the respective services of hospitals.² To obtain an adequate check on the manner in which these newly selected officers were performing their duties, as well as to determine the best methods of instituting courses of instruction, the chiefs of professional divisions, or assistants, in the Surgeon General's Office, personally visited many of the hospitals,³ or detailed traveling instructors to impart special instruction.⁴

With a view to improving the medical service, each chief of a medical service of a hospital was ordered to visit, during February and March, 1918, three other base hospitals.⁵

In August, 1918, a comprehensive system of consultation tours of chiefs of surgical services was inaugurated.⁶ These consultation tours were of great advantage to commanding officers and chiefs of service as well as to the Office of the Surgeon General, in that they encouraged the mutual exchange of ideas, the consultant being prepared to give all the information which he had gathered from various hospitals visited, and he in turn was able to carry away much that was helpful in the perfection of the system of careful professional demonstration. Most of the defects found by the consultants on their visits were due to lack of knowledge as to the necessity of certain requirements of the Surgeon General's Office, and were readily corrected by such conferences. Consultants were assigned groups of camps, in geographic relation, and were instructed to cover all possible topics pertaining to every phase of surgery. Each consultant, on his return, submitted a report covering his consultation, appending a special estimate of the professional qualifications of the surgical personnel of the various camps visited.⁶

INSPECTING NURSES

Several well-trained nurses, of large executive experience in the best civil hospitals, were assigned to duty as inspecting nurses. They visited the various Army hospitals systematically, inspecting them thoroughly, particularly with reference to nursing, but made of note any ward administrative feature requiring corrective comment.

The reports they obtained did much to stimulate a perfected organization and better care of the sick.⁷

BOARDS

Boards of medical officers whose functions were the perfection and coordination of administration and professional care and treatment, were variously organized. These boards were both fixed and mobile.

Efficiency boards were appointed at each hospital,⁸ consisting of the commanding officer and the chiefs of the medical, surgical, and laboratory services. They met twice monthly to consider questions of policy and needs of the hospital, a stenographic report of their meeting being forwarded to the Surgeon General's Office with recommendations regarding policy, equipment, accommodations, and general administration.

During the period in which epidemic diseases were prevalent, three mobile medical units were organized,⁹ each composed of three officers selected for their  

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knowledge of infectious diseases. These units were moved from one hospital to another to assist in the care of cases of infectious diseases.

During the early months of 1918 cases of pneumonia in large numbers were reported from all the camps in the South. Accompanying this epidemic of what was termed pneumonia, many cases of empyema were reported. To determine the best operative means of treating this complication, local boards were appointed, consisting of a surgeon, an internist, and a bacteriologist.¹⁰ Information resulting from these board studies was collected in the Office of the Surgeon General and disseminated to the various camps.

A board of five officers was sent to Camp Funston in July, 1918, to make a thorough and complete study of the acute respiratory diseases at that camp, including epidemiological, bacteriological, and pathological investigation.¹¹ Upon the conclusion of their survey at Camp Funston, the group was transferred to Camp Pike, arriving about three weeks before the outbreak of the great epidemic. These studies were rich in results and gave a picture of the respiratory disease condition both before and after, as well as during, the epidemic, made in a similar way by the same group of men. Their reports were published in the medical literature.

CIRCULAR LETTERS AND LITERATURE

To the personnel of hospitals, desirable information was imparted by means of circular letters.¹² These contained not only original instructions, but features obtaining at one hospital believed to possess sufficient value to warrant bringing them to the attention of commanding officers of hospitals in general. 

To maintain professional efficiency, medical journals, and carefully selected practical treatises were furnished medical officers. It was realized that the exigencies of the service afforded comparatively little time for extensive reading or extensive study. Therefore, a carefully prepared digest of all important American, English, French, Italian, and German (when obtainable) contributions to surgery and medicine was distributed monthly as the Review of War Surgery and Medicine.¹³ A Manual of Surgical Anatomy was prepared for distribution.¹⁴ This manual was a volume of anatomical plates, without text, selected because of their use in war surgery. The British Official Manual of the Injuries and Diseases of War was widely distributed,¹⁵ as was Abstracts of War Surgery,¹⁶ furnishing abstracts, topically arranged, of all the important surgical articles published by the allies from the declaration of war to the time of American participation.

The Division of Infectious Diseases and Laboratories, at the very beginning of its work, instituted measures tending to standardize technique throughout the laboratories of the Army to such a degree as would make results from different parts of the country similar and at the same time permit individual officers to use their own ingenuity and any particular ability they might possess to simplify accepted methods and elaborate new methods which might be found of value in diagnosis and treatment. The Rockefeller Institute published Monograph No. 7 of that institution, on the subject of "Acute Lobar Pneumonia, Prevention and Serum Treatment," aiming at standardization.¹⁷ Early in 1917, a monograph was published by the same institution on request of the Surgeon

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General, entitled "Mode of Infection, Means of Prevention, and Specific Treatment of Epidemic Meningitis."¹⁸ At a somewhat later date, following a conference at the Surgeon General's Office, a standard procedure and technique for the isolation of meningococcus was adopted, and pamphlets describing these procedures were distributed.¹⁹ As a result of a subsequent conference a similar circular was distributed describing the technique for isolating the types of streptococci.²⁰

During the same period and continuing throughout the year 1917, data were accumulated for a manual to be distributed to Army laboratories and to cover, in a comprehensive manner, the technique of the more important procedures to be used in laboratory diagnosis.²¹ From time to time, as new methods of laboratory procedure were developed, and their value demonstrated, reprints of articles describing them were distributed to the service laboratories, while circulars describing recent advances and suggested methods of procedure were occasionally sent out from the Surgeon General's Office.

With the purpose of using all preventive aids and of applying modern scientific methods to the cure of such venereal diseases as did occur, the Surgeon General appointed a committee of specialists in genitourinary diseases and syphilis, which, in addition to other labors with which it was concerned, prepared a manual for the use of medical officers, giving a brief summary of existing knowledge on the subject.²²

The Division of Head Surgery distributed books dealing with special surgery of the head and all its branches;²³ and the Division of Orthopedic Surgery furnished special books for the guidance of officers concerned with that specialty.²⁴

In the Division of Physical Reconstruction, all available literature on reconstruction and rehabilitation of the disabled was analyzed and compiled. Four mimeographed and illustrated bulletins giving the complete account of the rehabilitation of soldiers in all the belligerent countries were prepared and distributed chiefly to medical officers of the Army.²⁵ With the issue of May, 1918, these bulletins were discontinued and their place was taken by Carry On-a monthly magazine edited by a board created by the Surgeon General.²⁶

Instructional moving-picture films, including among the more important, the diagnosis of tuberculosis, eradication of louse infection, mosquito eradication, reconstruction, and training of a medical officer, were produced by the Surgeon General's Office for general exhibition.²⁷

REFERENCES

(1) Annual Report of the Surgeon General, U. S. Army, 1918, 273.

(2) Ibid., 344, 347-348.

(3) Ibid., 350-351.  

(4) Ibid., 344.  

(5) Ibid., 347.  

(6) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1086.

(7) Annual Report of the Surgeon General, U. S. Army, 1918, 309.

(8) Circular letter from the Surgeon General to commanding officers of hospitals, February 19, 1918.

(9) Minutes of the meeting of the pneumonia board, August 16, 1918.  On file, Record Room, S. G. O., 334.7-1 (Boards).

(10) Annual Report of the Surgeon General, U. S. Army, 1918, 351-352.  

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(11) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1043. 

(12) Ibid., 1153.

(13) Review of War Surgery and Medicine, Vol. I, Nos. 1 to 10 (March to December), 1918; Vol. II, Nos. 1 to 6 (January to June), 1919. Government Printing Office.

(14) Manual of Surgical Anatomy, Office of the Surgeon General, U. S. Army, 1918.

(15) Injuries and Diseases of War. A manual based on experiences of the present campaign in France. January, 1918. Reprint of the Official British Manual. Government Printing Office, Washington, 1918.

(16) Abstracts of War Surgery. Surgeon General's Office, 1918.

(17) Monograph No. 7. Acute Lobar Pneumonia, Prevention and Serum Treatment. The Rockefeller Institute for Medical Research, 1917. Waverly Press, Baltimore, Md.

(18) Mode of Infection, Means of Prevention, and Specific Treatment of Epidemic Meningitis. Simon Flexner. The Rockefeller Institute for Medical Research, 1917.

(19) Circular letter from Surgeon General to officers in charge of laboratories, 1917. Subject: Technique for detecting meningococcus carriers. On file, Laboratory Section, Division of Sanitation, Surgeon General's Office, 730 (Laboratory Technology).

(20) Recommendation of the Committee on a Standard Routine Method for the Detection and Isolation of Hemolytic Streptococci from Throats, Sputa, Pathological Exudates. On file Laboratory Section, Division of Sanitation, S. G. O. 730 (Laboratory Technology).

(21) Medical War Manual No. 6. Laboratory Methods, U. S. Army. Compiled by the Division of Infectious Diseases and Laboratories. First edition, 1918: second edition, 1919. Surgeon General's Office.

(22) A Manual of Treatment of the Venereal Diseases. Prepared under the direction of the Surgeon General of the Army. First edition, 1917; second edition, 1918; third edition, 1919. Chicago American Medical Association.

 (23) (a) Manual of Ophthalmology. Prepared by the Subsection of Ophthalmology, Section of Surgery of the Head, Division of Surgery, Office of the Surgeon General, War Department.< Government Printing Office, 1917.

         (b) Medical War Manual No. 3. Lea and Febiger, Philadelphia and New York, 1918.

         (c) War Surgery of the Nervous System. Compiled by the Division of Brain Surgery, Section of Surgery of the Head, Office of the Surgeon General, War Department, Washington, August 26, 1917.

         (d) Surgery and Diseases of the Mouth and Jaws. V. P. Blair. Third edition.< C. V. Mosby Co., St. Louis, Mo., 1917.

         (e) Medical War Manual No. 8. Lea and Febiger, Philadelphia and New York, 1918.

         (f) Survey of Head Surgery. Prepared by the Division of Surgery of the Head in the Office of the Surgeon General. August, 1918, to January, 1919.

         (g) Manual of Neuro-Surgery. Prepared under the direction of the Neuro-Surgical Section of the Division of Surgery in collaboration with the Sections of Head Surgery, General Surgery, Orthopedic Surgery and Neuro-Psychiatry, the Army Neuro-Surgical Laboratories, and the Instruction Laboratories of the Army Medical Museum.  Government Printing Office, Washington, 1919.

(24) (a) Minor Foot Ailments, Shoe Fitting. A manual for noncommissioned officers and selected enlisted men. Prepared under the Direction of the Surgeon General, U. S. Army.

        (b) Medical War Manual No. 4, Military Orthopedic Surgery. Prepared by the Orthopedic Council, Medical Department, U. S. Army. Lea and Febiger, Philadelphia and New York, 1918.

(25) Reconstruction Bulletin Nos. l to 4 (January, March, April, May, 1918). Copy on file, Journal Reprint Section, S. G. O.

(26) Carry On. Published for the Surgeon General by the Red Cross Institute for Crippled. New York City. Vol. I, Nos. 1 to 7, June to December, 1918, inclusive. Vol. II, Nos. 8 to 10, January to March, 1919, inclusive.

(27) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1064.  

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